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ePatients: The Medical, Ethical and Legal Repercussions of Blogging and Micro-Blogging Experiences of Illness and Disease – Call for Papers and Conference Details

22 Mar, 15 | by Deborah Bowman

Queen’s University Belfast, 11-12 September 2015 Call for Papers

Referring to the growth of online patient-initiated resources, including medical blogs, the BMJ noted in a 2004 editorial that we were witnessing ‘the most important technocultural medical revolution of the past century’. Ten years later, the controversy caused by Bill Keller’s opinion piece in the New York Times (‘Heroic Measures’, January 2014) and a blogpost on the Guardian US website criticising Lisa Bonchek Adams’s decision to tweet her experience of breast cancer, remind us of the ongoing sensitivities surrounding online patient narratives and the complex relationship between the world of medicine and social media. Emma Keller, the freelance journalist (and wife of Bill Keller) who questioned Adams’s use of twitter to discuss terminal illness, wrote the following: ‘Should there be boundaries in this kind of experience? Is there such a thing as TMI? Are her tweets a grim equivalent of deathbed selfies? Why am I so obsessed?’ Adams, in emails to the Guardian, said that the column was ‘callous’ in its treatment of her and noted that the blogpost was riddled with inaccuracies and quoted a private direct message without permission.

As debates on the ethics, dynamics and even legal repercussions of online patient narratives become more prevalent, an international, interdisciplinary conference at Queen’s University Belfast, hosted by the Health Humanities Project Research Group at the Institute for Collaborative Research in the Humanities, will focus on how those with life-threatening or incurable illness use social media, as well as the medical, ethical and potential legal consequences of online accounts of pain, suffering and the clinical experience. We welcome paper proposals dealing with ePatient accounts from a variety of countries and cultures which address the following questions:

  •   What does the rise in social media (“web 2.0”) participation by patients tell us about the ways in which the growing influence of e-patients is challenging the power structures of traditional healthcare and, as a result, proving contentious?
  •   In what ways might social media narratives of illness be seen as a useful source of information for medics? What, conversely, are their limitations?
  •   How do patients influence their online followers, and vice-versa?
  •   What are the ethical issues involved in documenting ‘the public deathbed’?
  •   What are the potential legal consequences of publicly chronicling the clinical experience?

250-word proposals for 20-minute papers (or three-paper panels), in English, should be sent to Dr Steven Wilson by email attachment at the following address: steven.wilson@qub.ac.uk. The deadline for receipt of proposals is Friday 3 April 2015.

Art in Arthritis by Nancy Merridew

22 Mar, 15 | by BMJ

 

 

I called Marco from the waiting room.

 

Everyone looked waxen under the fluorescent lights of Rheumatology Clinic. His olive skin looked grey. He rose like a grapevine on the trellis – thickset but gnarled through the seasons.

 

Marco helped his wife with her handbag and they walked together. Her gait was robust; his was antalgic and unhurried, though slower than he’d have liked.

 

In the consulting room we shared our introductions. I explained that I was aware of his medical history and asked “what are your biggest joint troubles today?”

 

Marco’s molten voice was rounded with a beautiful Italian accent and 80 years of life.

 

Apologising in fluent English Marco said that he didn’t speak English well and that it’s important to “talk the talk” of the doctors.

 

He looked down, reached into a shopping bag, and handed me three sheets of drawings.

 

I was stunned by beauty, utility, and clarity.

 

Brown ink outlined each picture, backfilled with camel watercolour. One image revealed the face of a younger man and the muscular shoulders of youth – his mind’s eye self-portrait.

 

Marco nodded to confirm that he had drawn them all.

 

Each drawing was anatomically correct and swelled from the parchment like parts of an amputee ghost. In some, his bones were bare. In others Marco had blended superficial features of skin with deeper structures of the appendicular skeleton.

 

A left hand floated on one page, like Adam’s in his Creation on the Sistine Chapel ceiling. Words – “Pain here” and “Here too” – were anchored by lines drawn to the hand, portraying metacarpophalangeal and proximal interphalangeal pain.

 

Figure.1_Hand.Shoulder_BMJ

Figure 1. Annotated drawings of right shoulder, face, and left hand:

  • “Pain here” [SHOULDER]
  • “Pain here” [5th METACARPOPHALANGEAL JOINT]
  • “Here too” [2nd METACARPOPHALANGEAL JOINT]
  • “Pain here” [FINGER]

 

Six weeks earlier a rheumatologist had diagnosed Marco with recurrence of polymyalgia rheumatica, with shoulder and small joint features, and with a possible component of new onset rheumatoid arthritis. Recurrent carpal tunnel syndrome was diagnosed in his right hand.

 

On the other pages Marco had drawn his hips, knees, and feet, and annotated their aches with cursive writing.

 

These bones it seems that they are coming apart. When I walk for about ¾ of an hour then it start to give pain. Swells up and gets quite hot. The knee.

 

Figure.2_Knee.Foot_BMJ

Figure 2. Annotated drawings of foot and knee:

  • “Pain here especially at night.” [KNEE]
  • “These bones it seems that they are comming (sic) apart. When I walk for about ¾ of an hour then it start (sic) to give pain. Swells up and gets quite hot. The knee.” [KNEE; TIBIOFIBULAR JOINT]
  • “Pain here last for days on both feet. Not all the time” [TALUS]

 

Marco was seen in the hospital’s Orthopaedic Clinic for severe osteoarthritis of his knees.

 

A carpenter, who still bent those knees to work, Marco explained that he once did a Fine Arts degree to support his business. Beyond that expertise, his careful handling of the autographed pictures revealed an artist.

 

The edge of one page cut through the word “foot” at “foo” which perhaps reflected Marco’s life.

 

Born during the Great Depression he was of the frugal generation – practical, resourceful, industrious. I wondered if Marco had ever rationed paper as a luxury, each sheet precious and saved for handsome cabinet designs.

 

Perhaps as an artist, unwilling to share flaws, he had cropped a larger page of sketches.

 

Figure.3_Hip.Foot_BMJ

Figure 3. Annotated drawings of right foot, pelvis and right lower limb:

  • “Both feet hurt at times” [FOOT]
  • “Pain in here sometimes not all the time” [HIP JOINTS BILATERALLY]
  • “Right leg. Pain here” [FEMORAL HEAD, TIBIAL PLATEAU]

 

I was enthralled.

 

Marco’s eyes danced like bubbles from the surface of Prosecco – the muted pleasure of artistic pride.

 

Already he had offered his pictures to me three times as a gift.

 

Yet I had declined as it seemed too generous. I thanked Marco and encouraged him to keep bringing the drawings to appointments given their clinical value.

 

I completed the history.

 

Marco’s main concerns were steroid-related weight gain, although his arthralgia had improved.

 

As he talked I noticed subdued hand gestures. Given his Italian heritage, perhaps Marco suffered a cultural version of locked-in syndrome from the pain that restricted his upper limbs.

 

After completing the physical examination, I liaised with my registrar about Marco’s clinical plan. In a makeshift gallery behind the consulting suites I showed his artworks to the rheumatologists.

 

They advised that I could keep the pictures, and to take photocopies for the medical record. I made an extra copy either for me or for his art portfolio.

 

I returned to the clinic room. Marco’s wife, who had been silent, was keen to hear the consultants’ opinions of his drawings.

 

She beamed on learning that they were unanimously said to be “the most beautiful ever seen in clinic”, and particularly enjoyed by the Head Professor of Rheumatology.

 

Again Marco offered his pictures and this time I accepted with delight.

 

Smiling, he received his own copies as I explained his treatment changes and follow-up plan. We shook hands. Those aching hands created beauty and conveyed exceptional insights.

 

I watched as he left with his wife and wondered about their lives, leaving Italy to bring their charisma to Melbourne.

 

Two days later I framed the drawings – an exquisite medical document and gift. They hang in my home and evoke Marco’s grace, eloquence, and vitality.

 

* * *

 

Acknowledgements and Postscript

 

Marco, a pseudonym, has consented to the release of his artworks for the purposes of this article. See Figures 1, 2, and 3. Sincere thanks to the patient for his generosity and insights.

 

Thanks to Dr Thomas Lawson Haskell BMBS for his excellent photography of the drawings.

 

Correspondence: Dr Nancy Louisa Gwen Merridew BA BSc MBBS DTMH

Basic Physician Trainee, Launceston General Hospital

PO Box 1328, Launceston, Tasmania, Australia 7250

Nancy.Merridew@gmail.com

The Reading Room: The Wellcome Book Prize

9 Mar, 15 | by cquigley

 

The shortlist for the Wellcome Book Prize was announced today (http://wellcomebookprize.org/)

Awarded annually, and open to works of fiction and nonfiction, the prize focuses on books that have some aspect of medicine, illness or health as their central theme.

This year’s shortlist includes the following six titles:

  • The Iceberg by Marion Coutts
  • Do No Harm by Henry Marsh
  • All My Puny Sorrows by Miriam Toews
  • Bodies of Light by Sarah Moss
  • The Incredible Unlikeliness of Being by Alice Roberts
  • My Age of Anxiety by Scott Stossel

The Reading Room has already featured reviews of The Iceberg (http://blogs.bmj.com/medical-humanities/2015/01/09/the-reading-room-a-review-of-marion-couttss-the-iceberg/) and Do No Harm (http://blogs.bmj.com/medical-humanities/2015/02/10/the-reading-room-a-review-of-henry-marshs-do-no-harm/)

Reviews of the remaining four shortlisted titles to follow, before the winner is announced on April 29!

The Reading Room: A review of Henry Marsh’s ‘Do No Harm’

10 Feb, 15 | by cquigley

 

Reviewed by Eoin Dinneen, Academic Clinical Fellow, University College London Hospital

 9781780225920

Do No Harm is a remarkably simple book. So much so, The Guardian (the book was short listed for The Guardian ‘First Book Award’) asks, ‘Why has no one ever written a book like this before?’ Each chapter’s starting point is a real life case. The clinical and extra-curricular vignettes recited allow the reader the privilege of being a fly-on-the-wall during moments of incredible personal and professional strain, sometimes during frank disaster, and occasionally during enormous relief and hilarity. In total, the book makes up a lean, unadorned, honest memoir of just some of the emotional thrills and surgical spills from a life spent in a busy tertiary neurosurgical unit. There is no twisting, confluent, fictional, engineered storyline because the quotidian of Marsh’s operating theatres, clinic rooms and foreign trips provides a surplus of heroes and heartache to sate the appetite of even the most demanding reader, publisher or dramaturge.

Do No Harm is beautifully written. Most impressively and intimately so when Marsh is describing what a living functioning brain actually looks like. Many doctors will have encountered cadaveric specimens as medical students, but their warm, electrochemically fizzing, ‘live’ predecessors evoke true wonder, especially when the reader (or the patient for that matter) is in the hands of Marsh and his remarkable familiarity, structurally at least, with our grey matter.

The illuminating passages detailing neurosurgery are intense and intensely bright. Time seems to slow with each passing pulsation nervously noticed. Marsh describes the clean and perfect cerebral anatomy; the glistening dark purple veins, the clear liquid crystal CSF, the flashing strands of arachnoid, the smooth yellow surface of the brain and the minute bright red blood vessels. Despite repeating modestly, both in the text and in promotional work around the book’s publication, that neurosurgery is but a simple matter of thuggish hole drilling and the such, this is brain surgery. Intricate, terrifying, compelling brain surgery. The minute topography of what lies inside the human skull under the meninges sparkles and moves almost as much for the reader as we feel it continues to sparkle and dance dangerously for Marsh. When Marsh was a student at the Royal Free Hospital, the doors to the neurosurgery theatres were closed to juniors. Now at St George’s Hospital, medical students are still not allowed into the neurosurgery clinic consultation rooms. Do No Harm briefly opens the door to the world of neurosurgery, doors traditionally closed to doctors let alone to patients.

If describing the anatomy of the brain should be considered ‘home turf’ for Marsh, what is even more remarkable is the profound illumination he pours on humanity when he turns his literary attentions to his patients as people, rather than brains. Cartesian duality complexly and complicitly underpins all the surgical stories, but on a simpler level the book is rich in revelatory illustrations of the doctor-patient relationship and of plain, complicated, sometimes nonsensical human behavior itself. As a surgical trainee myself, it has often vaguely agitated the foreground of my mind during busy days how few difficult questions prospective surgical patients ask prior to their surgery. Marsh notices this discrepancy also, but with characteristic flair and simplicity born of experience he highlights that, ‘as patients we are deeply reluctant to offend a surgeon who is about to operate on us.’

Also worth noting are Marsh’s musings on modern hospital care. When caring for his own dying mother in the family home, Marsh reflects on the difference between his mother’s death and that which is afforded the vast majority of dying patients who are ‘cared’ for in hospitals, care homes, nursing homes and palliative care centres. With trademark honesty Marsh points out that hospital workers are ‘caring professionals whose caring expressions (just like mine at work) will disappear off their faces as soon as they turn away, like the smiles of hotel receptionists.’ Marsh’s uncompromising frankness to tell it how it is makes for unsettling yet categorically undeniable reading for today’s healthcare professionals. Sadly, it may ring a bell for some of our patients too.

Amidst the achingly tense surgery and desperately sad patient case histories (so tragic that when Marsh met the producers of Holby City he dissuaded them from creating a central role for a neurosurgeon because his tales were so forlorn), there is much more to be taken from this book. Do No Harm, I suspect, will come to be seen in the future as a time capsule of the NHS of 2014. Though many of the patient and surgical anecdotes are picked from the many years of Marsh’s medical career, the book is predominantly written in the current day: the 21st century NHS with all its vaunted idealism, sheer enormity, HR directives, staff diversity, exasperating IT systems and senseless inefficiencies. Yes, the NHS we know, work in and die in. Marsh’s caustic commentary of the systemic incompetence and his grumbling subversive distrust of management will of course be familiar to many, but it is here much more cleverly penned than our daily flippant, flapping volleys.

On that note, though they provide the lightest and most sardonic moments in Do No Harm, Marsh’s thoughts on modern hospital management and individual managers is (with one notable exception involving the Chief Executive in Chapter 13) quite adversarial and sometimes pithy. Marsh is not unique in this respect; in fact his attitude again captures the prevailing mood amongst his Consultant colleagues nationwide. However, in the same way that Marsh tells us how he idolized and imitated his great bosses, we junior surgeons are highly likely to follow their lead in a similar apish process. It is not at all a surprise, therefore, when popping into the Doctors Mess, or passing even the most junior of doctors chatting in the corridor, to hear them complaining bitterly about managers they have had no real recourse to come into contact with yet. One feels that Marsh writes of his surgical mistakes in a genuine attempt to inform his successors so that such mistakes are not lost to a graveyard of long forgotten medical errors and repeated unwittingly. If the book is meant to be instructive in any respect for junior doctors, should there not also be some leadership on how to create harmonious interactions with hospital managers who are, lest we forget, our colleagues, and the people who run our hospitals and our healthcare system?

Do No Harm presents itself as a collection of parables, with Marsh himself cast in a panoply of roles, from the international surgeon superhero in Ukraine to the local friendly south London doc who cycles to work like the village vicar. He writes himself as a naughty schoolboy figure furtively struggling against the hospital establishment, and then challenges this by impatiently chastening a scruffy, insouciant junior doctor at the morning meeting like a schoolmaster from his days at Westminster College. Marsh represents an authoritative member of the modern medical milieu but also, movingly, puts himself on the ‘other side’ as a family carer.

Marsh does not dwell on religion or on God. He seems to intimate in a variety of ways that organized religion is not how he makes sense of the cosmos. After an ill-fated operation, which goes catastrophically wrong in the 18th hour of surgery, Marsh renders a young man paralyzed. When he breaks the terrible news to the waiting family, the patient’s mother beseeches Marsh to remember her now quadriplegic, mute son in his prayers. The neurosurgeon does not pray within the context of Do No Harm. Instead, a man of letters, of learning and of neuroscience, in this startlingly honest book about ‘Life, Death and Brain Surgery’, Marsh remembers his patients.

Do No Harm by Henry Marsh. London: Phoenix (an imprint of the Orion Publishing Group Ltd), 2014

The Reading Room: A review of ‘Performance, Madness and Psychiatry’

4 Feb, 15 | by cquigley

 

Performance, Madness and Psychiatry

Isolated Acts

Edited by Anna Harpin & Juliet Foster

 

Reviewed by Femi Oyebode

National Centre for Mental Health

25 Vincent Drive

Edgbaston, Birmingham B15 2FG

Femi_oyebode@msn.com

 

In the spring of 1836, John Clare (1793-1864) visited Peterborough and accompanied Mrs. Marsh, the bishop’s wife, to the theatre to see Merchant of Venice. At the beginning of the fourth act, Clare became restless. In the scene where Portia delivered judgment, Clare stood up and addressed the actor performing the part of Shylock: “You villain, you murderous villain”. Frederick Martin 1 wrote

“Great was the astonishment of all the good citizens of Peterborough…Such an utter breach of decorum was never heard of within the walls of the episcopal city. It was in vain that those nearest to Clare tried to keep him on his seat and induce him to be quiet; he kept shouting, louder than ever, and ended by making attempts to get upon the stage. At last, the performance had to be suspended, and Mrs. Marsh, after some difficulty, got away with her guest”.

Soon after that event Mr. Skrimshaw, a surgeon, saw Clare and declared “what, indeed, was obvious to all the persons in the house – that the poor poet was a lunatic”.

This book, edited by Harpin and Foster deals with many of the issues that are raised by the account above: What is the nature of mental illness? How do we come to recognize it? What is the right (morally right) stance to take in respect of it? In what way can theatrical (P)erformance be distinguished from (p)erformance in everyday life? And, so on. We can and do denote a theatrical space as a place designated for performance and this is not necessarily merely a building. In traditional society it might very well be a clearance in the forest first encircled by trees and then by a circle of people. The theatrical space in this arrangement is literally centre stage and the theatrical performance is encircled (What Elias Canetti terms “The Crowd as a Ring”) as it is in an arena. Think of the Roman Coliseum or the Grand Amphitheatre in Ephesus, or Congo Square in New Orleans. In contemporary European tradition, the stage is at an elevated focal point, usually at one end of an oblong building. Convention determines where the actors play and how the audience behaves and this is always being re-defined by playwrights. There is a sense in which the distinction between being a spectator or an audience is itself a commentary on the implicit rules governing what is expected in theatre. We go to see a play but sit in the auditorium as part of an audience whereas at a football stadium we are spectators. To return to John Clare, one could argue that in performing from the audience’s space, Clare was making of himself a spectacle and this breach in the usual conventions of behavior was a social signal that all was not well with him. In essence he had breached the implicit rules that governed how theatrical space is utilized.

Harpin and Foster write in the afterword to their wonderful book

“This is a book about madness, space and performance. In it we have paused over these three concepts and their interrelations in order to try to better understand the cultural politics and meanings of madness. The diverse, even clashing voices in the collection evidence how far this remains fiercely contested terrain”.

The remarkable achievement is that the editors, despite the extent of the contested and disputed territory, have managed to produce a text that sticks to task, that is thematically unified, except for the first chapter. Richard Stern in his chapter “Smart’s Authority and the Eighteenth-Century Mad-Business” focuses on Christopher Smart, a poet and Dr. William Battie who may have treated him. We are told that Smart was admitted to St. Luke’s where William Battie was Head Physician in May 1757 and discharged in May 1758. He was later admitted to Potter’s private madhouse in 1759 and discharged in 1763. He was arrested in April 1770 for debt and died n prison in May 1771. Stern’s approach is to examine the use of language in Smart’s poem Jubilate Agno and Battie’s A Treatise. There is practically no reference to the nature of theatre nor is there reference to the problematics of performing madness, of representing madness in language, or of the true dilemma of what one does when challenged by obvious anomalous experiences and behaviors that cause concern.

Stern writes

“I want to conclude this chapter by firstly celebrating Jubilate Agno as a poem. At the very least, it is a voice from the madhouse at a time when many other people in similar circumstances were silenced. The content of the poem challenges psychiatry to justify its terminology, its methods and the language that it is using. It represents the richness of felt experience and warns against a rigid determinism. It also shines a light on confinement as seen of the perspective of the confined, where there can be a sense of double-suffering, or of suffering played out again and again: suffering as mental disturbance, alienation, isolation, social death, and the suffering under the fact of confinement…”

This is all very well, but the superior tone of admonishment of an abstraction termed “psychiatry” does little to sketch out what Stern’s own contribution would be in a complex area that demands more than merely clever and righteous statements. John Perceval’s (1803-1876) A narrative of the treatment experienced by a gentleman during a state of mental derangement; designed to explain the causes and the nature of insanity deals comprehensively with the facts of confinement and makes a clearer, more directly eloquent and, fulsome case against unnecessary confinement. For a description of the subjective experience of severe delusions and hallucinations including a legal argument against incarceration Daniel Schreber’s (1842-1911) Memoirs of My Nervous Illness is unparalleled. And, if it is poetry written under conditions of incarceration that one seeks then John Clare’s poetry written whilst he was at Northampton Asylum or Ivor Gurney’s (1890-1937) poetry written whilst at the City of London Mental Hospital speak to the distress, the emotional turmoil and the desolate inner landscape that is mental illness.

Juliet Foster, in her chapter “Performance in Bethlem, Fulbourn and Brookwood Hospitals: a social psychological and social historical examination”, deals with theatrical performances in psychiatric hospitals. This is a reminder of what has been lost with the closure of Asylums. This is not to glorify asylums but rather to say that community care has not fulfilled all its promise and the idea that communities will embrace the mentally ill was just that, idealistic. The paradox is that there can be even more isolation and alienation in wider society than in asylums. Theatrical performances were only one of the variety of entertainments put on in asylums, dances were another popular form of entertainment. John Burnside’s poem “The Asylum Dance” and Patrick McGrath’s novel Asylum take the asylum dance as a centerpiece of asylum life. Foster concludes that

“Entertainment…is centred around the idea of providing a diversion or a distraction, or even a link in some way to the world outside of the asylum, and to everyday experiences and practices”.

It isn’t often that the literature on asylums recognizes and acknowledges the desire to do good, to alleviate suffering in the residents, and to harness the humanity of the staff in the service of their charges.

In the section titled “Applying Performance”, first Susan Cox in her chapter “Reflections on autonomy and ethics in research-based theatre and then Sarah Rudolph’s “Whose mind is it anyway?: Acting and mental illness” deal with the intricacies of ‘acting mad’ in theatre. There is here an assumption that theatre has an implicit educational if not moral purpose. Cox talks about

“When applied theatre is successful in opening us differently to experiences of mental illness…we may reflect from a new vantage point, on the implications of our own forms of engagement with mental illness, such as through understanding what it might be like to live with dementia…”

And,

“Challenges include the ethics of fictionalizing the real life experiences of research participants and the problems that can arise when participants and/or audiences over-identify with the physical or mental health conditions being performed, perhaps even becoming re-traumatized by a highly convincing theatrical performance”.

This view suggests that a special duty of care exists towards the audience when theatre tackles sensitive issues. This is on the face of it a thoughtful and caring position. But, it can also be read as assuming vulnerability in participants and audiences in special settings that inexorably results in self-censorship. The implication is that there are matters that are too sensitive to be enacted. Or, that there are particular enactments that will be more troubling than others. All audiences bring with them, into theatre, inner life of varying composition. Blanche Dubois in Streetcar Named Desire or the Tyrone family in Long Day’s Journey into Night depending on the sensitivities of the audience have the capacity to provoke disquiet in individuals who have been raped or whose parents have a strained marriage, etc. One could argue that the power of theatre resides precisely in this confluence between what is being played on stage and what is jostling for resolution in the mind of the audience. To make the point again and in a different way, I hope that a mobile library in a psychiatric hospital would have books of all kinds, not a list of the most supposedly innocuous texts so as to protect patients from troubling texts.

Rudolph’s chapter is a must read for anyone with an interest in the use of theatre in psychiatry. It examines the pitfalls as well as the triumphs of this area of work. It makes the point, that ought not to need making, that mental illness is not a metaphor, it is a real lived experience. Schizophrenia or dementia does not stand in for other matters, they are not symbols infused with meaning with the goal of speaking about a world in schism or a degenerate world, etc. And, mental distress is multifarious in presentation. The experiences are manifold. It may be true that ‘dramatic’ enactments in which florid gestures and violent outbursts occur are easier to comprehend but in fact life is more subtle, more nuanced, and hence representations that recognize that agony is best suggested than caricatured would ultimately be closer to the truth of mental illness.

The final section “Theatrical Maladies” is a tour de force. Bridget Escolme takes Ophelia and analyses different productions of Hamlet with a view to discovering the underlying motifs, the rationale for the varying portrayals. She traces “how different historical epochs have mapped their fears and wishes around children onto their fears and wishes around the ‘mad’…Questions of how ideas of insanity produce Ophelia and how Ophelia produces ideas about insanity…”. Hers is a feminist reading but her conclusion that there is a tradition of “calming and confining Ophelia and her representation” can just as easily be read as a fear of madness per se. Greek theatre kept mad actions from view and the Roman theatre only rendered visible the mad fool, innocent and funny, and thereby unthreatening for the audience. There is a way in which madness is hidden from view but it may be true as Escolme argues that madness is the more malignant, “embarrassing and disturbing” in a woman. Harpin’s final chapter “Dislocated: Metaphors of madness in British theatre” addresses the question of what it is, metaphorically, to be mad. This is quite distinct from using mental illness as a metaphor, a symbol for matters unconnected to it. It is examining what it is like, metaphorically, to be mad. This understanding is important because it gives a handle on the experience and allows it to be accurately represented in art. Harpin starts by saying that in relation to madness

“First, there is the recurrent sense of journeying that attends on madness. Secondly, the dominant notion of place renders ‘mad’ experience an inherently geographical encounter. Madness, then, is figured as a location, as site…To be mad is to be…displaced, dislocated, gone”.

She goes on

“Juliet LH Foster’s study of mental health service-users’ representations of their experiences argues that mental illness frequently figures as a place (woods, clouds, traps, prisons, abyss, pit) or journey (mountain, tightrope, maze, tunnel)”.

The challenge then is how to embody the metaphor, how to concretize what is beyond language, that which is unspeakable. That, after all, is what drama is.

To return to John Clare, his performance at the theatre during the production of Merchant of Venice signaled a dislocation within. And, this dislocation was made visible in his speaking from the auditorium to the actors on stage. Theatrical representation of madness could learn from this event, that speaking from the ‘wrong’ place is a possible expression of madness. And, this might involve shifting the balance of where the audience is in relation to the stage and emphasize that the person sitting next to you in theatre, that is your neighbor, like you is liable to emotional turmoil.

I will leave the last word to Anna Harpin

“Plays locate madness precisely along a spectrum of human experiences without ever flattening out the particularity of the encounter…dramatists encourage a political reflection on the nature and boundaries of ‘health’ and ‘illness’.

 

References

  1. Martin, Frederick (1865) The Life of John Clare. Gutenberg Ebook no B470 [http://eBooks.Gutenberg.us/Gutenberg/eBooks05/77jclr10.zip and http://eBooks.Gutenberg.us/Gutenberg/eBooks05/8jclr10.zip]

 

The Man in Bed Five by Jack Garnham

28 Jan, 15 | by BMJ

I go to see the man in bed five.

 

He winks at me. Cracked lips separate to reveal an imperfect set of yellow teeth as a wry smile spreads slowly across his face. It comes with an enormous effort. He looks worse; the burden of disease seems to weigh heavier with each passing hour. Sickness has slowly reshaped him, like an obsessive sculptor continually revising his creation. His wife fiddles nervously with her plain wedding band; I feel his decline, but for her each step in the inexorable march of his illness is devastation. She looks at me, and in her eyes I see a deep love and a profound fear. They have been married for forty years. He tells me about his two children. He loves them. His daughter lives in Australia. He has a dog that he takes for walks on the common. He waves a frail arm towards the trees outside the window and tells me that he is looking forward to going home. In our short time together he has granted me open access to his private world, to the countless unique experiences that conspire to create an individual. I will miss him when he is gone, the man in bed five.

 

This once vibrant character is dulled by his sterile surroundings: the bland hospital gown robs him of his humanity; the peeling walls and filthy windows drain him; plastic tubes run into and out of his body. For a moment the hospital is a colossal parasite, nourished by this wasted figure; it breathes in around me and exhales a fetid breath, content at having shelled the man in bed five.

 

I am protected. My fraying badge and cheap stethoscope defend me. The flimsy chart I hold is my shield. I am part of the profession, this most noble profession, and to hurt is weakness, to feel is fragility. He is his disease; he is a hospital number, a set of laboratory results, a trace on a machine, a faint bleep heard from the nursing station. To watch him break I must stand on the other side of the glass. I bid a clinical farewell to the peculiar collection of observations that was once the man in bed five.

 

One day the faint bleep fades. The rush of clinical medicine devours the mourning period; a different set of observations arrives to occupy the bed, and there are pressing results to chase and urgent investigations to order. He remains in my mind as the hours pass. Is it appropriate to grieve? Would it be easier to succumb to indifference? These were the questions asked of me by the man in bed five. Can you balance compassion with detachment? Can you manage the intolerable pain of regular loss? Can you walk the fine line? I bury these thoughts and continue to work.

 

As finals draw closer I find myself more frequently troubled by these questions.

 

I still have no answers.

 

Correspondence: Jack Garnham, Imperial College, London (jack.garnham09@imperial.ac.uk)

The Reading Room: A review of ‘Jo Spence, The Final Project’

23 Jan, 15 | by cquigley

 

Reviewed by Steven Kenny

 

 cover

Jo Spence, The Final Project, 1991–92. © The Estate of Jo Spence. Courtesy Richard Saltoun Gallery, London.

 

Jo Spence was a pioneering figure within the realms of photographic discourse, image based political activism and the application of photography as a therapeutic tool. From the early 1970s Spence worked within photographic collaborative modes, first with Terry Dennett to form the Photography Workshop Ltd and later co-establishing the Hackey Flashers and Polysnappers. Spence’s later works turned inwards, directing the gaze towards the body, and specifically her ill/diseased body, and her battles with breast cancer. Such works became charged with a context of survival and transgression, this photography ‘a response to her treatment by the medical establishment and her attempt to navigate its authority through alternative therapies’ (Vasey, s.d).

 

The Final Project is the last documentation of Jo Spence’s work. A book of eerie beauty and macabre investigation, The Final Project stands as the artist’s last photographic output before her death as a result of leukaemia in 1992. The resultant images stand as a testament of confrontation, expectation and spiritual transcendence. Within the book’s inside flap a small quote from Spence provokes thought, ‘“How do you make leukaemia visible? Well, how do you? It’s an impossibility”’. This quote particularly hit home as my uncle also died as a result of leukaemia. At the time I did not understand the condition, only hurt by its ramifications, never truly knowing its pathological effects nor its ability to conceptually redefine the body as sick and the other. The Final Project is a particularly significant book as it highlights the importance of representing the ill body, one that is affected by the invisible and the hidden. Spence’s work depicts a process of struggle, humour and later acceptance during her illness experience.

 

At the end of her career, Spence became too unwell to travel and work. However, the limitations imposed by physical frailty did not stop her determined and strong work ethic. During this time, Spence trawled through her vast photographic archive to create further visual documents from those that make reference to mystic realism. Her output became imbued with the anticipation of death, and as a result the imagery decoded visual artefacts of the iconography of the dead through the layering of two slides, one on top of the other. These objects, once photographed, became talismans of spiritual power, and as Louisa Lee (2013:11) comments, ‘allegorical props for representation’. The skull features consistently throughout The Final Project; in one photograph it engulfs the frame, in another the skull is depicted as a mask to be worn (see front cover above), and in others it appears to be used as an object to physically represent the artist’s presence. The skull is now a contemporary icon, a product of fascination that can be seen across various artistic forms and cultural practices. Her archive takes on its own being, and as a result comes to physically stand in for the artist; her visual history creating new histories that can be once again archived. The photographic montage can thus be seen within the book as a form of catharsis, the constructed image an item of therapeutic power with the ability to define new identities.

Pg-84

Jo Spence, The Final Project, 1991–92. © The Estate of Jo Spence. Courtesy Richard Saltoun Gallery, London.

 

On examining the work throughout the book, one might conclude that such images may be associated with Sigmund Freud’s theory on the death drive, which explored the apparent conflict between not having knowledge of our inevitable experience of death, and the resurgent repetition of unconscious exploration into gaining such insight. As suggested by the author Maria Walsh (2012), ‘Art can be tied to either of these strands, depending on whether an artwork is on the side of binding the chaotic force of the death drive or repeating its disruptive impulses’. Spence’s work within this series seems to lie preciously between the two, with such works seen as a taming or normalisation of death from acceptance of its iconography, yet becoming entangled within a mode of repetition as images are repeated and spliced with others to form new variations. It must be stressed, however, that such work is not at all chaotic, but is instead peaceful, dreamlike and calmly ambivalent. Thus it becomes difficult to categorise Spence’s final work, also true for her entire lifetime output, which confidently straddles various modes of representation and classification. The work is enigmatic, a photographic force in representing the invisible and redefining the ill body in transgression.

Humour has served as an important emotional device throughout Spence’s career and artistic work, and again is of great importance within The Final Project. Melancholy juxtaposed with laughter creates a darkly humoured conflict, the work’s methodology resembling the artist’s perseverance in contrast to her deteriorating health. Humour is utilised as a concept not only to promote positivism, but also to punctuate the isolation caused by disease. The skull as motif is disseminated as a cryptic symbol of both death itself and of its subsequent control over it. Spence does not trivialise death but instead attempts to seek some comfort and emotional release from its seriousness. As Sheri Klein (2007) suggests, ‘The intent of humour is to overcome the tragic impulse so that life is bearable’. Spence does not give up, nor does she stop creating. Instead, the artist utilises photography as a method to pictorially represent her own transition. The work serves as a form of therapy, much in the same manner as her previous phototherapy work represented her battle with breast cancer. One element has importantly changed, however. Spence now begins to absent herself from the frame, and instead presents her physical self through her previous constructed representations — a body not yet affected by the disease, a historical body that can be manipulated and freely controlled.

How do we come to terms with death? Perhaps more importantly, can we ever come to terms with our own limited physicality? I believe that these are deeply subjective, complex and quite probably impossible questions to answer, but as Klein (2007) suggests ‘Humour from art, as experienced through smiling and laughing, can be a catalyst for personal and collective healing, wellbeing and improved psychological health’. From reviewing the work of Spence, one could conclude that laughter and the ability to poke fun at death might be more therapeutic than resorting to a grief state that solely focuses on inexorable loss.

GRAVEYARDSESSION

Jo Spence, The Final Project, 1991–92. © The Estate of Jo Spence. Courtesy Richard Saltoun Gallery, London.

 

 

Lee, Louisa (ed.) (2013) Jo Spence: The Final Project. London: Ridinghouse.

 

References

Klein, Sheri (2007) Art and Laughter [Scribd Edition] From: www.scribd.com (Accessed on 13.01.15)

Vasey, George (s.d) Jo Spence – Biography. At: http://www.jospence.org/biography (Accessed on 13.01.15)

 Walsh, Maria (2012) Art and Psychoanalysis [Scribd Edition] From: www.scribd.com (Accessed on 13.01.15)

Physicians and Magicians: A Magical Education in Life, Death, Power, Potions and Defence Against the Dark Arts by Fiona Dogan and Mark Harper

20 Jan, 15 | by BMJ

Abstract

The worlds of magic and medicine both involve the sudden initiation of an intimate relationship between two complete strangers – the magician and their subject, or the doctor and their patient. Magic requires the subject to have some degree of trust in the magician, to accept that props and setting may be required to aid the illusion, and to witness such a high degree of skill that belief in the magician’s ability is sustained once the trick is complete. In the medical setting trust and confidentiality, the use of medical equipment, and the expertise and competence of the doctor are but a few essential components of a successful interaction. This is not to imply that the art of medicine is a trick, but rather a complex set of circumstances that can be engineered to promote the best possible outcome for both the doctor and the patient – or the magician and their audience.

The concepts of magic in the Harry Potter series can be used as examples to study issues that medicine raises in our own society. By focusing particularly on The Order of the Phoenix, The Half-Blood Prince and The Deathly Hallows, it is possible to compare the learning processes for both young magicians and medical students that are considered necessary to prepare them for life in their profession. Within the books there are interesting issues regarding perspectives of professional knowledge and power, with diverse examples of socio-economic status informing the treatment of certain groups by others. The psychology of the misuse of power by those in positions of authority and professionals acting under duress provide a measure of insight into the actions of doctors under a totalitarian regime. Finally the ethics of using science and magic are debated throughout the series, and provide valuable material for discussion of moral issues that can be translated directly to medicine.

Physicians and Magicians: A Magical Education for Physicians in Life, Death, Power, Potions and Defence Against the Dark Arts 

Education

There is a clear comparison between magic and medicine in the structure of training which can be classified into three, occasionally overlapping, areas which broadly equate to the classic educational paradigm of knowledge, skills and attitudes.

Right from the very beginning (we are excluding Owl Post although that may be equated to the acceptance letter) the similarities are striking. The young, aspirant magician’s trip to Diagon Alley, to buy a pile of books they don’t understand and a wand they don’t know how to use, equates to the medical student’s first visit to the University bookshop and purchase of stethoscope and other medical equipment. A cat, rat or owl would make a more interesting and interactive companion than a skeleton – if somewhat less relevant to medical studies. Here we see the first inklings of a professional attitude, in that both sets of students begin to take on the accoutrements that distinguish them from the non-medical or Muggle population.

There are also many similarities in the education process. Hogwarts requires seven years compulsory teaching, with the witches and wizards “coming of age” the year before they qualify. This provides a greater degree of freedom for them to practice their magic and hone their skills in the Muggle world, unprotected by the castle’s enchantments and restrictions on underage magic. Similarly doctors in the UK qualify after five years but have a further two years as junior doctors, gaining more responsibility during their sixth and seventh years.

Furthermore, both educations consist of a combination knowledge acquisition through book learning and skills through an apprenticeship. There is also a degree of crossover in the subjects studied: Potions and pharmacology, Arithmancy and chemistry, and Muggle Studies and communication skills.

There are even parallels in the same work hard, play hard ethic. Hours are long, learning goes on late into the night and copious quantities of beer are consumed – though there may be some suspicion that Butterbeer is not as potent as real ale.

Right from the beginning, both sets of students are externally regulated by either the General Medical Council (GMC) or the Ministry of Magic (MoM). As well as overseeing competencies these bodies define and regulate the appropriate attitudes through the ‘fitness to practice’ committee and, as Harry discovers more than once in the series, the Improper Use of Magic Department. Furthermore they effectively create a closed-shop which cannot be breached by the non-professional. (1,2)

However, whereas the GMC and the medical profession seem to be striving towards an ever more open and inclusive approach to the delivery of medicine, it could be argued that the MoM is rigidly sticking to a more archaic, paternalistic model. Muggles do not possess magic, and are generally not permitted to even know that wizards and witches exist. If mistakes are made and members of the Muggle population do become unintentionally aware of magic, it is acceptable to have memory charms performed on them without their knowledge or consent. This is demonstrated throughout the books, from the murders committed by Peter Pettigrew on the night of Voldemort’s destruction to the treatment of the Roberts’ family at the Quidditch World Cup in the Goblet of Fire. In The Deathly Hallows Hermione decides that the best course of action for her parents is to modify their memories, in order to make them forget they have a daughter and feel a sudden desire to leave the country. As she possesses the knowledge and skill to perform such a spell, she does this herself without consulting her parents or any of her fellow magicians. (3–5)

Much as one might, at times, wish to remove a patient’s memory of an interaction -ethics aside – conventional (i.e. non-magical) medicine still only has the power to induce prospective amnesia, and even then on an imperfect basis. (6) Additionally, research has shown that better outcomes are associated with patients understanding their illness and being involved in decisions about their treatment so maybe a shift towards a more informative and holistic partnership between patients, doctors, magicians and Muggles can only be a good thing. (7,8)

 

Power in life…

It’s not only actions that have consequences but attitudes too, particularly when it comes to wielding the kind of power possessed by physicians and magicians. The “use-or-not” of power is both a central theme of the Harry Potter books and an important consideration in terms of the doctor as magician.

The magical world is hidden from Muggles, as Hagrid explains to Harry at the very beginning of The Philosophers Stone, because people would want magical solutions to all their problems if they knew it was available. (9) His point is reinforced in The Half-Blood Prince during a conversation between the Muggle Prime Minister, the ex-Minister for Magic Cornelius Fudge and his replacement Rufus Scrimgeour:

‘The Prime Minister gazed hopelessly at the pair of them for a moment, then the words he had fought to suppress all evening burst from him at last.
“But for heaven’s sake — you’re wizards! You can do magic! Surely you can sort out — well — anything!”
Scrimgeour turned slowly on the spot and exchanged an incredulous look with Fudge, who really did manage a smile this time as he said kindly, “The trouble is, the other side can do magic too, Prime Minister.”’ (10)

This is useful in exploring the expectations some people – and some doctors – have about the power of medicine. In the past the physician was more like the magician, albeit one who used sleight of hand rather than real magic, creating power through obfuscation in a veneer of classicised language and instruments, such as the stethoscope, that put space between them and the patient. Interestingly, as their real powers have grown, the façade has come down to a large extent and patients can have much greater knowledge of their conditions and of the ‘spells’ possessed by the doctor.

Nonetheless, expectations have simultaneously risen and it often seems that patients think doctors should be able to do magic. Maybe it would help to show them how “the other side” also has “magic”; whether it is the ability of the virus to mutate to escape drugs and detection, or the cancer to hide in the patient’s own cells (DNA even) to evade chemotherapeutic spells and radiation wands, only to re-emerge like Voldemort from his Horcruxes. There is still no “Magic Bullet” to specifically target every disease process. (11–14)

The exchange above also illustrates how the patient can be affected by the amount of power they feel they have over their condition. As he feels he is losing control of the situation, the Muggle Prime Minister cannot contain himself any longer, and his words are redolent of patients and their relatives in the face of a poor prognosis. (15)

The Dursleys are Harry’s Muggle family from his mother’s side. Despite being among the few Muggles who know about magic, they choose to ignore it for as long as is possible because they see magicians as troublemakers and a source of embarrassment. They pretend that Harry is mentally unstable rather than admit to him being a wizard. It is only in The Order Of The Phoenix when…

“The arrival of Dementors in Little Whinging seemed to have breached the great, invisible wall that divided the relentlessly non-magical world of Privet Drive and the world beyond.”

…they see the possible impact of magic on their own lives, and they begin to ask for Harry’s advice and guidance.

There are patients who have an analogous distrust of doctors, to the extent that they will leave conditions far longer than they should in order to avoid confronting the medical world. The Dursleys represent this group and demonstrate how people can have deep-seated and rationalised (though not necessarily rational) views. The Dursleys are, therefore, useful characters to consider when dealing with patients can be very afraid of a condition that they do not fully understand. (2)

 

… and power over death

The biggest ethical dilemma raised in Harry Potter books relates to the death of Albus Dumbledore in The Half-Blood Prince. After putting on a cursed ring by mistake Dumbledore asks Severus Snape for help. Snape uses a potion to trap the curse in Dumbledore’s right arm temporarily, although they both know he will still be dead within the year. Dumbledore then asks Snape to kill him when the time comes, as this will prevent him suffering for longer than necessary whilst also solidifying Snape’s position with Lord Voldemort in his double agent role.

This situation is analogous to palliative treatment and physician-assisted death. As Snape delivers the final blow himself rather than provide the means for Dumbledore to take his own life, and Dumbledore is conscious up until the Avada Kedavra killing curse hits him, it would most likely fall under the category of voluntary active euthanasia. (5,10)

The first issue this series of events raises is that of the ethical dilemma that surrounds the boundary between a duty of care and actively shortening a patient’s life. Snape finally agrees to undertake this task ‘for the greater good’- to protect his double agent identity and therefore help assure the safety of the students at Hogwarts.

In medicine the death of a terminally ill person in order to benefit the life of another is one of the core issues when discussing the legalisation of euthanasia. Setting aside the moral issues, benefit may be derived from both the individual, in terms of reduced suffering, and the collective, through the reduced drain of limited resources. However, this must be set against the need to protect elderly and vulnerable people, and provide optimum medical care. (16)

The second issue this event raises is the emotional effect on the doctor or magician who delivers the final, fatal blow. We see Snape hesitate before killing Dumbledore and, even though at this stage he is portrayed as Voldemort’s henchman, we can feel his reluctance. This is despite the fact that he is acting on a well thought-out and considered advance directive. As Dumbledore explains in The Deathly Hallows:

“I ask this one, great favour of you, Severus, because death is coming for me… I confess I should prefer it to be a quick, painless exit to the protracted and messy affair it will be…”

Nonetheless, Snape fears for the consequences to himself:

‘“That boy’s soul is not yet so damaged,” said Dumbledore. “I would not have it ripped apart on my account.”

“And my soul, Dumbledore? Mine?”

“You alone know whether it will harm your soul to help an old man avoid pain and humiliation,” said Dumbledore.’ (5)

This illustrates a common argument against euthanasia, regarding the psychological burden that could be felt by the enabling physician. This has been a subject of specialist research for many years, involving doctors who work in clinics such as Dignitas in Switzerland and those who are required to administer lethal injections to criminals in the United States. (17)

Part of the problem is that Snape is, necessarily, acting alone. It would be much easier if he had advice, support and objectivity from others. It therefore underlines the need in medicine for a multidisciplinary approach to these situations. (18)

The description of the last moments before Snape kills Dumbledore bring up two further issues. The first is the effect on the peripheral characters: in the medical context, the relatives; in this context, Harry, who is shocked and frightened by the unfolding events.

‘“Severus…”

The sound frightened Harry beyond anything he had experienced all evening. For the first time, Dumbledore was pleading.’

It is not until The Deathly Hallows that it becomes apparent Snape was acting on Dumbledore’s wishes. At this point it seems that the old wizard is begging for his life to be spared.

‘…Snape gazed for a moment at Dumbledore, and there was revulsion and hatred etched in the harsh lines of his face.

“Severus… please…”

Snape raised his wand and pointed it directly at Dumbledore.

“Avada Kedavra!”’

But furthermore, it is impossible to tell whether Dumbledore had actually changed his mind at the last minute and was, as it seemed to Harry, pleading for his life. And this is something that needs to be considered with medical euthanasia, particularly in patients with degenerative diseases that may compromise their ability to communicate or comprehend over time. These decisions are often made a long way in advance, and it can sometimes prove very difficult to be sure that their wishes have not changed. (10,19)

 

Defence against the Dark Arts

The steady implementation of the totalitarian state in the second half of the Harry Potter series closely mirrors the rise of Nazism in Germany prior to the Second World War. The persecution of the Jews and the Muggle-borns, Neville Chamberlain’s appeasement policy and Cornelius Fudge’s feverish denial, and the use of propaganda by Voldemort and the Death Eaters are but a few similarities. The actions performed by different magicians under this regime is an interesting study in psychological terms, and provides some insight into the behaviour of professionals such as doctors during wartime and under duress. (20)

Under the rule of Hitler it was deemed necessary for doctors to experiment on classes of people who were considered ‘lesser beings,’ in order to further knowledge and discoveries in the field of medicine. This began with the psychological dehumanisation of the Jews and other ‘undesirables’ through smear campaigns, blaming them for the defeat of Germany in 1918 and the subsequent economic depression. Through the use of careful and steady propaganda it seemed like an almost natural progression for the Jews to eventually be segregated and placed on a registry system. Some doctors chose to accept the idea of the “Jewish plague” and took pride in providing what they believed to be a valuable service to Germany and scientific advancement, whilst other doctors performed their duties under duress to avoid being killed themselves. It became commonplace for those within the medical profession to control, torture and kill Jews, homosexuals, the disabled and many others as part of their day’s work, and to record the results of the various experiments performed. (21)

In Harry’s world there are certain witches and wizards who can be used to represent the actions of different medical professionals under the oppressive regime in Nazi Germany. Firstly interesting parallels can be drawn between Hitler’s “Angel of Death” Dr. Josef Mengele, and the Head of the Muggle-Born Registration Committee Dolores Umbridge. Mengele had a background in genetics and twin studies in particular, and revelled in the fact that Hitler’s regime allowed him to further his studies through experimentation in a way that would not have been possible previously. Similarly Umbridge is vociferous regarding the offensive nature of half-breeds and later Muggle-borns, and seems unperturbed who is in charge as long as she is able to increase her power and her freedom to use it. It later comes to light that she abused her position or power as early as the beginning of The Order of the Phoenix, when she illegally sent Dementors after Harry to try and silence him regarding Lord Voldemort’s return. She was initially appointed by the Ministry as the Defence Against the Dark Arts teacher at Hogwarts in order to keep a closer eye on Harry and Dumbledore, but rapidly progressed up the ranks due to her dedication and ruthless personality. Whilst not in league with Voldemort himself, she certainly upheld his ideals and, similar to Mengele in Germany, seemed to delight in using the political situation to her advantage to achieve her aims. (2,21)

Alecto and Amycus Carrow represent the Nazi doctors who truly believed in their leader’s vision and would do everything in their power to assist in its’ realisation. They differ slightly from the type of doctor portrayed by Umbridge, as they believed in Voldemort’s particular ideals rather than his general approach. The Carrows excelled under Voldemort’s rule during the Second Wizarding War, and revelled at the chance to freely use the previously illegal Unforgiveable Curses: Imperio (control), Cruciatus (torture) and Avada Kedavra (death) – the same methods used on the “undesirables” by the Nazis during the Second World War. Harry is depicted on posters and referred to by the Ministry as ‘Undesirable No.1’.

Professor Snape’s true loyalties are in question up until his dying moments at the end of The Deathly Hallows, where it is revealed that he had indeed been trying to protect Harry all along. Working as a double agent for Dumbledore, he made the difficult decision to continue to work for Voldemort in the hope that he could exert some control over the Carrows’ punishments inflicted upon the students they were in charge of. This has previously been the case with doctors who speak out after working under duress, in an attempt to limit suffering as much as they can in a difficult situation. (5)

The character of Voldemort himself raises important issues regarding the psychology of a dictator. Voldemort used great acts of evil to split his soul into 7 pieces (Horcruxes) to attempt to gain immortality and power. The concept of ‘doubling’ describes how a person is able to commit acts previously abhorrent to them, as they simply ‘switch off’ their other side. This has been offered as an explanation why people, such as Nazi doctors, were able to torture and kill ‘undesirables’ on a regular basis. (10,21)

Conclusion

Throughout the Harry Potter books there are many comparisons that can be drawn between the magical and the medical world. The similarities and differences that have been highlighted give us an original way of looking into important issues concerning the medical profession, and the magician-Muggle relationship raises interesting points regarding the doctor-patient interaction. Ultimately it leaves one wondering whether we as physicians try too hard to be magicians? Or is it that patients actually want us to be magicians? As always, the reality probably lies somewhere between the two extremes.

 

References

  1. General Medical Council L. Tomorrow’s doctors: Recommendations on undergraduate medical education. 2009.
  2. Rowling J. Harry Potter and the Order of the Phoenix. 1st ed. Bloomsbury; 2003.
  3. Rowling J. Harry Potter and the Prisoner of Azkaban. 1st ed. Bloomsbury; 1999.
  4. Rowling J. Harry Potter and the Goblet of Fire. 1st ed. Bloomsbury; 2000.
  5. Rowling J. Harry Potter and the Deathly Hallows. 1st ed. Bloomsbury; 2007.
  6. Twersky RS, Hartung J, Berger BJ, McClain J, Beaton C. Midazolam enhances anterograde but not retrograde amnesia in pediatric patients. Anesthesiology. 1993 Jan;78(1):51–5.
  7. Coulter A. Paternalism or partnership? BMJ. 1999 Sep 18;319(7212):719–20.
  8. Bond C, Blenkinsopp A, Raynor DK. Prescribing and partnership with patients. Br J Clin Pharmacol. 2012;74(4):581–8.
  9. Rowling J. Harry Potter and the Philosopher’s Stone. 1st ed. Bloomsbury; 1997.
  10. Rowling J. Harry Potter and the Half-Blood Prince. 1st ed. Bloomsbury; 2005.
  11. Williams S, Weinman J, Dale J, Newman S. Patient expectations: What do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction? Fam Pract. 1995 Jan 6;12(2):193–201.
  12. Kenten C, Bowling A, Lambert N, Howe A, Rowe G. A study of patient expectations in a Norfolk general practice. Health Expect. 2010;13(3):273–84.
  13. Illich I. Limits to Medicine: Medical Nemesis – The Expropriation of Health. Marian Boyars; 1976.
  14. Strebhardt K, Ullrich A. Paul Ehrlich’s magic bullet concept: 100 years of progress. Nat Rev Cancer. 2008 Jun;8(6):473–80.
  15. Lupton D. Medicine as Culture: Illness, Disease and the Body. SAGE; 2012. 79-136 p.
  16. Harris D, Richard B, Khanna P. Assisted dying: the ongoing debate. Postgrad Med J. 2006 Aug;82(970):479–82.
  17. Stevens KR Jr. Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians. Issues Law Med. 2006;21(3):187–200.
  18. Seale C. Legalisation of euthanasia or physician-assisted suicide: survey of doctors’ attitudes. Palliat Med. 2009 Jan 4;23(3):205–12.
  19. Hotopf M, Lee W, Price A. Assisted suicide: why psychiatrists should engage in the debate. Br J Psychiatry. 2011 Jan 2;198(2):83–4.
  20. Curthoys A. Harry Potter and historical consciousness: Reflections on history and fiction. Hist Aust. 2011 Apr 13;8(1):7–22.
  21. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books; 2000.

Author contact details:

1. Fiona N Dogan, 5th year BM BS student, Brighton and Sussex Medical School

f.dogan1@uni.bsms.ac.uk

2. Dr C Mark Harper BSc MBBS FRCA, Consultant Anaesthetist, Brighton and Sussex University Hospitals
mark.harper@doctors.org.uk

The Reading Room: A review of Katrina Bramstedt’s ‘Trapped in my own labyrinth: poetry spawned by vertigo’

16 Jan, 15 | by cquigley

 

Reviewed by Giskin Day, Senior Teaching Fellow, Imperial College London

 

Many people, including me until I read Katrina Bramstedt’s book, mistakenly use ‘vertigo’ to describe a fear of heights. The correct term for this is ‘acrophobia’. Vertigo is a serious and disabling symptom of a constellation of inner-ear disorders that describes a disorientating, spinning sensation, often accompanied by nausea.

Trapped in my own labyrinth: poetry spawned by vertigo is a collection of 50 or so verses divided into two parts, ‘Illness’ and ‘Recovery’. In the preface, Bramstedt explains that the poems were written as a form of personal therapy but also ‘to show others, especially the otolaryngology profession, a glimpse of the suffering of a patient with vestibular dysfunction’. If this sounds like someone who knows their nystagmus from their neuritis, it is because the author is a clinical ethicist with extensive experience of dealing with matters medical.

As a description of symptoms, the short poems are very effective. They describe difficulties in sleeping (‘I’d like to turn over / But my vertigo won’t let me’: p.18). Chronic nausea caused a complete lack of appetite, described in the poem ‘Straws’ (‘I am like the straws that feed me / Each arm, thin as a straw / Each calf, thin as a straw’: p.20). As successful medications are tried, the side-effects are also catalogued in verse.

In the recovery section, Bramstedt tells the story of flying to Italy (a daunting prospect for someone exquisitely sensitive to motion sickness) and being treated by the Semont manouver, a vigorous manipulation of the head which causes crystals in the ear to move to an area of the inner ear where they no longer cause vertigo. Happily, the treatment is a complete success.

I’m sure Bramstedt would be the first to acknowledge that the poems won’t be taking up the time of poetry prize judges anytime soon. They are ‘forensic’ rather than lyrical, their meanings explicit rather than being freighted with nuance. Few lines consist of more than five words. Metaphors are used sparingly in the text, although the well-chosen photographs do serve as visual metaphors very effectively, e.g. a poem called ‘Dr. Pecci’ describing the hope of a cure he proffers, is nicely illustrated by a photograph of a life belt.

For medical humanities teachers and researchers, however, the book might benefit from a bit more contextual commentary about the process of writing for therapy, especially in the midst of suffering. The ‘resources’ section at the end of the book gives just three organisations associated with vertigo, so there is room for development there. The poems cannot withstand removing them from the context of the whole story: they need to be read as a sequence.

Some books are eminently suited to e-publishing and Katrina Bramstedt’s book is definitely one of them. Its availability as an e-book makes it much more likely to reach its niche audience. The photographs and poems are nicely laid out for a tablet screen.

This book does exactly what it says on the tin: it gives those experiencing or attempting to treat vertigo an insight into the subjective experience of living with the condition.

 

Bramstedt KA.  Trapped in my own labyrinth: poetry spawned by vertigo (revised edition). Gold Coast, Australia: Salvataggio Press 2014. Available from https://itunes.apple.com/us/book/trapped-in-my-own-labyrinth/id928994688?mt=11

 

Tiger Country (Hampstead Theatre): A Review by Aneka Popat

13 Jan, 15 | by Deborah Bowman

 

 

For some, the workplace is synonymous with shiny desks, immaculate windows and a calm open sea of computers, complete with the reassuring hubbub of Monday morning gossip. Yet, for those that work in the capital’s hospitals, the workplace is a jungle where the gleam of a scalpel and the unforgiving glare of ward lighting mark the territory. We are in Tiger Country, a world where instinct stirs and we flirt with fate.

 

Nina Raine’s Tiger Country is a thrilling drama about professionalism, prejudice, romance, ambition and failure in an overburdened health service. It is far from the hyperbolic depictions of television soaps. It is frank and honest, exploring not only the daily challenges of a busy London hospital, but also the impact on the individual of being there both literally and metaphorically.

 

The emotional core of the play is with two ambitious female doctors, at different stages of their training, but each determined to succeed. Emily (Ruth Everett), a junior doctor, represents Tiger Country’s young blood. Though rigorous and thorough in all she does, we see her vulnerabilities as she attempts to juggle her professional identity and her relationship with medic boyfriend James (Luke Thompson). In contrast, Vashti (Indira Verma), the single and driven urology registrar rediscovers the identity that was increasingly obscured behind the surgical mask.

 

Raine seamlessly integrates medic ‘slang’, and inside jokes in her docu-play and avoids caricatures. The 14-strong cast creates a working hospital in all its diversity and detail. The squeaky wheels of hospital beds, the disposable coffee cup beside the computer station and the power walks of staff contribute to a stylistically sensitive set. The audience sits either side of the stage and is immersed in the frantic hospital environment. Fergus O’Hare deserves a special commendation for his sound design with Bollywood numbers sitting alongside the melodies of Nitin Sawhney.

 

Tiger Country is a sharp and quick-witted play about hospital culture. It offers more than a view of hospitals and the NHS. The piece is an intelligent examination of the human cost and achievements of medicine.

 

Tiger Country is at Hampstead Theatre until 17th January: http://www.hampsteadtheatre.com/whats-on/2014/tiger-country/

 

Aneka Popat, 4th Year Medical Student

St George’s, University of London

m1000780@sgul.ac.uk

 

 

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