Bioethics and Medical Issues in Literature

UC Berkeley

Perspectives in Medical Humanities

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Stripling, Mahala Yates

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2013-08-22

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Bioethics and Medical Issues

in Literature

Mahala Yates Stripling, PhD

First published in 2013

by University of California Medical Humanities Press

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Bioethics and Medical Issues in Literature, by Mahala Yates Stripling, was originally published in hard cover by

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Contents

Preface vii

Chronology of Events in Literature, Medicine, and

Science ix

1. Technology’s Creature: An Analysis of Mary

Shelley’s Frankenstein and Nathaniel Hawthorne’s

“Rappaccini’s Daughter” 1

2. A Brave New World: An Analysis of Aldous Huxley’s

Brave New World and Robin Cook’s Coma 24

3. Contagions/Isolations: An Analysis of Albert Camus’

The Plague and David Feldshuh’s Miss Evers’ Boys 47

4. Illness and Culture: An Analysis of Ken Kesey’s One Flew

Over the Cuckoo’s Nest and Alice Walker’s Possessing the Secret

of Joy 72

5. End of Life—Disease and Death: An Analysis of

John Updike’s Rabbit at Rest and Margaret Edson’s Wit 101

 Glossaryof Terms:Literary,Medical,andScientic 127

Index 148

Preface

Bioethics and Medical Issues in Literature, in the Pedagogy in Medical Humanities

series,isupdatedfromthe2005rsteditionusedworldwideinalllevelsof 

education.Therevisionsreecthowfastscienceistakingusintothetwenty-

rstcentury.Itdrawsonthedisciplineof bioethics(foundedinthelate1960s)

andtheeldof literatureandmedicine(establishedinthemid-1970s).Readers

will study both the technical and human side of science while gaining a respect

for diversity and the art of medicine. Although there are historical references

all the way back to ancient times, the selections span a 200-year period from

the birth of modern medicine in the early nineteenth century to the present.

The10worksof accessiblectioninvethematicchapterscanberead

alone or in chronological order because each successive work builds on concepts

that precede it. For example, in chapter 1, “Technology’s Creature,” Mary

Shelley’s Frankenstein and Nathaniel Hawthorne’s “Rappaccini’s Daughter”

describe science taking precedence over individual human rights. It is not a

great leap into chapter 2, “A Brave New World,” to discuss Aldous Huxley’s

description of dispassionate eugenics in Brave New World and Robin Cook’s

imagined commercial avarice in the human transplant industry in Coma.

In chapter 3, “Contagions/Isolations,” Albert Camus’ The Plague reveals

the unrelenting nature of plague, initiating philosophical discussions about

man’s morality in an atmosphere of every-man-for-himself. David Feldshuh’s

Miss Evers’ Boys describes a baseline syphilis study on blacks, without their in-

formed consent, who were denied the standard of care for whites. The main

theme in chapter 4, “Illness and Culture,” as described in Ken Kesey’s One

Flew Over the Cuckoo’s Nest and Alice Walker’s Possessing the Secret of Joy, is that

illnesscanbeculture-specicandthatdiagnosticmethodsandtreatmentop-

tions change throughout the years. At last, chapter 5, “End of Life—Disease

and Death,” shows in John Updike’s Rabbit at Rest and Margaret Edson’s Wit,

how, respectively, a self-indulgent man shortens his life and a cancer-stricken

woman deals with psychic and physical pain as she nears the end of hers.

Thereisavastrangeof topics,includingscienticrivalry,mentalillness,cul-

viii Preface

tural rituals, obesity, bioterrorism, and stem cell research, listed in the compre-

hensive index.

Each selection is placed in an historical context and has a plot synopsis

and literary analysis. A glossary givesclear denitions of  literary, scientic,

and medical terms, providing easy access to the non-specialist. The chronol-

ogy is a useful timeline of events. Suggestions are provided to provoke lively

discussions and to stimulate further reading. In a skills-across-the-curriculum

approach, this book puts a human face on medicine as science forges ahead.

What science cannot explain, literature explores.

A running theme throughout Bioethics and Medical Issues in Literature is the

Hippocratic need to be useful, and in this vein I thank Linda Lucas for her

careful proofreading and Dr. Brian Dolan for his help in developing this second

edition, offering a way to understand how to balance advancing technology

with individual human rights as well as responsibilities.

Chronology of Events in Literature, Medicine, and

Science

These Western medicine selections relate to the works included here. This is

not a comprehensive timeline, but to provide context some unrelated historical

events are shown.

B.C.

c. 4500 Sumerian and Egyptian Cultures begin.

c. 3000 Writing invented.

c. 450 Hippocrates, the Father of Medicine, wrote Corpus Hippocrates,

asystematicandscienticapproachtomedicine;hisdenition

of a doctor’s position and role in society is incorporated into his

Hippocratic Oath, central to medicine today.

A.D.

129 Birth of Galen Pergamum, Greek physician called the Father of

SportsMedicine,whorenedandorganizedthehumoralsystem

of medical knowledge and gave an account of the skeleton and

the muscles that move it.

476-1000Fallof WesternRomanEmpire;theDarkAgesbeginwhen

classical learning and literacy decline.

c.750-1485—The Middle Ages

1037 Deathof IbnSina(Avicenna),authorof Canon of Medicine.

1137 St. Bartholomew’s Hospital founded in London.

1270 Invention of spectacles in Venice.

1336-1453 Hundred Years War.

1340 End of the Plague of Justinian, following trade routes to France

and Italy, killing 70,000.

1347-1352TheBlackDeath(theBubonicPlague)hitsEnglandthehardest

in1348-49,killing40percentof thepopulation;inwestern

x Chronology of Events in Literature, Medicine, and Science

Europeone-thirdof thepopulation(20millionpeople)died.

1440-50 Printing invented, spreading medical knowledge.

c.1455 Gutenberg’sBibleprintedatMainz.

1485-1660—The Renaissance

1492 Discovery of America by Columbus.

1494 Syphilis appears in Europe.

1493-1541 Paraclesus, German alchemist and physician called the Father of

Pharmaceuticals, introduces remedies derived from chemicals

but stressed that nature heals.

1505 Royal College of Surgeons established in Edinburgh.

1510-90 The great surgeon Ambroise Paré writes about his work.

1519-22 Magellan circumnavigates the world, a voyage plagued by scurvy.

1532 London bills of mortality become our present-day death

certicates.

1543 NicolausCopernicuswritesof asun-centeredplanetarysystem;

Andreas Vesalius publishes his great work on human anatomy,

De Humani Corporis Fabrica.

1605 Champlaindenesscurvyduringanautopsy.

1610 Galileoistherstpersontoapplythetelescopetothestudyof

the skies and makes a series of astronomical discoveries.

1628 William Harvey publishes on the circulation of blood, De Motu

Cordis.

1665 TheGreatPlagueof Londonkills17,400people;reendedthe

outbreak.

1677 Cinchonabark(fromwhichquinineisobtained)islistedin

London Pharmacopoeia as a fever treatment.

1683 AntonvanLeeuwenhoek,withamicroscope,identiesand

sketches bacteria.

Eighteenth Century—The Age of Enlightenment in Europe

(Reason and Individualism)

1714 Gabriel Fahrenheit constructs the mercury thermometer.

1717 GiovanniLancisisuggestsmosquitoestransmitmalaria.

Chronology of Events in Literature, Medicine, and Science xi

1747 James Lind discovers citrus fruits cure scurvy.

1753 Linnaeus, Swedish botanist, physician, and taxonomist,

published Species plantarum, an attempt to classify all known

plants;hispeerswerejealousofhisfame.

1756 BenjaminFranklinhelpsfoundtheoldestAmericanhospitalin

Philadelphia, Pennsylvania.

1759 CasparWolff showsspecializedorgansdevelopoutof

unspecializedtissue.

1766 Albrecht von Haller proves nerve stimulation controls muscular

action.

1770s The Industrial Revolution begins in Europe.

1770 William Hunter established a school of anatomy in London.

1773 Therstmentalinstitution,aholdingfacility,isestablishedin

Virginia.

1774 JosephPriestlydiscoversoxygen;FranzMesmerusesmedical

hypnosis.

1776 The American Revolution(TheDeclarationof Independence,

July4).Smallpoxkills130,000NorthAmericans;theColonies

usevariolation(insertingsmalllpoxintotheskin,causingan

inoculationtoproduceimmunity).

1780 BenjaminFranklininventsbifocallenses.

1785 WilliamWitheringintroducesdigitalis(fromfoxglove)tocure

dropsy.

1789 The French Revolution(stormingof theBastilleonJuly14).

1794-96 Erasmus Darwin writes Zoonomia, or The Laws of Organic Life;

PhiladelphianDr.BenjaminRush,theFatherofAmerican

Psychiatry, performs revolutionary, but cruel, treatments to cure

insanity.

1796 Edward Jenner’s smallpox vaccination is based on evidence that

dairy maids exposed to cowpox never caught it.

1798 Thomas Malthus’s An Essay on the Principle of Population is

a cornerstone to Darwin’s views on the theory of natural

selection.

1800 Marie-François Xavier Bichat’s A Treatise on Membranes provides

an understanding of tissues as basic building blocks and prime

pathologicalsites;HumphryDavyannouncestheanesthetic

xii Chronology of Events in Literature, Medicine, and Science

properties of nitrous oxide, changing surgical procedures

forever.

Nineteenth Century—The Age of Modern Medicine

1811 Massachusetts General Hospital is founded in Boston.

1815 Waterloo(NapoleonicWars).

1816 René Laennec invents the stethoscope, beginning the age of

modern medicine.

1818 Mary Shelley publishes Frankenstein or, The Modern Prometheus.

1820s Homeopathy gains popularity in Canada and the United

States when in the late eighteenth century German physician

and chemist Samuel Hanemann developed the system from

experimentsonnaturalsources(plants,minerals,metals,etc.).

1832 Hodgkin describes cancer of the lymph nodes.

1843 Chloroform is discovered and used as a painkiller.

1843 Dr. Oliver Wendell Holmes writes The Contagiousness of Puerperal

Fever.

1844 HoraceWellsusesnitrousoxidetopullhisowntoothpainlessly;

Hawthorne publishes “Rappaccini’s Daughter.”

1846 Boston dentist William T.G. Morton uses ether during surgery,

ending indescribable pain and overwhelming dread associated

withsurgery;EduardSeguindescribesDown’ssyndrome.

1847 IgnazPhilipSemmelweis,theFatherof InfectionControl,links

unwashed hands to puerperal fever in a Vienna lying-in hospital.

1860 Florence Nightingale establishes St. Thomas Hospital nurses’

training program.

1858 Rudolf Virchow in Cellularpathologie demonstrates every cell is

the product of another cell, concluding that diseases result from

disturbances in cellular structures.

1859 Publication of Charles Darwin’s On the Origin of the Species by

Means of Natural Selection.

1863 T.H. Huxley, Aldous Huxley’s grandfather and “Darwin’s

Bulldog,” publishes Evidence as to Man’s Place in Nature, extending

Darwin’s Origin of the Species to human evolution.

1867 Joseph Lister introduces antiseptic surgery.

Chronology of Events in Literature, Medicine, and Science xiii

1869 Friedrich Miesher discovers nucleic acid.

1874 LouisPasteurboilsinstrumentsinwatertosterilizethem.

1876 RobertKochidentiesanthraxbacillus.

1881 Louis Pasteur creates a vaccine for anthrax bacillus.

1895 WilhelmRoentgendiscoversX-rays;H.G.Wells,theFatherof 

Modern Science Fiction, publishes The Time Machine, a dystopia

with a divided humanity.

1896 AntoineBecquereldiscoversradiation.

1897 Ronald Ross locates the malaria parasite in the Anopheles

mosquito.

1900 Sigmund Freud publishes The Interpretation of Dreams.

Twentieth Century—The Age of Global War

1904 IvanPavlovwinstheNobelPrizeinphysiologyforresearchon

digestion(thePavlovianstimulus-response).

1905 GermanbacteriologistRobertKochwinstheNobelPrizefor

tuberculosis research, presenting an airtight case that a single

bacterium caused the condition.

1906 First corneal transplant by Austrian ophthalmologist Dr. Edward

Zim.

1909 Oslo study begins on autopsied white males to report natural

history of untreated syphilis.

1912 The Titanic sinks on its maiden voyage.

1914 World War I (precipitatedbytheassassinationof Archduke

FranzFerdinand).

1917 The Russian Revolution(CzarNicholasII,lastof the

Romanovdynasty,abdicates).

1918 Spanishinuenzakillsatleast30millionpeople;rstblood

transfusion.

1920s Jean Piaget begins work on describing the stages of cognitive

development;EarlDicksoninventstheBand-Aid.

1928 AlexanderFlemingdiscoverspenicillininamold;Harvey

Cushingrstusespenicillinandsulfaantibiotics.

1830 Cholera epidemics.

1932 In Brave New World Aldous Huxley predicts a controlled world in

xiv Chronology of Events in Literature, Medicine, and Science

which art, science, and religion are banned.

1933 Horrendous concentration camp medical experiments take place

whenNazisseizecontrolof theGermangovernment.

1935 TheMayoClinicestablishestherstbloodbank.

1936 Dr.WalterFreemanperformstherstlobotomyintheUnited

States.

1938 B.F. Skinner publishes The Behavior of Organisms(operant

conditioning).

1939-45 World War II

1943 Waksman discovers the antibiotic streptomycin.

1946 French philosopher Albert Camus publishes La Peste(The Plague).

1947 The birth of bioethics, facilitated by World War II when science

andtechnologywerebothbenecialandthreatening;the

Nuremberg Code is signed.

1949 Establishmentof theU.S.NavyTissueBank;theNational

Instituteof MentalHealthcreated,recognizingtheneedto

diagnose and to treat the mentally ill.

1952 JonasSalkdevelopsrstpoliovaccine;BriggsandKingclone

tadpoles from cells.

1953 James Watson and Francis Crick describe the double-helix

structureof DNA;RosalineFranklin’searlierworkinspired

them,causingcontroversyoverwhodeservedtheNobelPrize.

1957 AlbertSabindevelopsalivepoliovaccine;Thorazine,“the

prescriptionstraitjacket,”isputintowidespreaduse,beginning

the psychopharmaceutical revolution in mental healthcare.

1960 The birth control pill is approved for general use.

1962 MurrayandHumeperformtherstsuccessfulcadaverickidney

transplant;KenKesey’sOne Flew Over the Cuckoo’s Nest takes

another look at electroshock therapy.

1963 Dr.ThomasStarzlperformstherstlivertransplant;avaccine

formeaslesisintroduced;MartinLutherKing,Jr.’s“IHavea

Dream”speechmobilizessupportersof civilrights.

1964 Civil Rights Act of 1964 is signed into law by President Johnson.

1966 Star Trek TV series, created by Gene Roddenberry, debuts

(sciencection).

1967 SouthAfrica’sDr.ChristianBernardperformstherstheart

Chronology of Events in Literature, Medicine, and Science xv

transplant;therecipienthasnormalheartfunctionfor19

months.

late1960s Birthof thedisciplineof bioethics(SeeDr.AlbertR.Jonsen’s

The Birth of Bioethics.N.Y.:OxfordUniversityPress,1998).

1968 Braindeathcriteriaestablished;TheUniformAnatomicalGift

Act allows the gift of organs.

1969 LunarmoduleEaglelandsonthemoon,July20;astronautsNeil

ArmstrongandBuzzAldrinwalkonthelunarsurface,fullling

President John F. Kennedy’s 1961 commitment.

1970 The American Lung Association begins its “Kick the Habit”

antismokingcampaign;PresidentNixonsignslegislation

banningcigaretteadvertisingonradioandtelevision;the

antibiotic vancomycin, regarded as the so-called silver bullet

against Staphylococcus aureusisintroduced;theFDAapproves

lithiumformanicdepressives;ananthraxvaccineisrstused.

1972 The Uniform Anatomical Gift Act’s Uniform Organ Donor

Card is a legal document in all 50 states making it possible for

anyone18andoldertodonateorgansupondeath;front-page

national news blows the whistle on the U.S. government-

Suggested Further Reading

Bear, Greg. Darwin’s Radio. New York: Ballentine, 2000. A cautionary tale

describing a human species that only survives by mutating beyond what

is acceptably human.

Bulgakov, Mikhail. “Heart of a Dog.” Trans. Mirra Ginsburg. New York:

Grove P, 1968. Creature turns creator’s life into a nightmare.

Clarke, Arthur C. Childhood’s End. New York: Harcourt, 1953. After many

yearshumansndoutwhatkindlyalienswholandonEarthlooklike.

Ehrenreich, Barbara et al. Witches, Midwives, and Nurses. Old Westbury:

Feminist, 1973.

Keyes, Daniel. “Flowers for Algernon.” Science Fiction Hall of Fame 1. Ed.

Robert Silverberg. New York: Avon, 1970: 605-35. A brain operation

Technology’s Creature 15

triples Charlie’s intelligence.

Seymour, Miranda. Mary Shelley. New York: Grove, 2001.

Stapledon, Olaf. Sirius. New York: Penguin Books, 1973. A lonely dog has the

mind of a man.

Stevenson, Robert Louis. Strange Case of Dr. Jekyll and Mr. Hyde (1886). The

Complete Short Stories 2. Edinburgh: Mainstream, 1993. Split personality.

NATHANIEL HAWTHORNE’S

“RAPPACCINI’SDAUGHTER”(1844)

Rappaccini! Rappaccini!

And this is the upshot of your experiment?

- Signor Pietro Baglioni in “Rappaccini’s Daughter”

Historical Context

As Shelley did in Frankenstein, Hawthorne drew from his background to cre-

ate a supernatural tale in “Rappaccini’s Daughter.” Born in 1804 in Salem,

Massachusetts, Hawthorne descended from Puritan immigrants. When he was

justfour,hisseacaptainfatherdiedof yellowfever,leavingbehindhiswife

and three children. All his aunts and uncles helped raise him, and he attended

Bowdin College where he befriended the poet Longfellow. He returned home

to write but was not immediately successful, so he worked in the Custom

House.ThenhelivedbrieyatBrookFarm,anexperimentalutopiancom-

munitybasedontranscendentalphilosophy.Findingittoodifculttowrite,he

left in a huff. As a nonconformist, Hawthorne’s commune experience might

explainwhyhisgardensettingfor“Rappaccini’sDaughter”reectedmoreof 

Dante’s inferno than romantic idealism.

Hawthorne married Sophia Peabody. They moved to Concord,

Massachusetts, where they raised several children. Sophia’s upbringing directly

inuencedHawthorne’sthemes.Herfather,Dr.NathanielPeabody,grewthe

purplewildower,Solanum dulcamara, in his Salem garden, using it for tooth

pain relief. From her early childhood Sophia kept records on the garden. Her

father, despite his homeopathic tendencies, made her the object of  some

experiments, as Dr. Rappaccini did with Beatrice. He dosed her with paregoric

(opium),laudanum,andmercury,andHawthorne,tohishorror,laterfoundit

16 Bioethics and Medical Issues in Literature

necessary to cure his wife of these addictions.

Another incident central to Hawthorne’s theme was the bitter medical

rivalry between two famous regional doctors, Dr. Oliver Wendell Holmes and

Dr. Robert Wesselhoeft. In 1842 at the prestigious Boston Society for the Dif-

fusionof UsefulKnowledge,HolmesaccusedWesselhoeftof quackeryand

ranhimoutof town,denouncinghisdelusionaluseof homeopathy(awater

cure) and calling him an empiric with fantastic theories. In addition, Wes-

selhoeft’s brother, William, used experimental hypnosis on the young Sophia

Peabody, which Hawthorne viewed as a violation. Hawthorne reconstructs the

bitter Holmes-Wesselhoeft rivalry into the heart of “Rappaccini’s Daughter.”

Other well-known Hawthorne works, The Scarlet Letter, The House of the

Seven Gables, and The Blithedale Romance, visit the theme of how good fends off

evil.TheyreectAmerica’sAgeof Romanticism,aliterarymovementdrawn

from European literature to invent the Gothic terror genre, a gloomy, dense,

and dark style that aroused in readers a sense of the supernatural. Nathaniel

Hawthorne and his contemporaries Edgar Allan Poe and Herman Melville

used Puritan legends to create mysterious and evil characters.

Two other Romantic authors who inuenced Hawthorne were Henry

David Thoreau(Walden),whousedthescienticmethodtoobserveandrecord

natural phenomena, and Ralph Waldo Emerson(Nature),whobelievedGod

created nature and held dominion over everything, including science. Tho-

reauandEmersonrejectedharshPuritanbeliefstofoundTranscendentalism,

which like nineteenth-century Enlightenment caused a cultural awakening. In

theirourishingutopiancommunalsocietiestheycastoff theideathatSatan

caused illness and disease to punish man. Instead, they held the belief that man

was innately good and that by using his intuition, alone, he could arrive at a

deeper truth than experience offered.

Transcendental views helped to spread democracy and social reform, such

astheabolitionofslaveryandtheghtforwomen’srights.Whencompulsory

school attendance was enacted into law, a more literate population spread

progressive ideas that set the cornerstone for medical reform. As in Europe,

the United States was changing into an industrial and urban society. In fact, in

1829 the term technology was coined to describe new inventions: the cotton gin,

the sewing machine, and the telegraph.

It is important to note that “Rappaccini’s Daughter” is set in Renaissance

Padua, Italy, where at Padua University, a thriving medical center, a sixteenth-

Technology’s Creature 17

centuryscienticcontroversybrewed.Upuntilthattimeoldmedicaltraditions

were practiced based on the Roman-era views of Galen of Pergamum(130-201

A.D.);heiscalledtheFatherofSportsMedicine.Galenwasprimarilyagladi-

atorialsurgeonwhosynthesizedallthatwasthenknownof medicalpractice.

His framework for explaining the body and its diseases included numerous

anatomical and physiological discoveries about heart-muscle action, kidney

secretion, respiration, and nervous-system function. Primarily, he believed in

the balance of four body humors: blood, phlegm, and yellow and black bile.

Debates ensued when Paracelsus(1493-1541),aSwissalchemistandphysician

considered the Father of Pharmaceuticals, broke with the long-held traditions

of Galentorevolutionizemedicalpractice.

Paracelsus observed plants and minerals like sulphur, iron, and copper

sulfate, and he conducted experiments with their active ingredients. He taught

that the activities of the human body are chemical, with health depending on

theproperchemicalcompositionof theorgansanduids,whatarenowcalled

pharmaceuticals. Paracelsus encouraged research into the nature of poisonous

substances, proving that if they were given in small doses they could often cure

the disease they caused. It was the principle of “like can cure like,” relating to

present-day inoculations. “Rappaccini’s Daughter” introduces the Paracelsian

idea of an antidote based on the principle that what makes a person ill may

also be the cure. Unfortunately, in the plot’s denouement, or outcome, when

Rappaccini’s daughter grabs the antidote from Giovanni’s hand and swallows

it, she dies in a Romeo and Juliet twist of fate. However, rather than two

families being at odds over their star-crossed lovers, Hawthorne reenacts the

bitter rivalry between the Galenic whole-body approach and Paracelsian phar-

maceutical advances, or the traditionalists and the empirics.

The idea of “like can cure like” is a forerunner to today’s homeopathy,

which stresses looking at the symptoms of each individual patient for clues to

acureratherthanatclassicaldenitionsofdisease.Inhomeopathicmedicine,

practitioners identify cellular abnormalities that hinder the body’s ability to

remove toxins, and they introduce pharmaceuticals to augment the body’s

natural healing process.

Another term used to identify a Paracelsian approach is holistic. That is,

Paracelsus believed that a physician should be an alchemist, astrologer, and

theologian in order to tend the body, soul, and spirit. He also gave us the best

denitionof syphilisuptothattime,and,althoughnowknowntobetoxic,

18 Bioethics and Medical Issues in Literature

invented a mercury treatment for its cure. Hawthorne, who understood the

Galen-Paracelsusdebate,characterizedDr.Rappaccini asa Paracelsianwho

observes nature and experiments. In fact, Rappaccini’s archenemy, Baglioni,

tells Giovanni that Rappaccini is a “vile empiric” who does not respect “the

good old rules of the medical profession.” On the other hand, Baglioni, as

Rappaccini’s counterpart, is more of a Galenist, a traditional academic.

Carol Marie Bensick offers another interesting interpretation of “Rappac-

cini’s Daughter” in La Nouvelle Beatrice: Renaissance and Romance in “Rappaccini’s

Daughter.” Reconstructing the historical Padua setting to be the site of syphilis

research and drawing on the Galen-Paracelsian controversy, she diagnoses the

main characters with syphilis. She says descriptions in the story of fever and

strange bursts of energy support her supposition. In her view, Beatrice inher-

itedsyphilisatbirththroughherfather(therebydevelopinganimmunityto

it),andGiovanniissimplyanunknowingcarrier.BensickaddsthatBaglioni’s

vial carrying the antidote was made by Benvenuto Cellini, a known syphilitic,

and she points out that in the sixteenth-century the common term for syphilis

was poison.

Medical topics arising from Hawthorne’s story include cures for syphilis

and theories of inoculation, the premise being that today’s lethal toxin may

contain tomorrow’s lifesaving drug. Primarily, however, Hawthorne pits the

conservatives who endorse the tried and true ways against the innovators who

endeavor to advance new and sometimes more radical treatments. While sci-

enticdiscoveriesrangefromthebasictothelofty—lookingintoprehistoric

dinosaurs, studying DNA and stem cells, and exploring the stars—the nature

of scienticrivalryisalwaystwo-fold.Onamultinationallevelscientistscom-

petetoadvancescienticdiscoveries,andonapersonalleveltheymaywant

toexposearival.Itcanalltakeplaceonabattleeld,asexempliedin“Dr.

Rappaccini’s Daughter.”

Synopsis of the Short Story

“Rappaccini’s Daughter” opens with Hawthorne mocking himself as its

allegory-lovingauthor,M. del’Aubepine(FrenchforHawthorne).Thenhe

gets right into the sixteenth-century story of Giovanni Guasconti, an impres-

sionable,self-absorbedyoungmanleavinghomeforthersttimetoattend

medical school at the University of Padua. Giovanni’s room overlooks a garden

where the eccentric Dr. Rappaccini, a genius but an outcast from the medical

Technology’s Creature 19

establishment, cultivates plants for medicinal purposes. One day Giovanni is

excitedtoseethedoctor’sbeautifuldaughter,Beatrice,enterthegarden;atthe

sametimehe ispuzzledwhenRappaccini carefullyinspectsapurpleshrub

without touching it, while Beatrice embraces it.

Signor Pietro Baglioni tells Giovanni more about the mysterious Dr.

Rappaccini and his daughter, but his view is tainted by years of professional

jealousy, saying that Dr. Rappaccini cultivated poisons for their medicinal

virtueswithouthesitatingtosacricewhatwasdeartohim.Secretly,theless

brilliant Baglioni fears that Rappaccini is grooming Beatrice to unseat him

from his professorship and that he may be taking over his promising young

protégée, Giovanni.

Besides having Baglioni’s skewed point of view—unreliable and slander-

ous—we draw conclusions about Beatrice and Rappaccini out of Giovanni’s

own paranoia and lust. In fact, most of what he and the reader think they

know of this daughter-father duo comes from these two sources. In the key

gardensceneinwhichGiovanni“sees”proof of Beatrice’spoison—alizard

dropsdeadafterafewdropsfromthepurpleowerfalluponit—hehasjust

come from Baglioni. Giovanni is drunk, according to his own admission, and

almost everything he suspects is undermined by the author.

AsGiovanniisnallydrawnintoBeatrice’sgarden,thereaderisdrawn

in through his viewpoint, fed again by paranoia and lust. The ever-scheming

Baglioni has warned Giovanni that Rappaccini is a “vile empiric” who plans

to use him in one of his experiments, and he gives him a silver vial containing

apoisonantidote.InatestGiovanniplanstohandsomeowerstoBeatrice,

but, inspecting them in his room, they wilt in his hands. In a scene in which

he turns on her, Giovanni rushes into the garden to meet Beatrice. He offers

thevialtoher,declaringtheymustrstdrinktopurifythemselves.Inactions

showing her to be innocent and of a loving heart—not poisonous—she grabs

the vial from his hands and drinks the antidote. What she says rings true:

“Wastherenotmorepoisonfromtherst,inthynaturethaninmine?”Sheis

poisonousonlyinthatsheissexual;heis“poisoned”byherbecauseshesexu-

allyexciteshim.Thatiswhatheresentsandfears.Inthenalanalysis,isnot

Giovanni’spoisonalovelessnessandalustfulnature;isnotBeatrice’spoison

more literally sexual—ultimately related to our humanness and mortality?

Rappaccini then enters the garden and tells Beatrice that Giovanni was to

beherbridegroom.WhileBeatricefeltherfatherhadinictedalifetimeof 

20 Bioethics and Medical Issues in Literature

horrible pain on her, he believed he had given her a great gift: she was invin-

cible to any power and could defeat any enemy. Declaring that love would be

preferabletofear,shedied.Theantidote,whichGiovanniavoidedtakingrst,

was a poison to her. In the last line of the story, our suspicion of Baglioni’s

professionaljealousyandhisviewof Rappacciniasanevilexperimenterare

conrmedwhen,afterseeingBeatricedieasaresultof hisantidote,hediaboli-

cally gloats “in a tone of triumph mixed with horror”: “Rappaccini! Rappac-

cini! And this is the upshot of your experiment?”

Literary Analysis

ScienticrivalrydrivesHawthorne’sfamoussupernaturaltaleof poisonand

intrigue. It reconstructs an Italian Renaissance setting at Padua University

when two camps were at war: the traditional Galenists and experimental Para-

celsians. Paracelsus was an empiric, the Faust of Renaissance medicine, whose

new science of medical chemistry transcended tradition. He opposed the

orthodox Galen, who until that time was regarded as an indisputable source.

Andreas Vesalius, professor of anatomy at Padua University, a famous center

formedicaltraining,wasanothercentralgureof Renaissancemedicinesup-

porting Paracelsian reform. In 1543 his famous anatomical text, The Fabric of

the Human Body, was published, based on stolen criminal bodies because the

churchdidnotallowdissection.Forthersttime,heprovedwrongGalen’s

observations, which had been based largely on animal observations. Vesalius

also helped establish surgery as a separate medical profession.

Paracelsus’s and Vesalius’s remarkable convergence of ideas with Renais-

sance humanism was the beginning of the great transformation from archaic

medicine to modern technology. Their medical breakthroughs, along with Wil-

liam Harvey’s discoveries on blood circulation, contradicted the old ways, which

led to suspicions and bitter rivalries. Likewise, in “Rappaccini’s Daughter” the

traditionalist Baglioni opposes the experimentalist Rappaccini, a Faustian char-

acterinsearchof knowledgeorperfection.Inascienticresearchscenario

replayed many times over the years, archrival Baglioni uses his apprentice

Giovanni as a pawn against Rappaccini. And, at a time when Victorian views

of sexuality caused doctors to examine women with their clothes on, Beatrice’s

sexuality motivates all three men: Rappaccini must control her, Giovanni must

dominate her, and Baglioni fears her.

Great literature is often perceived in many different ways, with “Rap-

Technology’s Creature 21

paccini’s Daughter” included in anthologies of the best nineteenth-century

science ction; great American love stories; famous poison stories; and

Garden of Edenstories.Italwaysevokesastronglypolarizedandviscerally

emotional female-male response in discussions on the nature of Beatrice’s and

Giovanni’s romantic love. In literary analysis, however, Hawthorne’s Garden

of Eden allegory pits good against evil using literary allusion and devices such

as symbolism and ambiguity. In addition, he plays out the romantic themes

of nineteenth-century science seeking perfection and, when things go terribly

wrong, the scientist’s unpardonable sin for not asking for forgiveness. Dr. Rap-

paccini, who uses his daughter in an experiment, is the hubristic scientist play-

ingGod.Heshowshistragicawbyexaltingthemindattheexpenseof the

heart,expressedsymbolicallyinthehead(intellect)versustheheart(emotion).

A hotly discussed issue today is the need to balance clinical medicine

with human rights. When Rappaccini thrusts his innocent daughter into a life

of isolation, herationalizesthat shewill becomeinvincibleand thankhim.

Through no fault of her own, she turns deadly. But she is ignorant of her

poisonous nature because her only companions have been her father and her

“sister,” a poisonous purple bush that mocks her beauty and is symbolically

rooted in evil. In fact, the duality of nature, also seen in the garden’s broken

fountain, is expressed throughout “Dr. Rappaccini’s Daughter” as a major

theme. Ultimately, Dr. Rappaccini’s unconscionable plan extends into “infect-

ing” Giovanni, an intended bridegroom who is excited by a beautiful young

womanandpuzzledbyhereccentricfather.

Hawthorne repeatedly shows Beatrice’s and Giovanni’s inner feelings, and

howtheyfallinlove.Giovanni’sisanidealizedromanticlove—untilherealizes

he has taken on her poison. In the end Rappaccini’s detached intellect allows

himtovaluescienceoverhumanity,reprehensiblysacricinghisdaughterto

addtohis“heapof knowledge.”Indeed,thethemeof sacricingtheonefor

the many is often played out in modern medicine. Dr. Rappaccini’s “fatal love

of science”envelopsBeatriceandGiovanniintoaninescapablesituation;only

death will liberate them. Rappaccini’s fate is ambiguous. Baglioni’s conserva-

tiveviewisthatRappaccini’sawisnothavinga“sounderviewof thehealing

art.”Andauniversalsciencectionthemeincludinga“vileempiric”scientist

whosescienticmethodisexaltedoverhumanlife is the main focus of this

analysis.

Forallof thereasonshighlightedinthethemesof scientichubrisandof 

22 Bioethics and Medical Issues in Literature

the stealth of research, today’shumanresearchsubjectguidelinesarestrictly

monitored.Furthermore,thestory’smajorthemeinthecontextof scientic

rivalry is the importance of striking a balance between human needs and sci-

enticprogress, a concern many medical professionals and bioethicists face.

In the end, “Rappaccini’s Daughter,” like Shelley’s Frankenstein, reminds us of

what happens when unsupervised scientic experiments go terribly wrong,

especiallywhenscienticrivalryintervenes.Inmedicalresearch,weallhaveto

decide what is acceptable.

Topics for Oral and Written Discussion

• WhatItalianRenaissanceadvancesimprovedthescienticmethodin

studying medicine?

• Relate the 16th-century Galen-Paracelsus debate to Baglioni’s and

Rappaccini’s rivalry. Who does Hawthorne cast as the villain?

• Deneandrelatethehomeopathicprinciple,“likecancurelike,”to

the story.

• Discuss the theory of inoculations.

• Deneandapplytothestory:“vileempiric,”detachedintellect;and

head versus heart.

• How did Peracelsus’ and Vesalius’ works transform medicine from

archaic to modern?

• Was Rappaccini’s experiment a rational and/or unconscionable action?

• RelatethestorytotheRomanticviewof scientichubrisandbeing

wary of seeking perfection. Then attribute the characteristics of good

and evil to the four main characters.

• Apply the main theme in “Rappaccini’s Daughter”—striking a bal-

ance between human needs and scientic progress—to arguments

recommending a ban on human reproductive cloning.

• Who should decide what is acceptable research?

Bibliography

Bensick, Carol Marie. La Nouvelle Beatrice: Renaissance and Romance in

“Rappaccini’s Daughter.” New Brunswick, New Jersey: Rutgers UP, 1985.

Genesis: 2 and 3. The Holy Bible. King James Version. New York: The

American Bible Society, 1816. Garden of Eden story.

Hawthorne, Nathaniel. “Rappaccini’s Daughter.” The Complete Novels and

Technology’s Creature 23

Selected Tales of Nathaniel Hawthorne. Ed. Norman Holmes Pearson. New

York: Random House, 1937: 1043-65. Also e-text.

Transcendentalists: http://www.transcendentalists.com/index.htm

Suggested Further Reading

Carlson, Laurie Winn. A Fever in Salem. Chicago, Ill.: Ivan R. Dee, Inc., 1999.

Amosquitoorbird-borneencephalitisoutbreakcausedsymptoms

leadingtowitchtrialinquisitions.

Doyle, Sir Arthur Conan. “The Adventure of the Copper Beeches.” E-text.

Holmesexplainsthescienticmethod,reasoningfromcausetoeffect,to

Watson.

Hawthorne, Nathaniel. “The Birth-mark.” E-text. A doctor renders his bride

perfect.

Poe, Edgar Allan. “The Facts in the Case of M. Valdemar,” “The Fall of the

House of Usher,” “The Black Cat,” and “The Tell-Tale Heart.” Complete

Tales and Poems. New York: Barnes & Noble, 1992. Anti-utopian themes.

Selzer,Richard.“Imelda.”The Doctor Stories. New York: Picador, 1998: 83-97.

A story about a doctor’s obsession and personal growth.

Turner, Arlin. Nathaniel Hawthorne: A Biography. Oxford UP, 1980.

Chapter Two

A Brave New World: An Analysis of Aldous

Huxley’s Brave New World and Robin Cook’s Coma

Introduction

Aldous Huxley wrote Brave New Worldtoshowhowindividualityissacriced

when the government controls and conditions its people with science and

technology. It casts a cautionary light on the inherent dangers from genetically

determining a society where pharmaceuticals and psychological conditioning

try to keep everyone healthy, happy, and conformed until it is their time to

die. The novel is timely as we enter a brave new world of genetic engineering

and cloning, highlighting the issue that our technical ability to create and to

manipulate human life runs well ahead of public policy. While other countries

boldly advance biotechnology promising perfected, disease-free humans, in

2001 President George W. Bush said he was deeply troubled and remarked:

“We have arrived at that brave new world that seemed so distant in 1932 when

Aldous Huxley wrote about human beings created in test tubes in what he

called a hatchery.”

Indeed,manyelementsof Huxley’ssciencectiondystopia have come

true:anthraxthreateningeconomicstability;drugscontrollingthoughtsand

feelings;articiallyfertilizingeggsandgrowingbabiesinsurrogates;andlife-

longconditioningbygovernmentandcommercialconcerns.Butthesignicant

advanceinthelatetwentiethcenturyof mappingandsequencingthegenetic

patternformostorganisms,calledtheHumanGenomeProject, means we can

nowalterhumanlifebygoingforacureratherthanforaquickx.Rapidly

advancing biotechnologies give rise to hope and fear, putting legal, religious,

and scientic communitiesat odds overour sometimes unchecked faith in

technology. Advocates favor government funding for National Institute of

Healthprojectsthatwillfueldiscoveryandcreatemedicalmiracles;opponents

argue that the technology involved in genetically altering life is moving far

A Brave New World 25

ahead of a necessary ethical and regulatory framework.

Similarly, Robin Cook said his medical thriller themes in Coma are not only

possiblebutevenprobable.Theyaredenitelynotsciencection,headded.

He puts the organ transplant industry under a microscope, giving a Hippo-

cratic“rst,donoharm”warningtodoctors.Cook’shorricplotof turning

healthypatientsintoprotabledonorsdevelopswithinthepowerstruggleof 

the lower and upper worlds of the hospital hierarchy. He shows the problem

of drugged doctorsand thedehumanization of patients, and how weaken-

ing the doctor-patient relationship contributes to medical mistakes. Research

advanced in secret is also a problem.

The key issues in Coma are the safe procurement and the fair dissemina-

tionof humanorgansandthedenitionof “braindeath,” which continues

to undergo medical, religious, and cultural interpretations. At present, organ

harvesting gives back life and adds to its quality; its protocol is fairly well

established. However, Cook said there is a problem when the black market in

human organs sells a rare commodity to the highest bidder. In addition, with

technical advances 30 years after Coma was published, some fear scientists are

bending the rules of nature and heredity by cloning transgenic or cross-species

transplant organs. Stem-cell derived organs or those cloned from our own

tissuepromisetransplantwithoutrejection.Thescienceishere,alreadybeing

applied from other mammals to humans.

Inthistwenty-rstcenturybravenewworldof scienticandtechnologi-

cal advances into the secrets of life, we will all need to understand the new

scienticknowledgeanddecidehowfarwewanttotakeit.AldousHuxley’s

Brave New World and Robin Cook’s Coma highlight important bioethical and

medical issues that stimulate discussion.

26 Bioethics and Medical Issues in Literature

ALDOUS HUXLEY’S

BRAVE NEW WORLD(1932)

The theme of Brave New World is not the advancement of

scienceassuch;itistheadvancementof scienceasitaffects

human individuals.

  —AldousHuxley(1946Foreword)

Historical Context

TheprolicauthorAldousHuxley(1894-1963)wroteessays,novels,shortsto-

ries, poetry, and screenplays. Brave New World is his best-known work. As is the

case with every author, Huxley’s background shaped his work. He was born in

Surrey, England, on July 26, 1894, the third of four children. His father, Dr.

Leonard Huxley, was an author, and his mother, Julia Arnold Huxley, was a

girls’ school founder. Tragedy befell the household when his mother died of

cancer. The 16-year-old Aldous attended Eton but left a year later with the

serious eye disease keratitis punctata. He was blind for more than a year, which

preventedhimfromnishingrigoroussciencetrainingandendedhisdream

of becoming a medical doctor like his famous grandfather T.H. Huxley.

Instead of a medical career, he received a degree in English Literature

fromOxford.Hemarriedhisrstwife,Maria,incollege,andtheyhadason.

After Maria died in 1955, he married another writer, Laura Archera. Huxley’s

literary ancestors include a novelist aunt and great-uncle Matthew Arnold

who wrote the famous poem “Dover Beach.” Aldous’ brother, Julian, was

a respected biologist. An element clearly present in Huxley’s novels is the

indomitable human spirit, an ideal that tested the family when one of Aldous’

brothers committed suicide. Huxley moved to the United States in 1937, and

in 1959 the American Academy of Arts and Letters gave him the Award of

Merit for the Novel. He died of cancer on November 22, 1963.

Brave New World,writteninthepost-WorldWarIperiodof industrializa-

tion and the rise of fascism, derived from Huxley’s fascination with science,

medicine, and technology, as well as from his concern for problems arising

from their unchecked advances.Huxleydrewfromseveralinuencesandpro-

jectedthemintoanimaginedtotalitarianWorldState.First,heusedthework

of hisoutspokengrandfather,T.H.Huxley(1825-95), abiologist,educator,

A Brave New World 27

and medical doctor, who was called “Darwin’s Bulldog” because his Evidence

as to Man’s Place in Nature(1863)daredtoembraceCharlesDarwin’sunpopular

theory of natural selection. Inspired by his grandfather, Huxley asserted in

Brave New World that our individual freedoms must be carefully guarded, even

if the stance we take is unpopular.

AsecondinuenceonHuxleywasgeneticist-psychologistFrancisGalton

(1822-1911),theFatherof EugenicsandDarwin’scousin,whobelievedsci-

ence could increase human happiness through improving breeding patterns.

Hefavoredgeneticdeterminationoverenvironmentalinuences(i.e.nature

over nurture). Galton’sinuence is clearin Huxley’sgenetically determined

caste system.

ThethirdtoinuenceHuxleywaspoliticaleconomistThomasMalthus

(1766-1834), whose work fueled Darwin’s theory and inuenced Huxley’s

economy-driven, population-controlled brave new world by describing how

plants and animals naturally produce more offspring than can possibly survive.

Malthus blamed nineteenth-century England’s decline on too few resources

for the increasing population and on an irresponsible lower class. He believed

that only curtailing reproduction would prevent a global famine, a natural phe-

nomenonhethoughtGodcreatedtokeepmanfrombeinglazy.

Lastly, Aldous Huxley’s concept of life-long Neo-Pavlovian Conditioning

in Brave New World stems from behavior scientist Ivan Pavlov’s 1880s work in

human behavior. Russian chemist and physiologist Pavlov studied the diges-

tive system, drawing a link between salivation and the stomach’s action in his

stimulus-response theory. He rang a bell at the same time he offered food to

dogs;then,evenwhennofoodwaspresent,thebell’ssoundcausedthedogs

tosalivate.Hecalledhisresultaconditionedreex.

Drawing from these forbearers, T.H. Huxley, Francis Galton, Thomas

Malthus,andIvanPavlov,Huxleycreatedwaysinhisfutureworldtoarti-

cially reproduce humans and to condition them to be content with their pre-

determined lots. Writing Brave New World was his way to address a fear that

the world was becoming spiritually bankrupt and settling into an abhorrent

conformity. In his economy-driven population, physical and psychological

control is essential.

In 1996 Brave New World was evoked when Dr. Ian Wilmut of the Roslin

Institute in Scotland cloned Dolly the sheep through somatic cell nuclear

transfer(SCNT).Thepublicandpress,scientistsandclerics,raisedthedreaded

28 Bioethics and Medical Issues in Literature

specter of Frankenscience. As an embryologist, Dr. Wilmut said his primary

objective was therapeutic (to help mankind); subsequently, he produced a

human protein in Dolly’s milk, creating transgenic or cross-species organisms

from cloned genes. In 2005, the British government granted Wilmut a license

to clone human embryonic stem cells for therapeutic use in research on motor

neuron diseases like Lou Gehrig’s disease. Pro-life activists condemn the

decision.

Withthesciencealreadyinplaceforcloningmammals,thesetechniques

can be applied readily to humans. Lay, religious, legal, and science communities

areurgentlyposingspecicquestionsaboutwhatsomeconsiderthehorric

cloning of human beings:

• Is it morally justiable to clone a dead child to fulll his/her lost

destiny?

• Couples using in vitro fertilization can choosethe desiredsex from

their collection of eight-cell embryos and then discard the rest. Is

this preimplantation genetic diagnosis sex selection, sex discrimina-

tion, when sperm-sorting effects the same result? During the embryo

selection method horrendous diseases are genetically screened, but

how does it affect humanity when other characteristics such as eye

color and intelligence are isolated?

• Parents have procreated a child to provide tissues, organs, and bone

marrow transplants for another child. Is there anything wrong with

cloning the donor child for a perfect match?

• If you cloned yourself, who would that be?

Incredible advances in genetic engineering help infertile couples and eliminate

inherited disorders such as Tay-sach’s disease, sickle cell anemia, and Down’s

syndrome. The ability to clone, or to duplicate, humans, almost as described

in Brave New World, is here. With biotechnological advances begun when Wat-

son and Crickidentiedthemolecularcodeof DNAandcontinuedwiththe

HumanGenomeProject,ethicalchallengesfollow.Sometwenty-rstcentury

bioethicistsareaskingthequestion,HowsoonwillweforgetWorldWarIIand

theNazi’seugenics-driven genocide?

While Brave New World was published in 1932, the themes in Huxley’s

novel take us into the debate over human cloning, with the technical ability

A Brave New World 29

to create and genetically manipulate human life running well ahead of public

policy. Stem cells are found in human embryos, umbilical cords, and placentas

and, when divided, can become any kind of body cell. When terminated at

theve-daystage,thein vitrofertilizationprocessyieldsembryonicstemcell

lines that can grow into 200 cell types, potentially repairing or even replacing

damaged body parts. Proponents argue that the value of therapeutic clon-

ing,includingndingmissingclottingfactorsinhemophilia,benetingcystic

brosis,andcreatingnewanti-rejectionfactors,faroutweighsthefactthatthe

so-called activated cells are terminated. Opponents of therapeutic cloning fear

the precedent set for experimenting on life, born or unborn, and believe no

way exists to bar reproductive cloning once therapeutic cloning is legal and

government-funded. The National Academy of Sciences opposes reproduc-

tive cloning. Other private and governmental bodies concur, asserting that

once we have designer children and clones, the brave new world will have

arrived. Individual states, like California, have passed legislation to fund state-

wide embryonic stem cell research, attracting world-wide talent to what has

been termed the stem cell gold rush.

Biotechnologycontinuestopromisedazzlingchangesinmodernsociety

but some fear its power to lead the human race down a slippery slope, mak-

ingit vitally important foreveryone—notjustscientists andtheclergy—to

understand this new knowledge and to decide how we want to use it.

Synopsis of the Novel

TheWorldState’sbravenewworldof 632A.F.(AfterFord)isautopiaHuxley

imagined in 1932 and set 600 years into the future. An autocracy of 10 Con-

trollersmanageslifefromanarticiallymanufacturedbirthtoapainlessand

unemotional death. Everything is done for the welfare of the human collective.

Instead of  old-fashioned two-parent reproduction (viviparation), maternal

impulsesaresuppressedandeggsfertilizedinbottles.Controlledthroughthe

BokanovskyProcesstotintoaclass—fromsuperiortomoronic—humans

have an inescapable destiny.

Neo-Pavlovian behavior conditioning controls the population who are

taught that books and roses have no value. In place of religion, society wor-

shipsFord,symbolizedbyHenryFord’sModelTreplacingtheChristiancross.

Repetitive subliminal messages inculcate propaganda. All games are designed

to increase economic consumption and promote promiscuity. The word family

30 Bioethics and Medical Issues in Literature

is vulgar. Everyone pops the pleasure-enhancing drug soma, which has no side

effects and masks discontent.

The Controllers decide what is best for the common good, but from time

to time things go wrong. The Alpha-Plus psychologist Bernard, a loner who

isintoxicatedwithhisownsignicance,isdifferent.HefearstheDirectorof 

Hatcheries and Conditioning will ban him for his non-conformity. Bernard

and the lower-class woman he likes, Lenina, go on a vacation to an Indian

reservation,anoutpostnotworthcivilizing.LongagoaBeta-Minuswoman,

Linda, was abandoned there by the Director while they were on vacation.

Leninafeelsrepugnanceatthewildanduncivilizedwaysonthereserva-

tion. Disease and deathare visible,in contrastto thecivilized World State.

LeninaandBernardmeettheoldsquaw,Linda,whoboretheDirectorason,

John. John, like Bernard, feels trapped between two cultures.

Bernard takes the two savages back to the World State, thinking he will

have some leverage against the Director, who he fears will ban him for his

unorthodox ways. To all in the World State, Bernard presented the savage John

andhismotherLinda,nowoldandfat;theDirectorresignsinpetrieddis-

gust. But all are curious about the savages.

John, who learns his mother is dying, is grief-stricken, a strange emotion in

aworldwhereanindividualisinsignicantamongthemasses.Atthehospital

Linda cannot communicate, making John fearful he is losing his one human

connection.Agroup,inuredtodeath,comesintotheroom,horriedatseeing

Linda. Their modern medicine is able to give even a moribund sexagenarian

a girlish appearance. When his mother dies, John’s grief is palpable, upsetting

thevisitinggroupthatassociatesdeathwithpleasure.Johnrealizesinaash

he must make this slave-world free again.

Mond, one of the Controllers, at last bans the insubordinate Bernard for

causing instability. He explains the World State to John in a declaration of

Huxley’s core Brave New World ideology. Science, art, and religion were sacri-

cedforthecommongood.Drugscontrolthepopulation;newdiscoveries

are subversive and outlawed. High art is banned, too, because it stimulates

individuality and blocks conformity. Religion in a youthful and prosperous

society, when people are safe, well, and not afraid to die, is unnecessary. “God

isn’tcompatiblewithmachineryandscienticmedicineanduniversalhappi-

ness. You must make your choice,” the Controller says. They lived in a utopia

where security and happiness replace desire for beauty and truth.

A Brave New World 31

In the end, John, hopelessly between two worlds, faces a bleak future. He

isolates himself in an old lighthouse to purify himself from the contamination

of civilizedlife.Inold-worldtradition,heagellateshimself,callingonGod

toforgivehim.Forawhilehelivesinpeace,buttheninquisitivepeoplend

his pain fascinating and invade his privacy. Giving John the pleasure-inducing

drug, soma, they all engage in an orgy of pain. John hangs himself. He cannot

bring freedom and love to a world convincing him it was pointless to live, and

he cannot return to his savage roots.

Literary Analysis

Brave New Worldcontinuestocastacautionarylighton twenty-rstcentury

bioethical questions on genetic engineering, especially with technology far

outpacingregulation.Concernsare,howfarshouldwegotoxwhat’swrong

with us, and should this even include cloning a new and better species that is

smarter, more beautiful, and more talented? In Huxley’s World State, a tech-

nocraticgovernmentanditsscienticelitemakedecisionsforthegoodof the

entirepopulation,sacricingindividuality.ItsmottoisCommunity,Identity,

Stability. In the previous era, anthrax bombs had threatened the war-torn

economy during the Nine Years’ War. The government’s response to anthrax

threats,whichrelatestoourowntwenty-rstcenturyfearsof bioterrorismin

the United States, was to create a one-world state and to fortify the economy

by controlling the population. In order to maintain a stable community, indi-

vidual identity was forsaken. The most interesting aspect to the plot is that,

rather than exercising military control, biotechnologies took over. Humans

were mass-produced, then physically and psychologically conditioned into a

specicclass,eachwithitsowndestiny.Althoughlesstimeisspentoncharac-

teranalysisherethanonbioethicalissues,theveclassesorcastes—Alphas,

Betas,Gammas,Deltas,andEpsilons—allwerexedintotheirpredestined

tasks to keep the economy running.

Huxley’s imagined ectostatic(outsideof thewomb)methodof creating

human life by placing fertilized eggs into bottles eerily comes close to the

now common practice of in vitrofertilizationandthearticialwombcreated

in 1997. Moralists fear Huxley’s imagined world in which two parents are no

longerrequiredtomakeababy,andthewordfamily is vulgar. Huxley’s idea that

onefertilizedeggwouldbeclonedinto96identicallower-classEpsilonstolock

in conformity, highlights the hot contemporary debate in cloning. Geneticists

32 Bioethics and Medical Issues in Literature

argue that cloned humans have 100 percent identical DNA but that transfer

of genetic material is not the transfer of consciousness. In fact, it would be

no different from naturally conceived identical twins who maintain unique

personalities.Butpsychologistsnowtheorizethatasmuchas50percentof a

person’spsychologicaltraits,suchasshynessandfearlessness,areinuenced

by genes.

With some changes in terminology, the human condition in Huxley’s

futuristicbravenewworlddoesnotsoundverydifferentfromourtwenty-rst

century. Instead of the pleasure-inducing drug soma to control thoughts and

feelings,wehaveProzacandRitalin.TheInternalandExternalTrustextracts

hormonestokeeppeopleyoungandhappy;wehavehormonereplacement

therapy and Viagra. Instead of the Neo-Pavlovian conditioning and hypno-

paedia, some say our subliminal governmental and commercial messages cause

conformity in what we want to have and to be.

Huxley’s human babies are manufactured, and a medical procedure called

a pregnancy substitute gives women the psychological experience of having

babieswithoutactuallyhavingchildbirth.HisPodsnap’sTechniquearticially

speedsuptheripeningof embryosforextraction;wehavefollicle-stimulating

drugsto extractova.Instead of Malthusianbeltstodiscourageunsterilized

women from having sex and getting pregnant, we have the birth control pill,

fallopian tube-tying, andmale sterilization. In Huxley’s World State, imper-

fectlyclonedhumansarediscarded;weroutinelyscreenforgeneticfaultsand

abort within the limits of the law. Both manipulate reproduction. Huxley’s

LinersandMatriculatorsworkintheBottlingRoom,placingarticiallyinsemi-

nated embryos into sow peritoneum-lined bottles for maturation, at which

pointtheyaredecanted(born);wearticiallyinseminateovawithspermina

glassdish(in vitrofertilization)andimplanttheminasurrogatehumanwomb

orarticialwomb.

Underscoring Huxley’s one-world utopia is the Malthusian philosophy of

achieving a reproduction-consumption balance in a world without disease and

fear of death. Our contemporary view is a desire for human perfection by

eliminating disease, all the while consuming however much we want. In the

end we wish for a painless morphine-induced death.

Hence,muchof whatisgoingoninbiotechnologytodayisreectedin

Huxley’s cautionary theme, and, in particular, that we must control the rapid

advances in biotechnology before they control us and our individuality. His

A Brave New World 33

Brave New World, in which economic stability supersedes art, science, and

religion, was written in the early 1930s before the beginning of the totalitar-

ianNazi state, the communistSovietregime,and World WarII.Incredibly,

however, the criticism of Huxley’s World State parallels that which fell on

eugenicswhen theNazi governmentsanctionedDr.Josef Mengele’sWorld

War II medical research atrocities.

In his 1976 novel, Boys from Brazil, Ira Levin imagines how Mengele plans

to clone a new generation of Hitlers. Levin used the twentieth-century tech-

nology to turn skin cells salvaged from Hitler into his clones who are then

placed into preselected homes to mimic Hitler’s youthful environment. That

is, the cloned babies are environmentally nurtured to become a new race of

Hitlerswhowillthentakeovertheworld,fulllingadestinythatWorldWarII

cutshort.Usingtoday’stechnology,whichisnottoofaraeldfromHuxley’s

1930s theories, stored cells collected even from the dead could be cloned into a

Mozart,anEinstein,andevenaHitler.Levin’snovelreplaystheHuxleytheme

describing what can go terribly wrong when biotechnical scientists are left to

their own devices.

In essence, Brave New World’s reproductive methods derive from the Mal-

thusian idea that anything not contributing to the economy, for the greater

good, should be forbidden. In Huxley’s dystopian vision, the family unit is

obsolete because reproductive sexual intercourse would be too genetically risky

andwouldrelinquish thegovernment’scontrol. Instead, eggs areharvested

from women taking Hormone Stimulate Surrogate, which releases the eggs

and diminishes any maternal impulse. To continue a comparison of Huxley’s

futureworldandourstoday,hisreproductiveprocessequateswiththewilling

surrogate(paidornot),herwombavailabletohostthefertilizedeggof two

donor parents.

Because the World State requires conformity, it creates conditions it

believes are only good for the community as a whole. Subliminal propaganda

called hypnopaedia inculcates early prejudices. Soma drugs, a chemical called

Violent Passion Surrogate, and multisensory movies called feelies promote

sexual promiscuity and a sense of well-being. The Controllers have decided

what is best for all. Unfortunately, Huxley’s imagined social engineering, taking

drugs to numb a harsher existence and having few family bonds, is not foreign

to today’s reality.

The Controllers use neo-Pavlovian stimulus-response to condition their

34 Bioethics and Medical Issues in Literature

people to relate death to something pleasant. Critics say today’s American

wayof isolatinganddruggingdyingpeopletendstosanitizedeath.Inalike

manner, the World State conditions its people to not fear death, and, when

faced with it, they are repulsed. Furthermore, the contrast between Huxley’s

imagined future world and ours today shows what might go wrong when the

government controls art, science, and religion. The World State discourages

literature because it might cause discontent in people thinking about the old

ways. Science not contributing directly to the overall plan is outlawed, and

religion has no place in a world without disease and fear of death.

In his plotline, Huxley contrasts his main characters, the nonconform-

ist upper-class Bernard with the highly conditioned lower-class Lenina con-

formedtoherlotinlife;andthewomanLinda,raisedinWorld-Statevalues

but relegated to an Indian reservation life, with her savage son John, who

is caught between worlds and cannot be happy where there is no hope and

love. Huxley’s characters set into the contrasting worlds, the World Society

and the Indian reservation, show how class discontent begins to unravel the

society.BernardandhisfriendHelmholtz,independentthinkersandmists,

arejoined byJohn,aromantic savage, todestabilize society. Passages from

Shakespeare run throughout the book, signaling notions of romantic love.

Achieving stability through conformity and induced states of happiness, not

individual romances, are key ingredients in the brave new world. But John the

savage can neverbe happy there because itscivilization has poisoned him.

AlthoughhewantstojointhebanishedBernardandHelmholtz,heisdenied

doingsobecauseheisstilltheobjectof anexperimenttoamalgamatehim

into the culture.

In Huxley’s 1946 foreword to Brave New World, the author states that he

erred in not giving John the savage a third choice in addition to either a primi-

tive reservation life or insanity in utopia. He could choose to live in sanity on

the borders of the reservation within a “society composed of freely cooper-

atingindividualsdevotedtothepursuitof sanity,”wheretheloftyquestion

posed is, “How will this thought or action contribute to, or interfere with, the

achievement, by me and the greatest possible number of other individuals, of

man’s Final End?”

Related to today, Huxley’s brave new world of genetically engineered

humans shows us what might happen when measures are taken to control

andtoconditionus.Thefamilyunitisobsolete;chemicalskeeppeoplehappy.

A Brave New World 35

While presented as a utopia without disease and warfare, free will is lacking.

Consumption of goods that boost the economy, promiscuous sexual interplay

thatkeepsemotionalattachmentsfromforming,andtheredenitionof reli-

gion and the banning of history and art are all elements that keep the totalitar-

ian society intact.

Huxley’snovelpredicts theeugenicsissues wecurrently face,rst with

test-tube babies and now with human cloning. Fears center on the possibility

of cloning worker and controller types as well as stagnating gene pools. In

summary, Huxley’s caste system includes manufactured, conditioned, and con-

formed human beings. By contrast, our natural, so-called brute-force evolu-

tion drops genetic traits into an organism hoping for the best. There are many

failures and surprises. In the end, we must all wonder how biotechnological

intervention in the genetic process, such as the probability of human cloning,

will interfere with evolution itself and affect the human race.

Given the legal, ethical, and social backdrop of Huxley’s cautionary Brave New

World,weshouldaskourselvesthesemajorquestionsaboutgeneticengineering:

• Because scientists and the biotech industry have vested interests in

research, will our legislatures pass effective laws to prevent genetic

determinism(physicalandpsychological)andgeneticdiscrimination?

(Huxley’sAlphasarethegeneticallyengineered,advantagedfew.)

• What would happen if our world’s gene pool became controlled by

thescienticelite(Huxley’sControllers)?

• What is the present administration’s stand on approving the creation

of new stem cell lines for therapeutic use and/or reproductive cloning?

In our brave new world, which is a phrase spoken by Miranda in Shakespeare’s

The Tempest, wemustalldecide—notjustthescientists,philosophers,lawyers,

and clergy—where we want biotechnology to lead us as a human race.

Topics for Oral and Written Discussion

• What scientic, behaviorist, and psychological theories inuenced

Huxley and how?

• Describe Galton’s eugenics and relate it to twentieth-century U.S. steril-

izationmovements.

• How does Huxley’s totalitarian society control its people through art,

science, and religion?

36 Bioethics and Medical Issues in Literature

• How,specically,doesthebirth-to-deathBokanovkyProcesscreate

the class system?

• Unlike Huxley’s brave new world, our democracy gives power and

responsibility to each of us to decide where we want technology to

take us. If we were genetically determined through science and tech-

nology, rather than born freely through natural selection, how might

that change our society?

• What imaginable problems might arise from using biotechnology to

restore prehistoric DNA?

• Describe the ethical issues surrounding human cloning. Could it ever

bejustied?

• ReadGleick’s“chaostheory”(seebelow)anddescribetheinherent

dangers in gene manipulation, especially as they are set into our non-

linear world, where random, unpredictable and chaotic events over-

ride whatever type of order we try to impose.

• With each new administration, the president forms a bioethics council

for guidance. What are the current views on creating new stem cell

lines?

• Relate Huxley’s totalitarian state to the U.S. government’s increasing

control over its people since the September 11, 2001, terrorist attacks

on the United States.

Bibliography

Huxley, Aldous. Brave New World. New York: Harper, 1989.

Levin, Ira. The Boys from Brazil. New York: Random, 1976.

Suggested Further Reading

Atwood, Margaret. The Handmaid’s Tale. New York: Houghton, 1985. A

dystopia.

Cook, Robin. Shock. New York: Signet, 2001. A fertility industry exposé.

Crichton, Michael. Jurassic Park. New York: Ballentine, 1990.

Gleick, James. Chaos: Making a New Science. New York: Penguin Books, 1987.

Groopman, Jerome. The New Yorker(January28,2002).http://www.

newyorker.com.(ResponsetoKass,below.)

Kass, Leon R. “Why We Should Ban Human Cloning: Preventing a Brave

A Brave New World 37

New World.” The New Republic(17May2001).

Lem, Stanislaus. Solaris. New York: Harcourt, 1987. Understanding what lies

within us might be the key to understanding the universe around us.

McHugh, Maureen F. Nekropolis. New York: Morrow, 2001. The poor

voluntarily sell themselves into servitude, altering their brains to love

their masters.

Michison, Naomi. Solution Three. New York: Feminist P, CUNY, 1995. All

futurecouplesarehomosexual;reproductionisbyin vitrofertilization

and surrogacy.

Orwell, George. 1984. New York: Signet, 1950. Relates to whistleblower’s

claims that the U.S. government is using widespread illegal surveillance

onitscitizensin2013.

ROBIN COOK’S

COMA(1977)

This novel was conceived as an entertainment, but it is not

sciencection.Itsimplicationsarescarybecausetheyarepossible,

perhaps even probable.

  –RobinCook(author’snote)

Historical Context

Robin Cook, master of the medical thriller, was born in Brooklyn, New York,

in 1940. He received an M.D. from Columbia University and did post-graduate

work at Harvard Medical School. Since 1970 Cook has written about hot issues

intheevolvingmedicaleld.HisnovelsincludeOutbreak(1987),Vital Signs

(1991),andToxin (1998).Cook’s1999novelVector about a bioterrorist anthrax

attack on New York City foreshadowed the real-life event in 2001. He has a

knack for anticipating public debate on controversial topics, as in Shock(2001),

which describes the fertility industry and controversy over federal funding of

stem cell research. Each novel is compelling and informing, while also exacer-

bating the public’s fear.

38 Bioethics and Medical Issues in Literature

Theorgantransplantindustryisthesubjectof Coma. Each day in 2012

an average of 80 people inthe UnitedStates received anorgan transplant;

another 18 on the waiting list died because organs were unavailable. Driver’s

licensesandlivingwillsmayhaveanadvancedonordirective;however,family

membersoftenhavethenalword.Therefore,potentialdonorsshouldtell

family members of their wishes in advance. Living donors cannot donate if

it is life-threatening, with uncoerced, voluntary informed consent required.

Then there are brain dead donors whose cessation of brain stem function

is indicated from an EEG test. Because the brain makes a person breathe,

organ vitality is sustained by cardio-pulmonary machines. Ethical concerns

arise when harvesting from brain dead donors because brain death is a process

without a distinctly pronounceable event like cardiac death. Hospice profes-

sionals,inparticular,exerciseethicalcareinwithholdingfoodandliquidfrom

and administering narcotics to a patient with auditory and visual responses.

In a recent development, doctors who felt there was only a small window

of opportunity for harvesting most transplant organs, now look to a 2002 Uni-

versity Hospital Zurich study that shows transplant success in even harvesting

older organs from cardiac death donors. This goes beyond the conventional

wisdom that only a few organs such as corneas and kidneys remain viable

for a time in cadavers. In heart transplantation, brain death as a criterion is

distinctly different from cardiac death because only a recently beating heart

canbeharvested.Articial,self-containedheartsonlyextendlifeuntiladonor

heart can be transplanted. Bioengineering a human heart from stem cells trig-

gered to become cardiac cells is decades and billions of dollars away. Existing

stem cell lines declined when President George W. Bush placed a moratorium

on cloning to reap human parts. But each new administration forms policy

with the help of its bioethics council.

While most industrialized nations legitimize brain death as a condition

for organ harvesting, there are many cultural differences. In 1968 Dr. Juro

WadaharvestedJapan’srstandonlyheartfortransplantfromabraindead

donor and was heralded as a hero and condemned as a murderer. China’s pri-

mary source of transplantable organs comes from executed prisoners without

their consent. Transplant proponents argue that fear and ignorance are great

barriers to collecting transplant organs. Most major U.S. religions consider

donation the ultimate act of charity and condone it. Other views prohibiting

donation include the religious belief the body must remain intact in order to

A Brave New World 39

beresurrected in toto;the belief that organ harvestingfrom aviable body

equateswithabortion;andthebelief thatthesoulstillresidesinthebodywith

a beating heart.

Because transplant organs are hard to get, there is a current debate over

the donor’s motivation or the commodication of  tissues. The U.S.Organ

Procurement and Transplantation Act makes it illegal to buy and to sell human

organs. Because of the great gap between supply and demand, wealthy recipi-

entswouldhaveinequitableaccesstodonororgans.Rightnowonlyadonor’s

medical and funeral expenses are paid, so an American Medical Association

ethics group suggested a small payment of $300-500 or tax credits to increase

donation.

Crimesof thetwenty-rstcenturyinclude organtrafcking,andglobal

bioethics initiatives are underway to identify the foreign countries where poor

people are waylaid, drugged, and surgically relieved of their organs. Advertise-

ments appear from time to time offering a kidney for sale from $1-10,000.

Pirated organs may be a rarity, however, because complex donor-recipient

matching,therequiredsurgicalskill,andfollow-upcareareessential.Myths

abound, such as therecipientacquiresthedonor’sdesires(likingcertainfoods,

for instance), the donor is limited by age (minors need guardian consent),

donation mutilates the body prohibiting open casket funerals, and the donor’s

estate pays the medical costs.

Potential donors may be afraid that indicating their wishes to donate

will forestall efforts to save their lives, but safeguards are in place because

the donor’s medical team and the transplant team are two separate entities.

Besides,theorganprocurementorganizationisnotnotieduntilbraindeath

is determined. Kidneys and corneas are the most transplanted organs, largely

becauseof progressivesurgicalskillsandfewerrejectionfactors.Otherorgans

and tissues transplanted are the heart and heart valves, liver, pancreas, lungs,

intestines, eyes, skin, bone and bone marrow, and tendons. A national organ

donation network matches donors and recipients for blood type, medical

urgency, geographical location, and time on waiting list.

Because many people die waiting for a suitable organ, recent develop-

ments in transgenic cloningaremakingitmorefeasibletotransplantmodied

animalorgansintohumanswithfewerrejectionproblemsandcross-species

diseases(xenotransplantation).Buttherealbreakthroughcamein2002when

Dr. Anthony Atala of Harvard Medical School took a donor steer’s skin cells

40 Bioethics and Medical Issues in Literature

and created functioning tissues that were transplanted into the donor steer.

Three months later the implanted tissues remained healthy and were perform-

ing their respective functions. In the case of humans these same principles

apply to growing body parts using a person’s own DNA, or body parts may

derive from human embryonic stem cells, an issue mired in abortion politics.

Public opinion is sharply divided on creating new stem cell lines for therapeu-

tic versus reproductive cloning.

Regeneration technology is here. A decade later, Dr. Atala is incubating

replacement human bladders in his lab. There may be no limit to the kinds of

organs and body parts that can be created from scratch, taking a skin cell to

grow a heart valve or kidney, for instance. Until then, we still need to address

the nation’s ctirical organ donation shortage.

Synopsis of the Novel

Coma is written in suspenseful daily and hourly entries over several weeks. It

begins at Boston Memorial Hospital with Nancy Greenly’s minor D and C

procedure for excessive uterine bleeding. All seems to be going well when

suddenly Greenly’s heart beats erratically. She lapses into coma. The doctors

arebafed.Greenly’sdiagnosisiscerebralhypoxiaoroxygendeprivationto

thebrain.SheissenttotheintensivecareunitwhereaatEEGindicatesbrain

death.Shebecomesatube-fed,temperature-controlledmachinewhoseuid-

electrolyte balance and ability to ward off infection are critical. Homeostasis,

orabalanceof herbody’sfunctions,isdifculttomaintain.

 On her rst day as a third year medical student, the beautiful Susan

Wheeler enters surgical clinical rotation on the ICU ward, and she connects

with Greenly, also 23. She sees the comatose Greenly as “a casualty of medi-

cine, a victim of technology” and wants to understand what went wrong. In

her second encounter with a patient, Susan starts the I.V. on Sean Berman,

an athletic architect in for knee surgery. They make a date, but, like Greenly,

he falls into an irreversible coma. Later in the ICU, Susan’s superior, surgical

resident Dr. Mark Bellows, draws the comatose Berman’s blood for analysis

while the contentious Susan Wheeler grills Chief of Anesthesia Robert Harris

about the hospital’s high risk statistics. She decides to look into the problem,

but the realist, career-driven Mark Bellows bows out.

Susan’sinvestigationbeginswithscrutinizingthechartonNancyGreenly’s

A Brave New World 41

physical exam. Trained in the scientic method, her extensive research

continues in the medical school library on “anesthetic complications followed

by prolonged coma.” She discovers a long list of possible causative agents

for coma or disrupted brain function, and that her hospital had 100 times

morecaseslikeGreenly’sandBerman’sthantherestof thecountry(or11

deathsin25,000surgeries).Half ofthecaseswereneverreviewedbyamedical

examiner. Susan watches an autopsy and learns of the hospital’s high number

of unexplained respiratory arrests and resuscitation failures.

Susan tells Dr. Nelson, the chief of medicine, and Dr. Harris, chief of

anesthesiology, about her ndings and requests their help. One conscates

her research data, and the other physically threatens her. Both show her the

door, close it, and immediately make a phone call. Chief of Surgery Dr. Stark

seems more sympathetic to Susan, acknowledging that Dr. Donald McLeary,

a neurology professor, has signed out all the patients’ charts. When Susan tells

Mark Bellows about her encounters and her strong intuition of foul play, he

admits problems but asks for a possible motive. He sees no conspiracy, saying

he is more concerned with the cache of drugs found in his old OR locker.

Mark worries about Susan’s delusional crusade, but their relationship takes

another turn during a romantic date.

The next day Dr. McLeary advises Hospital Director Oren how disruptive

Susan has become, and Dean of Students Dr. James Chapman switches her

surgical rotation to the V.A. hospital. On her way home from the hospital, she

runs in panic from someone following her. Later that evening, the same man

accosts her at home and threatens her family if she continues her investigation.

After regrouping, Susan reviews her research and sneaks into Dr. McLeary’s

ofcetogetthecomapatients’charts.ShetellsMarkof theconspiracyshe

suspects involving Harris, Nelson, McLeary, and Oren. Mark informs her of

ndingDr.Waltersdeadinhiscondemnedhouse.Heleftasuicidenote.

SusandiscoversallthecomaincidentshappenedinOR8,andshendsa

carbon monoxide gas line running from a hidden boiler room tank connecting

to the oxygen line in OR8. Hoping to get some respite in her dorm room, she

insteadndsthehiredhitmanthere,andhechasesherthroughthevacated

hospitalcampus.Theyhaveagrotesqueconfrontationinthehospitalanatomy

lab.

In the meantime, Berman was transferred to the private Jefferson Institute

in South Boston, a state-of-the-art government-built facility for chronic care

42 Bioethics and Medical Issues in Literature

comatosepatients. Itis alarge rectangularbuilding withno rst-oorwin-

dows.Visitorsarenotencouraged,butSusanreviewsthebuildingplansonle

with the city and goes disguised as a nurse for a tour. The facility has advanced

computer technology that keeps 132 naked coma patients in homeostasis,

eerily suspended by wires four feet above the oor in a climate-controlled

atmosphere. As the tension builds, Susan goes exploring on her own in the

facility,intentonndingBerman’sbody.Sheenterswhatisindicatedonthe

oorplanasanOR,andsuddenlythemotiveforcreatingcomatosepatients

becomes clear: “The Jefferson Institute was a clearinghouse for black-market

human organs!” She is discovered but escapes. She calls Dr. Stark, telling him

the secret of the Jefferson Institute. Carefully typed surgical patients have had

carbon monoxide added to their anesthesia. In addition, they have received

shots of succinylcholine in their IVs, causing brain hypoxia, all of which was

undetected in the ICU. A secret corporation has masterminded how to keep

thebodiesaliveuntiltheirorganscanbeharvestedandsoldforbigprots.

SusanmeetsDr.Starkathisofce—hehaswarnedhernottotellanyone.

After drugging her, he talks about his three-year plan to create the Jeffer-

son Institute. The sale of its product helped rebuild Memorial Hospital, he

rationalizes.Thedrug-addictedDr.Walterswithacacheof narcoticsinhis

ORlockerwasnotapartof theorganization;hissuicidewasfakedonlyso

the police would not investigate the hospital. Dr. Stark’s transplant work, he

argues,will benetmankind,helping tolearnthe secretsof  immunological

mechanisms and to advance the transplanting of all human organs. Like Leon-

ardo Da Vinci, who secretly dug up corpses for dissection, he believes the

Jefferson Institute is also beyond the law. Sometimes secrecy is needed because

the common man would not understand the immense gain to be had for the

greater good.

Stark schedules the drugged Susan Wheeler for an emergency appen-

dectomy, administering the anesthesia in OR8. Dr. Bellows remembers what

Susan had said about the mysterious valved line and investigates, reaching the

ORjustintimetosaveSusan.ThepolicearrestDr.Stark,endinghisskewed

rationale for transplant research.

Literary Analysis

In Coma, Robin Cook, a trained medical doctor turned writer, describes the

carefullycontrolledchaosof amajorurbanteachinghospital.Hetakesusall

A Brave New World 43

over the hospital—from the dingy basement to the lofty Grand Rounds—put-

ting the American transplant industry under a microscope. The novel’s central

themerevealsthecontroversysurroundingoursearchtodenebrain death and

the way transplant organs are procured and disseminated. In his author’s note

Cook says he intends to entertain, but Comaisdenitelynotsciencection.

Hisbelief,whichcontradicts theU.S.transplant industry’sofcial stance, is

that scarce organs are pirated and sold to the highest bidder every day.

At the time he wrote Comain1977,healsosawasunacceptablethedeni-

tion of brain death, which, as noted earlier, is contrasted with cardiac death.

TheAmericanMedicalAssociationandvarioustransplantorganizationsare

trying to improve legislation to effect a greater number of donors by offer-

ingnancial and moralisticincentives,by educatingthe publicon theneed

for donor organs, and by dispelling myths and misconceptions. However, the

signicantproblemremainsof legallyobtainingthedonor’sandthefamily’s

timely permission to harvest organs. The revised Uniform Anatomical Gift

Act, promulgated in 1987, increased donor awareness but has not solved the

problem of providing enough transplant organs.

The way Cook describes the hospital hierarchy is important to weaving

Coma’s sinister plot. The viewpoint is mostly third-year medical student Susan

Wheeler’s.Shehasleftherintensivebooklearningandjuststartedherclinical

surgicalrotation,goingonthewardwithpatientsforthersttime.Sheand

four others are on the bottom professional rung. Doing scut work—and often

learning from the more competent nurses—they do not have much credibil-

ityandpower.Theydonothavemuchcondence,either,oftenfeelinglike

imposters. Small accomplishments, like successfully inserting an IV needle into

avein,causeeuphoria.Onestudentfaintsathisrstoperation,notanuncom-

mon happening. The bright and beautiful Susan Wheeler feels panicked, like

the rest: Could she make the life and death decisions expected of her?

Themedicalstudents’superiorsaretheresidents(rstyearresidentsare

oftencalledinterns).Wheeler’simmediatesupervisorisintermediatesurgical

resident Mark Bellows, who is responsible for her learning and for her actions.

GeorgeChandleristhechiefsurgicalresident,ajobMarkBellowscompetes

for. Bellows does not want to make waves when the spirited Susan Wheeler

tellshimof ahorrichospitalconspiracytoturnhealthypatientsintoprot-

able organ donors. Her investigation shows a high incidence of prolonged

coma resulting from anesthetic complications in surgery. But, one by one, as

44 Bioethics and Medical Issues in Literature

shenaivelyapproacheshersuperiors forhelp,they try toquash herefforts

with a patronizing response.In the patriarchal system of  Susan’s time,her

aggression makes her “a castrating bitch.” Conversely, if she had taken a pas-

sive, more compliant stance in her daily duties, she would be told that she

cannot compete. The hospital’s lower and upper worlds collide, all within the

terror of a conspiracy, and Susan’s life is threatened.

Because the book was written in 1977, time has changed the system some-

what. For example, Susan Wheeler describes the “paradoxical loneliness” of

being the only woman on her rotation, among all-male superiors: “She felt she

wasenteringamaleclub;shewasanoutsiderforcedtoadapt,tocompromise.”

Now, however, more women are entering medical school than men, but the

hospital hierarchy Cook describes is still in effect today.

As would be expected, Cook describes the antagonism existing between

medicine and disease. He also gives enough technical descriptions of opera-

tions and details of diseases and autopsies to satisfy pre-med students. Real-

istic accounts of the intricacies of applying anesthesia and of the drama of

performing surgeries add to the growing terror. Surgeons are seen as the con-

queringwarriors.Datedaccountsofcomputerizedmedicalresearchwillmake

today’s students appreciate what is currently available.

Interwoven into the high tension of a covert hospital conspiracy, Cook

portrays the problem of  drug-addicted doctors, the dehumanization in the

medicaleld,andthedoctor-patientrelationship.Forinstance,ahoardof nar-

cotic drugs is found in an attending surgeon’s hospital locker once assigned to

Mark Bellows. The hospital wants the investigation kept internal and private,

a conspiracy of silence. The story puts a spotlight on the medical profession’s

efforts to deal with stressed-out doctors whose narcotic licenses make it too

easy to self-medicate. Now programs help with recovery to return valuable

medical professionals to their work.

Also as shown in Coma,doctors’dehumanizingpatientsleadstoerrorsin

theirmedicaljudgment.Cook’sconspiratorialandcynicaldoctorsdetachfrom

any human connection with their coma victims, avarice and greed being chief

motivators. In fact, generations of doctors were taught to have “detached

concern” and not to get too close to a patient. But now having empathy is

linked with communication for better doctoring. An unnatural distance also

creates a level of dissatisfaction in the doctor-patient relationship and eventu-

ally physician burnout. Susan Wheeler’s human connection with her two coma

A Brave New World 45

patients, in particular, and her attention to detail sustained her investigation

all throughout Coma. To borrow from legendary humanist doctor Sir William

Osler, with patients as texts, the best teaching during clinical rounds is done by

the patients, themselves.

Topics for Oral and Written Discussion

• When,if ever,isitjustiabletosacricethefew,medicallyspeaking,

forthemajority?

• Whatculturalandreligiousdifferencesinuenceorgandonation?

• What motivated Dr. Stark and others to create coma patients?

• Whilemoststudentsontheirrstclinicalrotationfeelinsecureand

like imposters, what special problems does Susan Wheeler have being

the only woman “in a male club”?

• Howdoesadoctor’slackof communication(orempathy)contribute

to medical mistakes?

• How can potential organ donors indicate, in advance, their wishes?

• What is the different between “brain death” and “cardiac death” in

harvesting organs?

• Howwillthecommodicationof organschangewhentheycanbe

grown from cells?

• What are the problems with xenotransplantation?

• How do the differences in the hospital hierarchy contribute to Cook’s

plot?

Bibliography

Atala, Anthony. “Regenerative Medicine’s Promising Future.” July 10, 2011.

TED 20 March Conference. http://www.cnn.com/2011/

opinion/07/10/atala.grow.kidney/index.html. Around the globe research

is ongoing into the new frontier of regenerative medicine, curing disease.

Dr. Atala, now the director of the Wake Forest Institute for Regenerative

Medicine in Winston-Salem, North Carolina, explains how he “prints”

replacement organs like kidneys.

Cook, Robin. Coma. New York: Signet, 1977.

U.S.Government(organtransplants):www.organdonor.gov

46 Bioethics and Medical Issues in Literature

Suggested Further Reading

Ash, Karin T. “Accident.” Sutured Words and Articulations. Ed. Jon Mukand.

Brookline, MA: Aviva Press, 1987. A nursing perspective on caring for a

patient in a persistent vegetative state.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science. New

York: Holt, 2002. Medical mistakes, trends, and mysteries.

Hilker,David.“Mistakes.”On Doctoring. Ed. Richard Reynolds and John

Stone. New York: Simon, 1991: 371-82

Selzer,Richard.“BrainDeath:AHesitation.”The Exact Location of the Soul.

New York: Picador, 2001: 110-20. A surgeon looks at “brain death” and

wonders.

— “Whither Thou Goest.” The Doctor Stories. New York: Picador, 1998: 64-2.

A Christian fundamentalist donates her husband’s heart and must listen

to it one last time to go on with her life. Also readers’ theatre.

Shem, Samuel. The House of God. New York: Dell, 1995. A cynic looks at

internshipyearandhowresidencyisselected(money,lifestyle,etc.)

Williams, William Carlos. “Old Doc Rivers.” The Doctor Stories. New York:

New Directions, 1984: 13-41. A beloved old-timey doctor self-medicates.

Chapter Three

Contagions/Isolations: An Analysis of Albert

Camus’ The Plague and David Feldshuh’s

Miss Evers’ Boys

Introduction

Camus,aWorldWarIIFrenchResistanceghter,wroteThe Plague, intending

“plague” torepresent all imprisonments. It characterizesthe despair felt in

occupiedFranceduringthe1940swhenNazismsneakeduponEuropeand

almostdestroyedit.Aworkof greatliteraryimagination,itemphasizesthe

re-emergent nature of all contagions, shedding light on contemporary plagues

such as AIDS. At issue is how the government and medical personnel in the

unsuspecting town of Oran, Algeria, fail to enforce in a timely manner the

city medical code by identifying the scourge, putting a vaccine into use, and

isolatingthetownfromtheoutsideworld.Therearequestions,aswell,about

media responsibilities in a medical crisis, illustrating how desperate people fall

victimtoquackeryandsuperstition.Eachcharacterinthenovelisexiledfrom

the outside world and deprived of not only food but love, teaching us lessons

about its importance to wellbeing and to happiness.

InOran’scollectivedestinyoneself-sacricingdoctorworkswithin the

community’s changing dynamics, highlighting political, social, economic, and

religious issues. In the unrelenting nature of plague his medical ethics are

challenged, provoking philosophical discussions about man’s morality in an

atmosphere of every-man-for-himself. The label heroismisalsoscrutinizedasa

descriptorsubjecttoexaggerationandabuse.InOran’sdiresituation,thetac-

ticsof thespiritualleaderarescrutinizedwhen,ratherthanprovidingcomfort,

hestrikesfearintoheartsbypreachingthatGodafictedthemwithplagueas

punishment. In the end, people die off, and the government and priests seem

ineffectual,leavingthereadertoappreciatethevalueof aselessdoctorand

to contemplate his warning that literature teaches the plague never disappears

for good.

48 Bioethics and Medical Issues in Literature

Just as in early views of plague, sexually transmitted diseases carry sig-

nicantstigmaasdeservedpunishment.Theprimaryissuein Miss Evers’ Boys,

however, is how the U.S. Public Health Service conducted clinical experiments

during the Tuskegee Syphilis Study(TSS)from1932-1972,andhowdoctors,

intheirscienticfervor,forgottheblacksubjectswerepeoplelikethemselves.

A brief look back at racial discrimination helps to put Miss Evers’ Boys in

context.Itdidnotendwiththe1863EmancipationProclamation,fortiedin

1865 by the Thirteenth Amendment’s abolition of slavery. Segregation during

the next decades of the so-called Jim Crow Era kept stereotypes of African-

Americans intact, hurting them economically, politically, and educationally.

Only with the Civil Rights Act of 1964, shepherded in by President Lyndon

Johnson, did racial segregation and discrimination become illegal in all of the

states.

For the 40 years of the TSS in a climate of segregation, the U.S. Public

Health Service looked on as 399 syphilitic black men suffered and infected

others.Thesubjectsreceivedthestandardof careinthebeginningbutwere

denied the silver bullet treatment, penicillin, until a whistleblower exposed the

injustices.In1997PresidentClintonformallyapologizedtothefewsurvivors,

calling them “a living link to a time . . . many Americans would prefer not to

remember, but we dare not forget.” Calling the study a betrayal by medical

people who should have offered care and a cure but instead lied and denied

help, he continued: “What was done cannot be undone. But we can end the

silence. . . . What the United States government did was shameful, and I am

sorry.“ The National Center for Bioethics in Research and Health Care has

emblazonedthesewordsonitswebsite,afterreceivinga1999federalgrantto

establishacenterthatmemorializestheTSSparticipants,hopingtoprevent

future ethical lapses in minority studies.

OtherissuesarisefromDavidFeldshuh’shistoricalmedicalction.Where

there is a legacy of distrust in the African-American experience, how do you

get subjects in research that benets them? And what lessons have public

health bioethicists learned from the TSS for reviewing protocol in current

infectious disease research studies?

Contagions/Isolations 49

ALBERT CAMUS’

THE PLAGUE(1946)

As he listened to the cries of  joy rising from the town, Rieux

rememberedthatsuchjoyisalwaysimperiled.Heknewwhatthose

jubilantcrowdsdidnotknowbutcouldhavelearnedfrombooks:

that the plague bacillus never dies or disappears for good. . . .

—Albert Camus, The Plague

Historical Context

The Algerian-born French philosopher Albert Camus(1913-60)wasanovel-

ist, dramatist, andjournalist. His father waskilled in World War I, andhis

illiterate and deaf mother raised him and a brother in poverty, making for a

very unhappy childhood. He studied philosophy at the University of Algiers,

quittingforawhileforhealthandnancialreasons,buthegraduatedin1936.

Camusheldavarietyof jobsandjoinedandquittheCommunistparty.He

livedinpovertymostof hislife,andbeingafictedwithtuberculosismoti-

vated him to write about contagion and isolation. He moved to Paris in 1940.

During World War II he became a member of the French Resistance. He

wrote political essays, but his most famous work is The Plague. Camus viewed

man’s condition as absurd and meaningless, which aligned him with the exis-

tentialists;however,inThe Plague he describes how courageous humans can be

when faced with increasing alienation in an indifferent world. In 1957 Camus

receivedtheNobelPrizeforLiterature.Hediedinanautomobileaccidentin

1960 at the age of 46.

Literary views of plague, besides appearing in Greek mythology, are

described in the Bible’s Exodus: God brought 10 plagues upon the Egyptians

until the Pharaoh let the Israelites go. Ever since it has been seen as a deserved

punishment. For the next 800 years plague, which could be bubonic plague,

smallpox, or gonorrhea, descended upon unsuspecting populations, brought

by trade routes and war. It drastically reduced populations and brought famine.

Western Europe was relatively disease-free from 800 until the fourteenth cen-

tury,andmedievalcivilizationourished.ThentheBubonicPlague(1348-50)

hit Europe, killing more than 25 million people, both peasants and gentry,

bringing a great recession to Europe. Sienese chronicler Agnolo di Tura wrote,

50 Bioethics and Medical Issues in Literature

“No one wept for the dead because everyone expected death himself.”

The bubonic plague (Greek boubon, meaning“groin”), a disease caused

by the bacterium Yersinia pestis,spreadsfrominfectedrodent’seasthatbite

humans, causing their lymph glands to swell. In advanced cases the skin turns

black, hence the alternate name, the Black Death. The plagues had high mor-

tality rates. Up to two-thirds of the population died in each epidemic. When

the attacks lessened, so did the immunities, and populations became vulner-

ableagain.OnlyarecouldcontaintheGreatPlagueof Londonof 1665.

Anineteenth-centuryincreaseinhygiene,purerwatersupplies,andefcient

garbage disposal decreased European plague epidemics. But in 1894—to show

the global nature of contagion—plague killed 100,000 in Hong Kong. Plagues,

exacerbated by famine and warfare, change the political, social, economic, and

religious dynamics of a country forever.

Contrary to popular belief, the bubonic plague is not a thing of the past,

although it is an extremely rare, sporadic event. About 20 cases appear in the

U.S. each year in endemic areas of the rural West. For people treated with

antibiotics,recoveryisimminent.Themedia,however,cancausequiteastir

by recalling the Black Death that had devastated medieval Europe. Plague, a

naturally occurring bacteria and generally not a public health threat, is pre-

ventable by washing hands with soap and water and being wary of handling,

dissecting,orskinningwildanimals.Peopleshouldwatchoutforeasorticks,

keep yards clean, and properly dispose of garbage that attracts rats. Ironically,

the second-century Greek physician Galen announced that poisonous swamp

vapors spread plague, so people did not wash, believing opened pores in skin

would let it in.

Other epidemics of  inuenza, smallpox, polio, and tuberculosis have

killed millions of people. So-called modern plagues, such as HIV, the human

immunodeciencyvirus,thatprogresses intoAIDS,acquiredimmune de-

ciencysyndrome,havebeenidentiedacrosstheworldinallstrataof human

life,leavingAfrica,India,China,andRussiaincrisis.Itrevitalizesfearsabout

arapidlyglobalizedworldwith everyoneinclosecontact,and immigration,

prostitution,andurbandecayascontributingfactors.ItallreectsonLouis

Pasteur’s observation, “The microbe is nothing, the terrain is everything.”

Synopsis of the Novel

Camus’ The Plague, divided into ve parts, chronicles the yearlong story of 

Contagions/Isolations 51

Oran,adismalcommercialseaportbattlingtheplague.OneneAprildayin

the 1940s Dr. Bernard Rieux, a 35-year old physician preoccupied with sending

his ailing wife to an out-of-town sanitarium, steps on a dead rat. Police mag-

istrateM.Othonnoticesothers.Later,ParisianjournalistRaymondRambert

interviews Rieux for a story about lack of sanitation in the Arab population,

but because the publication will compromise the truth, Rieux steers him to the

dead rat story instead. Rieux’s friend, Jean Tarrou, tells him about seeing more

convulsing, dying rats. All but the doctor’s mother, who comes to keep house

forthedoctorandhisson,areunsettledbytheevents;shehaslivedthrough

war, depression, and a husband’s death.

Deadrats beginappearing by thethousands.Thenjust whena sudden

drop in the numbers causes the town to feel hopeful, the concierge M. Michel

hasfever,thirst,delirium,anddies.Heistherstplaguevictim.Rieuxfailsto

make the diagnosis, and only his old asthmatic patient who survived the 1812

Spanishurecognizeditastherstphaseof anepidemic.Withincreasing

deaths,Rieux realizesthe plaguehas takentheir ordinarytown by surprise,

justasawarmight.Thecitygovernmentissuespropagandabulletins,treating

it as a problem of bad hygiene and sanitation. It takes too long to apply the

municipal medical code. Dr. Castel, who had seen plague in France and China,

develops a vaccine, but there is only a limited supply. Three months into the

plaguethereare700deathsaweek.Withoutquarantine, the epidemic rages out

of control,andthegatesof Oranarenallyclosed.

Rieux’s medical duties never end as he connects with the isolated towns-

people.Forexample,thebureaucrat JosephGrandcondesinhimthathis

failed marriage resulted from his working too much. He did not make his wife

feel loved or offer her hope for a better future. He remains commerce-driven

andloveless,obsessedwithwritingtheperfectnovel.ThejournalistRambert

asksDr.Rieuxtocertifyhimplague-freesohecanleavethecitytojoinhis

lover. Rieux, taking a moralistic stance, cannot oblige. Sending patients into

quarantine,separatedfromlovedones,andwitnessingdailysufferingandpain

cause Rieux to harden his heart.

FatherPaneloux,thecity’smainspiritualleader,deliversaerysermon

at the end of a Week of Prayer. Citing Exodus in the Bible, he preaches that

plagueisadeservedscourgesentas“punishmentfortheirsins,”justasGod

had brought plagues down on Egypt “to strike down the enemies of God” and

to “humble the proud of heart.” It will separate out evildoers, or the wheat

52 Bioethics and Medical Issues in Literature

from the chaff. Salvation, he concludes, only comes to repentant sinners who

embrace God’s teachings. Paneloux’s sermon creates widespread panic among

the “condemned,” especially when a new form of bacillus, pneumonic plague,

causes terrible suffering and seems vaccine-resistant. Adding to the pressure,

supplies dwindle, and dogs and cats are killed as possible carriers of plague.

Newspapers warn of long imprisonment for breaking rules. A new paper, The

Plague Chronicle, publishes the progress or recession of the plague, but is prone

toquackery,advertising“infallibleantidotesagainstplague.”

Some people scramble after the latest amulet, while others pore their

hearts out into recovery efforts, causing Dr. Rieux to make observations about

heroism. He cautions against “attributing over importance to praiseworthy

actions,”whichmaypandertotheworsesideof humannature;thatis,heroes

should not be coined from acts of normal human decency. To Rieux, Grand,

who volunteers torecord plague statistics, embodies quiet courage because

he does so with the “large-heartedness that was second nature with him.”

Grand believes he is simply taking a stand. Rambert is another matter. Rieux

ndsRambert’spersistenceadmirable.Buthehasbeensoobsessedwiththe

challengeofescapethathehasjustaboutforgottenhismotivation:tobewith

the woman he loves.

Mostcitizensof Oranareslackers,resignedtobeingplaguevictims,and

by mid-summer plague reaches crisis levels. Martial law and curfews help con-

tain areas of town cordoned off, but panic strikes. Townspeople, hoping to

killplaguebyburning their homes,setres thatoftenrageout of  control.

In a holocaustof  connement and of  deprivation, “No longer were there

individualdestinies;onlyacollectivedestiny,madeof plagueandtheemotions

shared by all.” With mass burials, there are no more individual death rites. Iso-

latedpeoplefeelthegnawingpainof separationandnowfaceanunagging

adversary that kills off the capacity for both love and friendship.

In the fall the “town lay prostrate, at the mercy of the plague.” Survivors,

gripped by fear, carry on, sometimes reecting sentimentally on what had

been. At a performance of Gluck’s opera Orpheus, the plague-stricken tenor

collapses on stage. Meanwhile, the godless Rambert still plans his escape,

rationalizingthatheneedsanotherhumantogivehislifemeaning.But,over-

whelmed by shame, he has a change of heart, deciding the plague is everyone’s

ght. The battle gets particularly poignant when the new Castel vaccine is

rsttriedonM.Othon’syoungsonPhilippe.Inthenalstageof thedisease,

Contagions/Isolations 53

Philippe’s vaccination is ineffective, and, after great suffering, he dies. The inci-

dentcausesgreatmoralizingamongRieux,Castel,andPanelouxabouthow

an all-powerful God can allow little, innocent children to suffer. Something

changes in Paneloux after he sees Philippe die. It causes his second sermon to

reectonthenatureof goodandevilandtosuggestthat“thechild’ssuffer-

ings would be compensated for by an eternity of bliss awaiting him.”

These are extraordinary times, Paneloux warns, and God is testing every-

one.Inthisghtagainstevileitheryouaresavedordamned.With“noisland

of escape in time of plague,” echoes of fatalism ring throughout the church.

For Paneloux everything is in God’s hands. Later when his temperature spikes

and he coughs up blood, he declares that it is illogical for a plague-stricken but

faithful priest to call in a doctor. With this resolve, he dies. Then the epidemic

reaches its high watermark with people scrambling to purchase waterproof

clothing,believingrubberizedmaterialwillsafeguardagainstinfection.With

the new pneumonic form of plague spreading, fatalities increase across town.

Thenewspapers,asorderedbytheauthorities,projectafalseoptimismnoone

believes.

Toward the end, Tarrou has a heart-to-heart talk with Rieux about the

plague within all of them. His father, a public prosecutor, was a kindly man,

although an adulterer. But one day Tarrou learned his father prosecuted a

young criminal condemned to die. From that day on, he considered his father a

murderer. He left home, becoming an advocate against the death penalty. After

a long talk, Tarrou and Rieux take a symbolic swim together. As Christmas

approaches, they all have become weary in the prison of plague. For Rieux,

facing death and despair every day has taken its toll on him. He concludes that

“a loveless world is a dead world.”

Then one day, Rieux notices that rats have not been seen for a while, and

the human death toll is subsiding. With hope restored, the authorities open the

gates. The new serum is working, and it seems “the plague had been hounded

down and cornered, and its sudden weakness lent new strength to the blunted

weapons so far used against it.” Rieux even dares to envision a reunion with

his long-absent wife when Tarrou is stricken and dies, the victim of two types

of plague. Rieux had been unable to help.

While lamenting the loss of a friend, Rieux gets a telegram stating his wife

has died of tuberculosis, which he has been powerless to cure. He has lost the

human love of a friend and of his wife, but there is no time to grieve. While

54 Bioethics and Medical Issues in Literature

listeningtothetownspeople’scriesof joyatanticipatingtheendof plague,

heseesadogdigateas.Heknowstheplaguebacilluscanliedormantfor

yearsandyearsinfurnitureandlinen-chests;thatitbidesitstimeinbedrooms,

cellars,trunks,andbookshelves;andthatperhapsthedaywouldcomewhen,

for the bane and the enlightening of men, it would rouse up its rats again and

send them forth to die in a happy city.

Literary Analysis

This analysis focuses on the social, political, economic, and religious aspects

of the plague’s effect upon the North African coastal town of Oran, Algeria,

population400,000.CamuswasaWorldWarIIFrenchResistanceghterwhen

he wrote The Plague.Itsallegoricalsignicancebeginswiththeepigraph,setting

thetonefortheplaguetosymbolizethescourgeof Nazismandtorepresent

occupied France during the 1940s as well as all imprisonments, past, present or

future.ThroughlinkingplagueandNazism,Camuswarnsthereadertolearn

from history and the literature that encapsulates it.

In an atmosphere of unrelenting gloom, his riveting novel asks us to con-

siderthevalueof humanlife.Itdescribesthecourseof adiseaseatitsrst

inkling,toisolatingthecityfromtheoutsideworld,tonallyopeningthegates

almostayearlaterunderthepresumptionthegoodghthaswonoverthe

horricdisease.Thenarrator,whoisnotidentieduntiltheend,reliesondata

collection,eyewitnessaccounts,andofcialdocumentstoreportthemedical

effects of plague on Oran. In the unattractive seaport the people are so habitu-

ally intent on commerce that the town even faces away from the life-enhancing

waters of the Mediterranean Sea.

Existential viewsof ndingmeaningindailyaccomplishmentsandaccept-

ingearthlyexistenceasnitegeneratefromCamus’work.InOran’scollective

destiny where death is wide-scale, one man, Dr. Bernard Rieux, stands out for

hismajorcontributionsandself-sacrice.Heworkswithinthecommunity’s

changing dynamics, showing the unrelenting nature of plague and provoking

philosophical discussions about man’s moral duty to preserve life. Every day

the suffering he witnesses causes him to confront loneliness, and during non-

stop medical rounds only minor victories bring triumph over universal despair.

Ironies abound in the novel, starting with the medical authorities’ failure

tofacethetruth,fearingtheymightalarmcitizens.Atrst,thegovernment-

run newspapers give daily tallies of dying rats, but they omit human deaths.

Contagions/Isolations 55

Relying on faulty statistics, Rieux is slow in identifying the scourge. There is

a standoff between Rieux, who simply wants to convince the authorities to

take proper medical measures to save lives, and the politicians, who are afraid

of losingtheirpositionsshouldtheyerrinjudgment.Thesituationgenerates

an atmosphere of every-man-for-himself, except for Dr. Rieux who ministers

to all. The government’s ineffectual response provides a study in bureaucratic

reaction to infectious disease, where martial law and curfews cause panic and

attempts to vaccinate are often too little, too late.

Although Dr. Rieux urges isolation, medical association president Dr.

Richard balks. Only Dr. Castel, who has seen plague in China and France,

takes a stand. He invents a vaccine that is immediately in short supply and then

becomes obsolete when a new pneumonic plague emerges. The authorities

have the newspapers report a false optimism no one believes. In desperation,

peoplefallvictimtomedicalquackery, from believing a winery’s slogan that

consuminglargequantitiesof winecreatesimmunity,toanewPlague Chronicle’s

ads for “infallible antidotes.”

The Plague is a good character study as well, showing how various people

copeinforcedisolation.Inthishumandramaseveralpeoplejoininsolidar-

ity with Dr. Rieux to battle their common enemy. In particular, Rieux’s pro-

fessional ethicsare apparentwhen heasks theParisianjournalistRaymond

Rambert to write the whole truth of their situation in Oran. Then, later, when

Rambert,whondshimself inthewrongplaceatthewrongtime,begsRieux

to certify him plague-free so he can return to a lover he calls his wife, Rieux

cannot, for “the law was the law.” All live in a state of constant fear, and their

vulnerability is brought home to them when even during Gluck’s opera Orpheus

the tenor collapses on stage. The opera’s theme evokes Rambert’s attempt

to reunite with his loved one; however, when weighingpersonal happiness

againstthegreatergood,hesimplycannotabandonhisfriendsandtheght.

Rieux’s friend, the newcomer Jean Tarrou, symbolizes the resistance

ghterwhoorganizesvolunteers.DutyforTarrou,likeRieux,isparamount,

even if he’s the lone survivor who remains to wash dead bodies. His moralistic

codeissimple:asagoodpersonhemuststayandghtthebattle.ForTarrou,a

threshingmachinesymbolizestheauthoritiesandtheplaguethatinictsdam-

age upon the victim. His black-and-white morality took hold when, as a youth,

he witnessed his prosecutor father cause a young criminal to die. Tarrou’s swim

in the sea with the young healer, Rieux, binds their friendship, until a whirlpool

56 Bioethics and Medical Issues in Literature

forces them to shore. Tarrou is the counterpart to Cottard, the symbolic col-

laborator, a criminal who attempted suicide, but once the authorities became

preoccupied, he turned to smuggling.

In another criticism of bureaucracy, Camus portrays the municipal clerk

Joseph Grand as a daily plodder so absorbed in work he does not know his

neighbor. He represents the townspeople of Oran who with their noses to the

grindstoneletthesmalldetailsof dailylivingoverwhelmitslargersignicance.

Grand’s wife leaves because he cannot show her affection and cannot promise

hope for the future, but he persists in trying to write a great novel. Finding the

rightwordforGrand’srstsentenceservesasadiversionforRieuxandothers,

acting as the novel’s leitmotiv to represent the indomitable human spirit.

Rieux contrasts Grand’s ingrained work habits, overlaid by routine vol-

unteeractivities,withRambert’smoredramaticdecisiontostayandtoght.

Thiscauseshimtoreectonthenatureof morality, or acting well in a given

situation.Rieuxtheorizesitwouldbesimplyunconscionableforthedecent

man not to respond, and therefore it is inappropriate to make him a hero. That

is,tofreethemselvesasprisonersof plaguerequirescommondecency,simply

doingajobweekbyweek.Inatownwheremanysurvivorshavebecomecyni-

cal, Rieux sees Grand as the closest to a hero for maintaining a business-as-

usual sanity. Grand has no illusions about the dire situation. He acts well in it,

exemplifying ingrained integrity, which reminds us that standards to measure

goodnessareimperfectandthatusingthelabel“hero”maybesubjecttoexag-

geration and abuse.

Each in his own way faces the plague’sdesolation,reectingthecondi-

tions of World War II prisoner-of-war camps. Lacking freedom and at times

minimalsustenance,somequestionGod’sexistence.TheJesuitpriestFather

Paneloux’sre-and-brimstonesermonendingtheWeekof Prayerstrikesfear

into the hearts of the people. He does not hold out God’s love for their salva-

tion but rather uses Christian doctrine as a threat to bring the commerce-driven

townspeoplebackintohisfold.HerstpreachesfromExodus that God sent

plague down on Oran to separate the wheat from the chaff, the believers and

nonbelievers, and that He was punishing them into becoming better people.

A small child dying a horrible death after receiving a vaccination prompts an

orthodox religious discussion. Rieux cannot understand how God would let an

innocent child suffer so, but Father Paneloux says humans cannot understand

“what is meant by ‘grace.’” The incident causes Paneloux to soften the tone of

Contagions/Isolations 57

his next sermon.

Suffering increases as the pneumonic vaccine-resistant plague takes hold,

and so do discussions of religion. Father Paneloux, Rieux feels, is theoretical,

not attuned to human suffering, and cannot possibly know the truth of their

dire situation as does he who takes the bedside vigil. How can plague have a

good side by helping “men to rise above themselves”? Life is sacred, period,

and Rieux, even if seen as prideful, must relieve suffering and pain through

whatever means available. A thinning congregation now wears prophylactic

St. Roch medals, and superstition has usurped the place of religion. Priests,

like government, become ineffectual as people die, and mass burials take the

place of religious rites. The priest Paneloux succumbs to the plague and dies,

believing until the end that his faith, only, would protect him, and that he had

no need of a doctor.

Dr. Rieux is seen as a true healer, a saint, for whom there is no rest. With

asinglenessofpurposehecarrieson,quarantininginfectedpeople.ByChrist-

mastime, the death toll is subsiding so the town plans to open its gate. Grand

seems infected and burns his manuscript, then recovers to renew his efforts.

Unpredictably, the valiant Tarrou contracts the plague and succumbs about the

same time Rieux receives word that his wife has died.

In the end, Rieux, whose exhaustion might leave him prey to crippling

emotions, understands “No resource was left him but to tighten the strangle-

hold on his feeling and harden his heart protectively.” For him, the relief he

needed to maintain sanity, in his wife’s absence, must come from his mother’s

unconditional love. With the disease lessening, Cottard’s fears return, and he

goesinsane;Rambertgreetshisloverattheopengates;andGrandreturnsto

what he hopes will be a literary masterpiece. Dr. Rieux, who we learn is the

narrator, focuses on nishing his plaguechronicle to providea lesson that

plague can strike the strong and weak at any time.

Topics for Oral and Written Discussion

• Denebubonicplagueanddiscussitshistory,symptoms,andrem-

edies.

• Whatistheallegoricalsignicanceof The Plague?

• Discuss Camus’ views in The Plague of suffering, death, and religion.

• What do Dr. Rieux’s relationships with Tarrou, Grand, and Rambert

reveal about his morality?

58 Bioethics and Medical Issues in Literature

• Howarethemajorthemesof isolationandsolidarity,sufferingand

the value of human life, and hope and despair played out in the novel?

• What roles do women play in the novel, especially Dr. Rieux’s sup-

portivemotherandM.Othon’swife,whoghtstoreleaseherhus-

bandfromquarantine?

• What lessons should we learn from Camus’ description of the

increasingly complex and symbiotic relationship between the media

and medicine?

• Relate The Plague’sdescriptionofwavesof plague,ebbingandowing,

to a recent newspaper account of a viral outbreak in your community.

• In light of Dr. Riuex’s views on heroism, who, in your estimation, is

a true-life hero?

• How does AIDS, a modern global disease challenge, shatter the illu-

sionthatindustrializednationsareimmunetoepidemics?

Bibliography

Camus, Albert. The Plague. Trans. Stuart Gilbert. New York: Random-Modern

Library, 1948.

Suggested Further Reading

Cook, Robin. Outbreak.NewYork:Berkeley,1988.Auepidemicsweepsthe

country.

Crichton, Michael. Andromeda Strain. New York: Ballentine, 1969.

Defoe, Daniel. Journal of the Plague Year. New York: Modern Library Classics,

2001.Anaccountof theGreatPlagueof London(1664-65)rst

published in 1722.

King, Stephen. The Stand. New York: Doubleday, 1991.

Maugham, Somerset W. Of Human Bondage. New York: Penguin, 1992.

Tuberculosis.

Selzer,Richard.“AMaskontheFaceof Death.”The Exact Location of the

Soul. New York: Picador, 2001: 121-133. AIDS in Haiti.

Contagions/Isolations 59

DAVID FELDSHUH’S

MISS EVERS’ BOYS(1990)

By too much frolickin’ you can get a dangerous sore down below on

your private parts and through that sore a bug can crawl inside you

and you won’t even know it. And then that bug goes to sleep for

twenty or thirty years so it’s not hurting anybody but you. Because

when it wakes up, you can’t walk, you can’t breathe, you can’t think.

That’s bad blood. That’s what you got.

—Nurse Evers in Miss Evers’ Boys

Historical Context

Syphilis is a chronic, contagious systemic disease caused by the microscopic

bacterial spirochete Treponema pallidum. It cannot survive for long outside

the body and enters through mucous membranes or skin, typically sexually

transmitted(venereal);passingfrommothertounbornchild(congenital);or

spreadingthroughbloodtransfusions.Itsfourrecognizablestagesareprimary,

secondary,latent,andtertiary.Treatmentshouldbeginatrstindication,usu-

ally when, in the sexually transmitted kind, a chancre or lesion appears on the

genitals within four to six weeks of infection. If untreated, the secondary stage

from six to 12 weeks after infection includes headache, fever, nausea, swollen

lymph nodes, rashes, sore throat, and fatigue. Lesions may persist, and grayish

patches with red areolae may occur in the mucous membranes of the mouth

andgenitalregion.Hairpatchesoftenfallout(alopeciaareata).

After three months, symptoms may come and go but the whole body is

now infected as bacteria invade vital organs, bone marrow, and the central

nervous system. During a period of latency, from a few years to the end of

life,theafictedmayappearandfeelnormal,exceptforvaguediscomfortsor

eye disorders. But one-third of untreated infections develop into the dreaded

tertiarystage,oftenmanyyearsafterrstinfection,bringingpainfullesionsor

tumors. By this time, the bones are eaten away, and an infected brain and heart

lead to insanity and then death. Syphilis is contagious until its latent stage. In

developed countries antibiotics given for other indications may cure undiag-

nosed syphilis, and aggressive public health education helps contain its spread.

Christopher Columbus, who exposed vulnerable American Indians to

pathogens such as smallpox and measles, is commonly blamed for bringing

60 Bioethics and Medical Issues in Literature

syphilis back from the New World to the Old World. However, new forensic

research might prove syphilis existed in Europe before 1493. What is known

isthatattheendof thefteenthcenturyagreatsyphilis epidemic hit Europe,

with the rate of infection in French soldiers so horrendous it stopped a planned

invasion of Italy. Since then, syphilis has been called the French Disease. Early

treatments included mercury ointments, oral applications, and vapor baths that

usually did more harm than good. Often “sinful” syphilitics were isolated in

leper colonies or hospitals. Later in the 1800s potassium iodide was an effec-

tive treatment.

The breakthrough came in 1905 when German microbiologists Schmudinn

andHoffmanidentiedthebacteria.Theirimportantdiscoveryledin1906to

the Wasserman test for detecting syphilis and in 1908 to Paul Ehrlich’s arsenic

treatment, Salvarson(meaning“Isave”).Salvarsonwasalandmarksilverbullet

techniquethattargetedadiseasewithoutinictingundueharmonthevictim.

Ironically, with the advent of Salvarson came a strange backlash. Elements of

society believed giving a cure to the sinful intervened in God’s punishment of

them and promoted promiscuity. Nonetheless, only one in 100 treated patients

recovered until, in 1929, British bacteriologist Alexander Fleming ushered in

the antibiotic era with his accidental discovery of penicillin. Although not

widely used for 15 years, it is still used today, even though bacteria continually

evolve into penicillin-resistant strains.

In Macon County, Alabama, in 1932, the U.S. Public Health Service began

the Tuskegee Syphilis Study(TSS)among600poorAfrican-Americanmen,

who were later excluded from new penicillin treatments. Researchers, who

believed syphilis developed differently in blacks, wanted to study the popula-

tion to improve health conditions in the rural South. For the next 40 years,

399subjectswithlate-stagesyphilisand201disease-freesubjectsinacontrol

group received free meals, general medical care, the Surgeon General’s signed

certicateof appreciation,anda$50burialstipend.Evenaftertherewaswide-

spread knowledge that penicillin could cure syphilis, only protiodide, iron, and

placebos(sugarpills)weregiventothestudysubjects.Painfulspinaltapscalled

“backshots”extracteduidfromthemen’sspinalcordsforneurologicaltest-

ing, with aspirin the only analgesic.

In a simultaneous assault on humanity vastly more extensive in scope,

aftertheNazisseizedpowerin1933,GermandoctorssuchasJosefMengele,

the Angel of Death, used concentration camp victims as human guinea pigs

Contagions/Isolations 61

inatrocious experimentsincluding freezing,burning, andvivisection.In an

effort to accomplish “racial hygiene” to build a master race, there were forced

abortions,sterilizations,and euthanasia. Campinmates deliberately infected

with bacteria or malaria had various drugs tested on them to determine effec-

tiveness. In twin studies, if one purposefully infected twin died, the other was

oftenkilledwithaninjectiontotheheartandusedinacomparativeautopsy.

Hitler’sdoctors killedmillions,inictingpain andsuffering inthe nameof 

science.

After World War II, a second syphilis epidemic occurred in 1947, with

106,000 cases reported in the United States. Public health measures were taken

toeducatethepubliconsexuallytransmitteddiseases(STDs),butthe1960s

sexual revolution caused an increase in cases. Meanwhile, in 1972 a whistle-

blower, alarmed that men in the TSS were not offered penicillin, caused the

study to stop. Because syphilis can pass through placentas into unborn babies,

many of the children had syphilis, and in 1974 the U.S. government paid an

out-of-court settlement of $10 million to the few survivors or the heirs of the

diseased.

Not until 1997, however, did the government, through President Clin-

ton, ofcially apologize to the surviving men and their families. Likewise,

sixdecadesaftertheatrocious Naziexperiments,leadingGermanscientists

apologizedtoHolocaustsurvivorsforpursuing“theirscienticgoalsbeyond

every moral boundary of humanity.’’ Public health epidemiologists continue

to study syphilis within populations. It gives important data for tracking syphi-

lis around the world and for targeting public education preventive measures,

leading to lower rates of infection. Routine STD testing, here and abroad,

helps stop widespread infections.

The history of Western medical ethics goes back to 400 B.C. when Hip-

pocrates, the Father of Medicine, promulgated guidelines for ethical medical

conduct referred to as the Hippocratic Oath, simply put: “to be useful, but,

rst,donoharm.”Thisstandard,consideredgentlemanlybehavioratthetime,

holdstoday.Professionalethicsbecamecodiedinthelateeighteenthcentury

when English doctor Thomas Percival published rules for morality and service.

HisCodewasadoptedandmodiedintotheAmericanMedicalAssociation

Code of Ethics in 1846.Recentrevisionsemphasizepublichealtheducation.

Theall-importantNurembergCode(1947)derivedfromthetrialof 23

Naziresearchdoctorsforcrimesagainsthumanity.Itsharplydenesboundar-

62 Bioethics and Medical Issues in Literature

ies for moral, ethical, and legal practices in approved medical experiments,

speakingtotheprimacyof humanworthoveranyscienticvalues,nomat-

ter how worthy. The 10 principles of the Nuremberg Code, used worldwide,

include:requiringasubject’sinformed,voluntaryconsent;showingthepro-

posedresearchisnecessarytobenetsocietyandthesubject’srisksarenot

greater than the study’s humanitarian importance; requiring it be based on

animalstudiesorjustiablerationale;attemptingtoavoidasubject’sinjuryor

mentalandphysicalsuffering;requiringapreliminaryinvestigationof thefacts

todeterminethereisnoreasontobelievedeathordisabilityinjurywilloccur,

and that the investigators be scientically qualied; and giving the human

subjecttherighttoterminatetheexperimentif physicalormentalconditions

warrant it.

Subsequentcodicationsaddressingcrimesof scienceincludetheDec-

laration of Geneva (1948), which mentions the importance of maintaining

dignityinthe art of medicineandavoidingprejudices; andtheDeclaration

of  Helsinki (1964), which, as modied in 2000, states “the well-being of 

thehumansubject shouldtakeprecedence overtheinterestof science and

society.”Ethicscommittees,suchasInstitutionalReviewBoards(IRBs),must

monitor ongoing trials, especially regarding use of placebos, funding details,

andconictsof interest.

BesidesIRBs,theU.S.Ofceof HumanResearchProtectionsischarged

with overseeing human research volunteers. At present, with technologies

rapidly evolving from the Human Genome Project, medical ethics (known

asbioethicssince1965)mustweighthebenettosocietyversusthedangers

to individuals. Unfortunately, unconscionable experiment protocols are not a

thing of the past, continually challenging IRBs to interpret research data and

toapplytheethicalprinciplesthatprotecthumansubjects.

Synopsis of the Play

Feldshuh’s seven-character, two-act play is set mainly in the sparsely fur-

nished Possom Hollow Schoolhouse in rural Macon County near the town

of Tuskegee, Alabama. A 1972 Senate subcommittee investigation is ongoing

in spotlighted testimony areas. In the prologue Nurse Eunice Evers gives her

professionaloathof faithfulness,condentiality,loyalty,anddevotion.Inact

I (1932-Contagion), shetalks about her motivation to be a nurseand how

she has become a PHS nurse-liaison to four tenant farmers, Hodman, Willie,

Contagions/Isolations 63

Caleb, and Ben, who are variously dgety, superstitious, and deant, while

being tested for “bad blood.”

Hodman, 37, believes in magic cures like putting a knife under the bed

to cut pain. Willie, 19, wants to win a gillee dancing contest and move North.

The analytical Caleb, 25, is the most literate. At 57 compliant Ben writes his

name with an “X” on the blackboard, but not wanting “to rile nobody,” hastily

erases it. Evers gains their trust and entices them into the TSS with promises

of hot food and “free doctorin’.” The men are afraid that blood-drawing to see

if theywerebittenbya“parakeet”(misunderstandingfor“spirochete”)will

cause impotence. They also suspect the government is lining them up for mili-

tary induction. But Evers sells the idea of government interest in their welfare

and that waiting for testing might be too late, leading to insanity and death. She

gives them a ride to the gillee contest, which they enter as Miss Evers’ Boys.

In scenes 2 through 5, the black Dr. Eugene Brodus, a 34-year-old U.S.

PHSeldphysicianwhoismoreof aresearch-orientedmedicaldoctorthana

congenial people person, does a trial workup on the four men. He asks Evers

tointerpretanemiaas“lowblood”;potencyas“hotblood”;andsyphilisas

“bad blood.” Brodus tries to connect with the men on a musical and dance

level.AfterEversconrmsherboystestedpositiveforsyphilis,theybegina

two-yearcourseof treatmentwithmercurysalvesandarsenicinjectionsthat

is55 percenteffective—“if it didn’t killyourst.” Theyare treatedfor six

months until government money runs out.

The Tuskegee Memorial Hospital administrator, Dr. Douglas, confers

with Brodus and Evers, convincing them to keep the federal government’s

attention by studying untreated syphilis for six months, to acquire facts to

differentiate the disease along racial lines, and to set new PHS priorities for

allocatingmoneyandofferingtreatment.Theirndingswouldbecompared

to a 1909 Oslo study of 300 white syphilitics, with the hope the government

would stop saying, “Don’t throw white money after a colored man’s disease.”

The plan, revealed in the play’s exposition, is for Douglas to examine

the men periodically, coordinate data, and be the liaison between Washing-

ton, D.C., and Macon County. He would be both physician and scientist, an

uneasycombination.Theirtwo-yearcomparisonstudywouldrequireX-rays,

drawn blood, and spinal taps for neurological tests, then money would become

available for treatment. The men must not suspect protocol change, Douglas

warns. Brodus agrees, desiring recognition for Tuskegee, but Evers knows the

64 Bioethics and Medical Issues in Literature

men are only getting heat liniment treatment and will infect others. Douglas

entices each man to stay in the study with $50 for a decent burial, and Evers

agreesbecauseshebelievesherboyswillberstinlinewhenthenewtreat-

ment becomes available.

In scene 6 at the schoolhouse, Evers helps Douglas give a searingly painful

spinal tap to Caleb, who does not tell the others, fearing they will be deprived

of government care. As Evers helps Douglas with the procedure, she recalls

thattheonlyjobshecouldgetbeforewashouseworkeventhoughshewasa

trained nurse. Caleb trusts them to help him get healthy.

Three days later, in scene 7, Evers delivers the spinal tap report to Dr.

Brodus, admitting she hated lying to the boys about the taps’ importance to

theirhealthandthattheheatlinimentwasmercurysalve.Herationalizesit

ishumanetozigzag“roundthetruthonceinawhile,”andhewarnsthata

medicalprofessionalhastostepbackattimes.EversisofferedajobinNew

York,whichsheconsidersbecauseithasbecomedifculttocarryherburden

of being both a caring nurse and a detached scientist.

In scene 8, one week later at the schoolhouse, the boys practice for the

gillee contest that evening. Evers teaches Ben to write his name on the black-

board, and he tries to convince her they need her. While they wait for the car

to arrive to take them to the contest, they talk about how a life insurance policy

helpedtopayanotherman’sburialcosts,butrsthewastakentothehospital

for an autopsy. The gillee contest is spirited.

Inact 2(1946-Progression),scene 1,theaudience learns that penicillin

has been introduced as a treatment for syphilis in all but the Tuskegee study

group. Evers has been close with the men for 14 years. They seem pain free

and appear healthy. But such a hidden, unpredictable disease can catch you

by surprise. Besides, treatment is dangerous and no money is available. Then

came the silver bullet, penicillin, which offered a cure for her men, who were

toberstinline.ButWillie’slegsgiveway.Therestareconcernedabouthim

and their gillee group. They demand some “new doctorin’.” Drs. Brodus and

Douglas tell Evers her boys are too far gone for penicillin to help, and, in

fact,itmightkillthemwiththeHerxheimerallergicreaction;or,if penicillin

kills the spirochete embedded in a heart muscle, it could cause the heart to

disintegrate—or to explode.

Inscenes2and3,EversndsCalebandWilliewaitinginaBirmingham

center to get a penicillin hip shot, but she talks Willie out of it, telling him

Contagions/Isolations 65

he’sagovernmentpatientand,besides,theshot(mold)couldkillhim.Later

Brodus and Douglas examine him, revealing a “slight slurring” of his right

foot, indicating progressive syphilis, but he feels special, like he’s “riding in

the front of the train.” Evers privately urges the doctors to tell Willie about

possibletreatmentsohecanchoosetheconsequences,buttheyaccuseher

of unprofessional behavior and too much patient attachment. Douglas says

penicillin is a small risk to Willie, but there is greater danger because if he gets

it and dies anyway, then all 6,000 untreated syphilitics in the county will resist

treatment and spread the disease. Brodus stresses to Evers that continuing the

study is a chance to do something special, pushing “past the hate, past the idea

of difference.” Willie comes back to the room and apologetically asks them

if he needs new “doctorin’.” Brodus’ half-truth response is that new research

science will not help every single person, but “more people are helped than

hurt.” Evers offers him hope, and that day the U.S. government gives each

studyparticipantacerticateof appreciationand$14,oneforeachyear.

In scene 4, outside the schoolhouse, the superstitious Hodman tries an

old May tea and moonlight cure on Willie. But Caleb knows that all over the

county penicillin is the new cure. Douglas convinces Brodus he will never

get future funding if  he wavers in this study, but Brodus says the equality

of penicillin’s response to the disease on whites and blacks has already been

proved. Douglas argues they need to foster a sense of fear in order to get more

moneytoeradicatethediseaseandsacricing600menversustreating6,000

or more is at stake. But to Evers these men are her friends and neighbors, and

her doubts multiply.

In scene 5 at the schoolhouse three months later, Caleb tells Evers peni-

cillin has helped him but the moon cure has not helped Willie. Evers repeats

that the government will not let her give Willie penicillin, but she must stay

there to help her people. Caleb invites Evers to go with him but then leaves,

saying he must use his brain and mouth.

In scene 6, four months later at Memorial Hospital, Ben is in a wheelchair

getting breathing instructions. Evers offers him $50 for burial if he’ll sign an

autopsy permission, but he resists, thinking he will look cut up in his open cas-

ket. She convinces him it is okay, and that he is part of something important

andlastingafterhepasses.Hisgovernmentcerticateisveryimportanttohim.

He has been practicing for 14 years and signs his name “Ben Washington.” He

thanks Evers for caring for him and for doing all she could to make him well.

66 Bioethics and Medical Issues in Literature

Besides, he loved riding in the government car. As a nurse she was following

the doctors’ orders, she told him, and cries remorsefully when Ben tells her he

knows she will always do right by him.

In scene 7, two months later, Dr. Brodus tells Dr. Douglas penicillin would

be too late, but Brodus argues it has helped others no matter what stage they’re

in.Douglassaystheyaredifferentasstudysubjectsbecause14yearsof work

cannotbeinvalidatedandpatientssacricedwithapossiblyuselessorlethal

injection.TomatchtheOslostudy,theyneedtotakeittotheendpointby

validatingthefacts byautopsy.He rationalizesonly thebest studypossible

will“unravelthesecretsof thisdisease”andhonorthemen’ssacrices“for

something greater than they’ll ever understand.”

Bendiesapainfuldeathbutlookspeacefulinhiscofn,asEversprom-

ised. She repeats her nurse’s oath before God “not to harm my patients.” Dr.

Douglas orders Evers to call every doctor in the Tuskegee area and tell them

they are not to treat study participants with penicillin. Evers begins cracking

from carrying too heavy a burden, but Dr. Brodus convinces her they each

serve their race in different ways and have trade-offs. In scene 8, two days

later, Evers gives penicillin to Hodman, whose eyes are being affected by the

disease. Having gone insane, he drinks poison and dies. Evers wonders if the

penicillin had given him Herxheimer reaction from which he died. She gives

Willie hip shots as well.

In the 1972 epilogue, the Senate committee hears the evidence. A whistle-

blowerinformednewspapersthe subjects werehuman guineapigs watched

to see what bad blood would do. Willie received a course of penicillin out of

the county and partly recovered. Caleb also left, was treated, and recovered.

Evers told the men the disease “had three parts: you get it, you forget it , and

then you regret it 20 years later when it comes back to haunt you.” And that

is how it was with her study participation as well. She continues reporting on

theremainingsubjects.Calebuseshiscerticateof appreciationasevidenceto

suethegovernmentthatwascallouslywatchinghimdie.Douglasrationalizes

that the study proved blacks and whites were affected the same, but Brodus

counters they were not given a choice. And what about Nurse Evers who

pulled Willie out of the treatment line in Birmingham? She loved her boys but,

bluntly put, got some of them buried.

In the end, Feldshuh tells us that Evers, even with her tarnished nursing

ideals, was left with “little blame” compared to the government and its doctors

who held “the big blame.”

Contagions/Isolations 67

Literary Analysis

David Feldshuh’s Miss Evers’ Boys derived from James H. Jones’ Bad Blood: The

Tuskegee Syphilis Experiment aswellasfrommedicalarticles,1930sAlabamaeld

interviews, and Senate testimony. In two acts set in the Possom Hollow School

Houseoutsideof thetownof Tuskegee,Alabama,theplayctionallyportrays

howtheU.S.PublicHealthService(PHS)experimentedonagroupof black

men.Thisanalysisfocusesonhowtheplayhighlightsimportantethicalques-

tionsabouthumanrightsinscienticresearch.PHSvenerealdiseasedoctors

set up the Tuskegee Syphilis Study (TSS) to nd better ways to treat poor

syphilitic southern blacks. Presuming there would be great value in studying

syphilis in different races, they were eager to compare their results with the

1909 Oslo studyanalyzingautopsiesof whitemaleswithuntreatedsyphilis.

In an unprecedented partnership, trained black medical staff worked

alongsidewhitemedicalprofessionalswhothought theirsubjectscouldnot

understand the research and would not consent to it without enticements.

Throughout the play the nurse liaison, Miss Eunice Evers, who was assigned

to foster trust and cooperation, gives us her views on the nontherapeutic study

and on her two doctors, U.S. PHS Dr. Eugene Brodus and Tuskegee Memorial

Hospital head Dr. John Douglas, the only white character. The action begins

in 1932 before penicillin was widely used, and it ends in 1972 after a public

health whistleblower closed the study down 25 years after the Nuremberg

Codesystematizedthelegalconceptofinformedconsent.Althoughthe1947

NurembergCoderequiresstoppageonceharmfulsituationsareascertained,

some say a complicit PHS, which lacked a master protocol and was severely

underfunded,rationalizeditsgoodintentions.Initsdefense,Eversremindsus,

it was a different time.

Evers, a pivotal character in Feldshuh’s play, speaks intermittently to the

1972 Senate subcommittee investigators, in scenes set up as testimony areas,

to give us a retrospective sense of the time period. Watching her father die

from untreatable pneumonia motivated her to become a nurse, and she takes

her professional oath seriously. Evers has sworn to maintain high standards

by practicing faithfully, condentially, and without administering harmful

medicine.Hertruedilemmacomeswiththesecondpartof theoath,ndingit

impossible to be both loyal to her physicians’ work and devoted to her patients’

welfare. Incredibly, the study is set up so that Evers’ duties simultaneously

requirehertobebothacompassionatenursewhotranslatesdoctor-speakand

68 Bioethics and Medical Issues in Literature

a detached scientist who withholds lifesaving medicine, a duplicity that cannot

berectiedethically.Inaddition,sheabridgesthe“boys”abilitytovoluntarily

consent by enticing them into the study with incentives of free meals, health

care,anda$50deathbenet,affordingtherareopportunityforadignied

burial. Although the 1947 Nuremberg Code’s standard informed consent rules

were not in effect, Evers withholds a great deal of information to gain their

trust. For example, when therapeutic mercury and arsenic treatment is stopped

after six months due to lack of funds, she does not tell them the study is

continuing on them as untreated syphilitics. Instead, they are promised, when

effectivetreatmentcomes,theywillbetherstinlinetogetit.

Drs. Brodus and Douglas have slightly different motivations for continu-

ing the TSS. Douglas wants to differentiate racial response to syphilis, believing

the humanitarian importance of the research to society outweighs the gravity

of thesubjects’deaths.Healsowantstokeepthefearlevelhighsothatmore

government funds will be forthcoming. Brodus initially wants to stop the study

once penicillin has been proved a silver bullet cure, but then he compromises

his integrity by going along with Douglas. Neither medical professional seems

to be able to perceive the difference between his doctor and scientist duties.

Instead,theybothrelyontheOslostudythatgavethemreasontobelieverst

disability and then death would occur in the study group.

What is most unconscionable, however, is that the PHS medical profes-

sionals watched the men unnecessarily suffer unbelievable mental and physi-

cal pain. For this reason, as the study progressed into the 14th year, lying to

her boys became a burden for Evers, especially when their suspicions caused

themtodemand“newdoctorin’.”Intheend,Ben,theoldest,acquiescedto

the study’s protocol and died, proud that he had earned a government cer-

ticate and a proper burial. The superstitious Hodman went mad, drank a

magic potion, and died from the poison. Caleb, the most literate, learned about

penicillin and was treated in time. Evers took dancing Willie, the youngest, out

of a treatment line, convinced by Douglas that penicillin in Willie’s late-stage

syphilis, with improbability of cure, might set off an allergic reaction or kill

off spirochetes, causing his heart to explode. He suffered the crippling effects

of the disease. Today, with a known cure available, it would be considered a

heinousbioethicalinjusticenottogiveparticipantsthechoicetoterminatethe

study.

Evenwiththesubjects’progressivephysicalandmentalsyphiliticsigns,

Contagions/Isolations 69

the doctors continued the delusion to keep the study viable for comparison

withOslo’s.Intheend,thecharadecontinued.Thedoctorsrationalizedthat

if the study participants were given penicillin but died, then the thousands

of untreated syphilitics in the country would refuse treatment. The doctors

convinced Evers that her part in the study is a chance to do something special.

Thestudywentbeyondtheperiodof aknowncureandaprovenequality

in black-white response because Douglas believed extending the fear would get

moregovernmentmoneytoeradicatethedisease.Herationalizedsacricing

the few for the greater good and argued against invalidating 14 years of work.

Taking their study “to the end point” meant to autopsy, and he ordered Evers

to advise all Tuskegee doctors to refuse treatment to study participants. Ironi-

cally, once penicillin was found to successfully treat syphilis, it made the study

marginally relevant. The big issue is that Evers’ boys, mostly illiterate men who

did not read the news, were lied to. They were told that diagnostic spinal taps

were therapeutic, and that penicillin could kill them. The enticements of food

and medicine negated any possibility of voluntary consent. Evers’ burden is

heavy especially because she watched two of her friends, the study’s human

guineapigs,sufferend-stagesyphilisanddie.Sheisleftguilt-ridden,reecting

on the nursing ideals that had guided her life.

By1947,14yearsaftertheTSSstarted,inaparallelworldNazidoctors

were on trial for research crimes on humans. Like Nuremberg, a legacy of dis-

trust follows the TSS, especially the rumor that participants were intentionally

infected with syphilis, promulgating notions of genocide. TSS folklore—scien-

ticfervortakingprecedenceoverbasichumanrights—passeddownthrough

generations explains the distrust of white medicine, creating a healthcare gap.

In 2011 a new government initiative, Eliminating Racial and Ethnic Disparities

in Health, helps to end the practice of lower minority medical standards in six

priority areas. They are infant mortality, cancer screening and management,

cardiovasculardisease,diabetes,adultandchildimmunization,andHIVinfec-

tion, which in 1997, the National Minority AIDS Council reported, infected

one in 50 black men. The catch-22isthatitisdifculttoobtainmoreblack

subjectsinclinicaltrialswithsuchanengrainedlegacyof distrust,including

the notion that the statistics are a hoax.

More than 30 years later, what lessons have we learned from the TSS,

a metaphor for research abuse? To begin with, it is necessary for studies to

applyacarefuldenitionof voluntary,informedconsentandtohavespecic

70 Bioethics and Medical Issues in Literature

institutional review boards monitor research protocol to preserve the rights

of  human subjects. Furthermore, scientists devising study protocols must

guardagainstbelievingsubjectsinaparticularlyvulnerablegroupareinher-

entlyinferior,andtheymustbewaryof puttingtoogreatasignicanceinthe

biological and social difference in race. And, lastly, researchers must see their

study participants as people like themselves.

Whileitmaybeshockingtohear,badethicsintheTSS(asintheNazi

experiments)didnotnecessarilyequalbadscience,althoughtheissueoftrust

permeates the results. The fact is that medicine still relies on the 40-year TSS as

a valuable source of information on diagnosing and treating syphilis. Clearly,

in teaching this medical history on the potential for immorality in research

methods,acautionarybioethicallessonshouldbetaughtalongwithscientic

results.

Topics for Oral and Written Discussion

• What did the legacy of the Jim Crow Era contribute to the Tuskegee

SyphilisStudyandhowspecicallydidtheCivilRightsActof 1964

change the potential for racial segregation and discrimination?

• How did British bacteriologist Alexander Fleming’s 1929 accidental

discoveryof penicillininuencethehistoryof syphilis?

• Denesyphilisanddescribeitsearlytreatments.Whatdotheterms

“bad blood” and “back shots” mean?

• Is Nurse Evers a traitor for using powerful incentives to entice her

subjectsintothetrial?

• In what way has the TSS’s legacy of distrust permeated the black

community, and how did President Clinton attempt to regain trust?

• What is the U.S. Public Health Service and how do their epidemiolo-

gists educate the public?

• WhatareInstitutionalReviewBoards(IRBs)anduponwhatcode(s)

do they base their human research protocols?

• Describe the ethical principles that would make it illegal and uncon-

scionable today for PHS doctors to engage in subterfuge in order to

entice participants into a study.

• How do you divide PHS blame in the TSS among Evers, Douglas,

and Brodus?

Contagions/Isolations 71

• Whatspecictenetsof theNurembergCodedidtheTSSviolateafter

1947?

Bibliography

Eliminating Racial and Ethnic Disparities in Health. A government initiative.

http://www.cdc.gov/minorityhealth/OMHHE.html

Feldshuh, David. Miss Evers’ Boys. New York: Theatre Communications

Group, 1990.

National Center for Bioethics in Research and Health Care, Tuskegee

University. http://www.tuskegee.edu/about_us/centers_of_excellence/

bioethics_center.aspx

“Syphilis.” The Merck Manual. http://www.merckmanuals.com/professional/

infectious_diseases/sexually_transmitted_diseases_stds/syphilis.html

Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study. Ed. Susan M. Reverby.

Chapel Hill: U of North Carolina P, 2000.

Suggested Further Reading

Benedek,ThomasG.;Erlen,Jonathan.“TheScienticEnvironmentof the

Tuskegee Study of Syphilis, 1920-1960.” Perspectives in Biology and Medicine,

1999(August):1-30.

Hurston, Zora Neale. “My Most Humiliating Jim Crow Experience.” On

Doctoring. Ed. Richard Reynolds and John Stone. New York: Simon &

Schuster, 1995: 121-2. Racist medical treatment.

Jones, James H. Bad Blood: The Tuskegee Syphilis Experiment. New York: Free

Press, 1993.

Klass, Perri. “Invasions.” On Doctoring. Ed. Richard Reynolds and John Stone.

New York: Simon & Schuster, 1995: 407-10. Insensitive residents’

responses upon learning an elderly man has syphilis.

“Lasting Legacy: An Apology 65 Years Late.” The News Hours with Jim Lehrer

(16May1997).www.pbs.org/newshour/bb/health/may97/tuskegee_5-

16a.html

Lederer, Susan. Subjected to Science: Human Experimentation in America Before

the Second World War. Baltimore: Johns Hopkins University Press, 1995.

Williams, William Carlos. “Use of Force.” The Doctor Stories. Ed. Robert Coles.

New York: New Directions, 1984. A young diphtheria patient rebels.

Chapter Four

Illness and Culture: An Analysis of Ken Kesey’s

One Flew Over the Cuckoo’s Nest and Alice Walker’s

Possessing the Secret of Joy

Introduction

Ken Kesey’s One Flew Over the Cuckoo’s Nest embodies the rebellious energy of

the psychedelic 1960s, a prosperous time following World War II when drugs

were rampant and the counterculture challenged authority. A classic descrip-

tion of mental illness, Cuckoo’s Nest encapsulates Kesey’s experimentation with

alternative forms of perception, while highlighting ethical issues.

The setting is a mental institution where a power struggle exists between

thestaff andthepatientsafictedwithmanytypesof mentalillness.Paradoxi-

cally, reading this important novel feels liberating while it asks the disturbing

question:Whoamongusiscompletelysane?

The United States has gone through a slow and arduous process to learn

how to identify and to treat mental disorders. Finally, in 1946 the National

Institute of Mental Healthwascreated,recognizingtheneedtodiagnoseand

to help the mentally ill. With the advent of mental institutions came radical

therapies such as electroshock treatment and lobotomy. Today these contro-

versial approaches are often replaced by psychotherapy, the so-called talking

cure, and by drug regimens. With today’s brain scans and DNA analysis some

mental disorders are more readily detected and easily treated. Other topics

Cuckoo’s Nestdevelopsconcernsexualityandinstitutionalization;humorand

illness;nursingandgrouptherapy;andpsychiatryandsurgery.

Kesey’s Cuckoo’s Nestcontinuestoinuencetwenty-rstcenturymedical

issues and ethics as does Walker’s Possessing by describing the cultural origins

of mental illness.Thefemalegenitalmutilation(FGM)ritualWalkerdescribes

in a certain African culture illustrates how society constructs practices that

Illness and Culture 73

inictpsychologicaltraumaandhavelong-termphysicalconsequences.FGM,

viewed as sane in one culture, is judged unethical and criminally insane in

others, linking health and human rights. Increasing immigration brings the

surgical ritual, once commonplace in Puritan times, back to the United States.

In addition, worldwide awareness causes petitioners seeking asylum based on

sexualdiscriminationtoocktotheUnitedStates.

Possessing the Secret of Joy also teaches morality lessons and shows the im-

portance of the mother-child relationship all within the context of cultural

relativism and Social Darwinism. The main issue, however, of global concern

is how human rights violations perpetuate women’s mental and physical health

problems. In the Western world the long history in which women were seen as

objectsspringsfromAristotle’sviewthatwomenwereunnishedmen.This

thinking was at the heart of early Greek medical practices such as female cir-

cumcision,justas,ironically,wasHippocrates’“rst,todonoharm”mandate.

Manyculturescontinuetosubjugatewomentofundamentalistbeliefs,denying

themequalprotectionunderthelaw,eventhoughtheUnitedNationsUniver-

sal Declaration of Human Rights states that human rights are inalienable: “No

oneshallbesubjectedtotortureortocruel,inhumanordegradingtreatment

orpunishment”(UnitedNationsGeneralAssemblyResolution,1948).

Both Kesey and Walker show how illness derives from culture as well as

from disease and that our views on normalcy depend on the culture and the

time in which we live. While Possessing the Secret of Joy projectsissuesthatfor

somemaybedifculttoexploreatrst,byputtingafaceontotheestimated

150 million women worldwide who have undergone FGM, Walker has crafted

a book of literary importance.

74 Bioethics and Medical Issues in Literature

KEN KESEY’S

ONE FLEW OVER THE CUCKOO’S NEST(1962)

The ward door opened, and the black boys wheeled in this

gurney with a chart at the bottom that said in heavy black letters,

MCMURPHY, RANDLE P. POST-OPERATIVE. And below this

was written in ink, LOBOTOMY.

—Ken Kesey, One Flew Over the Cuckoo’s Nest

Historical Context

Ken Kesey (1935-2001), born in Colorado and reared in Oregon, appreci-

ated nature and loved wrestling. He received a degree in speech and com-

munication from the University of Oregon. Then, with a Woodrow Wilson

Scholarship, he enrolled in the Stanford University Creative Writing program.

While a graduate student, he participated in life-altering psychology depart-

ment research involving psilocybin, mescaline, amphetamine, and LSD. For

severalweeksKesey,a24-yearoldpaidresearchsubject,ingestedthesemind-

expanding drugs. Later, as a Veterans Administration psychiatric ward orderly

on the night shift, he observed that many of the patients, rather than being

crazy,werejustnonconformistsinasterileenvironment.Whiledrug-induced,

KeseyhallucinatedaboutanIndiansweepingtheoors,whobecameChief 

Broom,hisschizophrenicnarratorinOne Flew Over the Cuckoo’s Nest.

His novel was an immediate success, allowing Kesey and his wife Faye to

buyafarmthatbecameasiteforaninuentialbohemiancommunityexperi-

menting with drugs, believing altered mental states could improve society. Be-

cause Kesey’s parties were notorious for illegal drug use, he was soon arrested

andjailedforseveralmonths.Nonetheless,withhisnewfame,Keseydrewthe

attentionof NealCassady(heroof JackKerouac’sOn the Road)andothers,and

soon the hippie-aesthetic, antiwar group the Merry Pranksters was formed,

exploding into the psychedelic era.

In 1964 the notorious Pranksters drove cross-country in a Day-Glo bus,

obstensively to see the New York World’s Fair, but it became instead a creative

adventure. Cassady drove the bus, and its riders dropped acid and smoked

marijuanaalongthejourney,whichwaslmedforposterity.Thebusbecame

a metaphor for “living your art,” and the saying, “You’re either on the bus or

you’re off the bus,” was Beat Generation lingo for creative tripping.

Illness and Culture 75

Kesey wrote other novels, but none achieved the success of Cuckoo’s Nest,

whichsubsequentlyinuencedpopularculturewithitsstageandlmproduc-

tions. Late in life, Kesey, the pied piper of the psychedelic era, took drugs only

forhisdiabetesandhepatitisC,ndingthepureadrenalineof experiencing

nature enough. He died November 10, 2001, in Pleasant Hill, Oregon, follow-

ing surgery for liver cancer.

Cuckoo’s Nest continues to be a prototypical depiction of mental illness by

describing various mental disabilities as well as the legal and ethical issues aris-

ing from them. The novel’s publication brought to the American conscious-

ness what a slow and arduous process it has been to dene and to devise

treatment for mental disorders. In Colonial times, before the proper diagnosis

of the mentally ill and retarded, madmen roamed free. Alternatively, shamed

families cruelly locked abnormal relatives in an attic or chained them to a wall.

Society’srstprioritywastofeelsafe,thentopunishtheeviltheybelieved

inherent in the mentally ill.

The very rst mental institutions were small, primitive nontherapeutic

holding facilities. Before then, troublesome individuals, including the poor,

were incarcerated with criminals or sent to the poorhouse. Over time, demonic

causationwaschallenged,and,instead,theafictedperson’senvironment,in-

cludingitsmorality,wasscrutinized.Civilrightslawshelpedtodifferentiate

criminals from the mentally ill who are often involuntarily committed upon

proof they would be a danger to themselves or others.

A shameful past includes the 1920s eugenics movement, a practice of

sterilizingthe feeblemindedand otherswith conditionssuchas alcoholism,

promiscuity, epilepsy, and even running away from home. In the 1930s an-

other procedure performed for the greater good was neuropsychiatrist Dr.

Walter Freeman’s icepick psychosurgery. Also known as lobotomy, it partially

destroyedoneof thebrain’sfrontallobes,causinggreatdisguration.Psycho-

surgery relieves suffering—their anxious and fearful personalities—Freeman

explains, “without the long, painful process of developing insight in the pa-

tients.” Going back to their homes, they can “survive in the very environment

inwhichtheirdisordersdeveloped”(RobinsonandFreeman15).InFreeman’s

case studies, the postoperative realities sound grim. Patients were described

as slothful, irritable, and angry. With the relationship between the brain and

the mind being continually studied, the idea of operating on the brain to cure

madness seems reasonable. Adverse publicity arising from Cuckoo’s Nest, how-

76 Bioethics and Medical Issues in Literature

ever, caused lobotomy to be largely replaced with antipsychotic drugs, but suc-

cessful psychosurgeries like cingulotomy relieve severe compulsive neuroses

and depression.

The use of electroconvulsive therapy(ECT),whichisalsocalledelectro-

shock therapy, is a central theme in Cuckoo’s Nest. In 1938, after an earlier sci-

entistobservedthatschizophrenicsseemedsymptom-freefollowingseizures,

Italian scientists Cereletti and Bini devised ECT as a way to manage uncon-

trollable patients. Today, a severely depressed patient receiving ECT, adminis-

tered in a series of treatments, has an intravenous relaxant administered and

a mouth guard inserted before an anesthetic renders him unconscious. The

airwayisprotected,andelectrodesareconnectedwithconductingjellyonthe

temples. Electric current comparable to a 60-watt bulb shoots through the

braincausinga20-secondgrand-malseizure.Thepatientwakesabout30min-

utes later, confused and disoriented, with a headache and short-term memory

loss. But complications from possible fractures and dislocations caused by

muscle contractions are a thing of the past. In essence, ECT helps disturbed

patients regain the control necessary to enter into a therapeutic relationship.

For generations Kesey‘s Cuckoo’s Nest inamedthepublicconsciousness

by depicting ECT as a means to punish misbehaving patients, easily associating

it with electrocution. Over the years attempts to pass state laws banning ECT

havefailed.Ashorricasitsounds,someneuropsychiatristsstillndECTto

be an effective treatment for severely depressed and suicidal patients, espe-

cially after psychotherapy and slow-acting, cyclical drug regimens fail.

Depression,morethanacharacterweaknessandfeelingjustdown,isa

brain disease often detectable on a PET scan that indicates receptor chem-

istry abnormality. It affects millions of Americans who often feel ashamed

they cannot pull themselves up by their bootstraps. Hence, they often fail to

seek help. New electromagnetic brain treatments, easily applied and without

side effects, are proving effective, and recent NIH DNA studies indicate a 50

percent to 80 percent genetic component. In 2003 scientists, after working

decades, documented a clear link between a gene controlling serotonin levels

in the brain and depression, leading to possible new drugs. Linking genes with

behavior, scientists say depression has roots in both genetics and personal his-

tory. For better or worse, drug regimens—even with their side effects—often

replace lengthy patient-oriented talk sessions as the standard of care.

ThesearejustafewwaystoilluminatespecicissuesinCuckoo’s Nest. As

Illness and Culture 77

explained earlier, over the centuries attempts to treat madness have, from our

perspectivetoday,seemedcruelandunusual.Withpathologypoorlydened,

oddbehavioralonewouldbecauseforconnement.Whilenewmethodsad-

vanceunderstandingandcare,asignicantpartofthefutureofmentalillness

diagnosis may lie in constant revelations arising from brain imaging and the

deciphered genome, with the promise of targeted treatments. Nonetheless,

even with vast knowledge of the human body, Edward Shorter adds: “Science

wandersastrayeasilyintheworldof quotidiananxietyandsadness,intheob-

sessivetraitsof behaviorandthemisringpersonalitytypesthatarethelotof 

humankind. Here the genetic trail grows dim and the neurotransmitters evapo-

rate.Biologycountsforlittle,cultureandsocializationforlots”(A History of

Psychiatry 288).Thenatureversusnurturedebate is very much alive.

Synopsis of the Novel

An Oregon state mental institution in the 1960s is the scene for a contest of

wills between the staff and the inmates. The catatonic Native American Indian

Chief (theBigChief orChief Broom)narratesOne Flew Over the Cuckoo’s Nest

even though he appears deaf and mute. Diagnosed with delusional paranoia,

while in a fog and feeling helpless, he fears the Combine controls everything.

The driving force in the mental institution is the militaristic Nurse Ratched

(theBigNurse),whowieldsher authorityseverelyovereveryone,including

the professional medical staff, the black boy aides, and the patients. The new

patient,RandleP.McMurphy(Mack),whomthecourtruledapsychopathic

prisoner, has feigned insanity to be transferred from Pendleton Work Farm. In

his cocky, in-your-face manner, he introduces himself as “a gambling fool” to

other asylum inmates. Using his charm, he craftily sets them up as pigeons to

pluck in card games.

The patients are divided into the incurable Chronics like the big half-breed

Chief,whoisaawedproductof theCombine,andthecurableAcuteswho

Nurse Ratched eggs on, attacking them where they are most vulnerable. A

patient may come in as an Acute and then be turned into a robotic Chronic

(Walker,Wheeler,orVegetable)afterbeingpunishedintheShockShopwith

electroshock or psychosurgery. Threats with these therapies enforce coopera-

tion while keeping the two groups separated. Ratched has already assessed

Mack as a troublemaker who will manipulate the system and disrupt the ward.

She runs a tight ship, shunning outside disturbances to keep the precision asy-

78 Bioethics and Medical Issues in Literature

lummachinery(TheCombine)humming.Heridealmedicalstaff,theChief 

tells us, has been handpicked and after years of training modeled to suit her

needs, staying “in contact on a high-voltage wavelength of hate.” She taught

them her way to get inmates into shape was to patiently “wait for a little advan-

tage . . . then twist the rope and keep the pressure steady.”

Throughthefogof hisschizophreniatheChief keenlywatchesthenew

admission, McMurphy, in the group psychotherapy session. Ratched begins

the discussion from a topic logged in the ward book having to do with patient

Dale Harding’s promiscuous, well-endowed young wife, his feelings of inferi-

ority, and the resultant sexual dysfunction. He is a probable case of situational

madness resulting from his wife’s emasculating nature.

Mack had initially challenged Harding, the effeminate, college-educated

president of the Patients’ Council, for the role of the Bull Goose Loony or the

Alpha male, but they soon become friendly when Harding proves a valuable

source of information. Mack garners the most interest in the meeting, how-

ever, when Ratched introduces him as a recipient of the Distinguished Service

CrossinKoreaforleadingaCommunistprisoncampescape.Subsequently,he

was dishonorably discharged for insubordination and later arrested for drunk-

enness, gambling, assault and battery, and statutory rape. Mack refutes only

the latter. Dr. Spivey, the ward doctor, misaddresses him as “Mr. McMurry”—

Ratched’s attempt to demoralize Mack by mispronouncing his name—and

looksintohisle,readingthediagnosis:“repeatedoutbreaksof passionthat

suggest the possible diagnosis of psychopath.” In retaliation, Mack tries to

intimidate Ratched.

Dr. Spivey explains the group meeting protocol and why a democratic

therapeutic community, as a prototype of  the outside world, requires con-

formity that will allow them to return to the outside. The patients in group

therapy are encouraged to discuss and confess, revealing the secrets of the

subconscious. Rather than being Freud-inspired talk therapy, though, it turns

out to be a Ratched-led pecking party, and this time Harding is unmercifully

grilled and shamed. Hearing all this and watching an agitated patient receive a

subduing hip shot, Mack, in the end, thinks it might be smart to carefully as-

sess the situation before he makes any kind of play. He enters into a lengthy

dialogue with Harding and others about Ratched’s role in emasculating them,

culminating in a bet that he will “get her goat” within a week.

Mack’s rebellious nature takes over as he begins rallying the patients and

Illness and Culture 79

gaining hero status by challenging Ratched’s authority and by procuring special

favors for them. For example, in the shower room Mack complains to a black

orderly about the ward policy that he can brush his teeth at only a certain time,

and when Ratched comes in, he tells her his clothes were taken and threat-

ens to drop his towel. Ratched angrily calls for new clothes. Further taunting

Ratched, Mack complains about loud ward music overriding his conversation

whilegamblingforcigarettes;however,Ratchedsaysitconsolesthehard-of-

hearing older patients. Mack then presses to move his game to the old tub

room, no longer in use because drugs have replaced hydrotherapy. She refuses,

but Mack persuades Dr. Spivey to change the venue. Mack continues to break

the rules by using real money, not cigarettes, to play Monopoly. He takes bets

on the World Series. In a key vote to watch the World Series, Mack gets the

Chief to raise his hand. Ratched balks at the schedule change, and the Acutes

do a sit-in protest in front of the TV set. With each loss of authority Ratched

patiently, coldly waits: “She has all the power of the Combine behind her.”

In Part 2 Ratched is suspicious of the Chief ’s new cognitive responsive-

ness,andeventhoughhestillexhibitsparanoia,hisschizophrenicfogmaybe

lifting.Ina staff meeting, thequestionariseswhetherMackisaclevercon

man or a violent psychopath. Ratched convinces others that sending Mack to

theDisturbedWardwouldonlyenhancehisherostatus;therefore,shefavors

keeping him in the general population where, before long, he will show his

ownavariceandcowardice.TheChief,inhisnarration,theorizesMacktruly

is an extraordinary man, capable of resisting the Combine. Noting aberrant

staff actions,however,hequestionswhointhementalinstitutioniscomplete-

ly sane. Mack’s leadership continues to embolden the Acutes. He has given

themareasontowakeup,andtheynowquestionwardpolicies,suchason

rationingcigarettes.ThenMack,inacatch-22,backsoff whenherealizes,as

an involuntarily committed patient, that Ratched decides if he is cured or not

(releasedornot).ByfailingtorallyforcesagainstRatched,hedisheartensthe

other patients, possibly leading to patient Cheswick’s suicide. Ward privileges

are revoked, and therapy sessions return to silence.

Mack witnesses an epileptic seizure, learning about the side effects of 

the drug that may prevent it, as well as the staff wielding its power through

usingECT(“brainburning”),which,ironically,isactuallytheinductionof a

seizure.MackisshockedtolearnthatHarding,Billy,andtheotherswhohave

voluntarily committed themselves, are free to leave at any time. It is only their

80 Bioethics and Medical Issues in Literature

fears of the outside world that keep them there. Ratched, feeling her control

returned, smugly informs the men that they must have the privilege of using

the tub room for card playing taken away as punishment for their insurrections

andthathavingasenseof orderanddisciplinewillhelpthemadjusttosocietal

rulesintheoutside world.Convincedshehad thenal victoryandcontrol

over Mack, Ratched is startled to see him plunge his hand through the glass

window of the nurses’ station, extracting one of his own cigarettes. She does

not retaliate but bides her time.

In Part 3 sports are introduced, causing the men to renew their muscle-

exingandtobuildself-esteem.Beingdenieddaypasses,Mackagainputshis

hand through Ratched’s glass window. Tension builds as Mack’s rebelliousness

increases. At this time, he recruits the patients to go on a supervised deep-sea

shingtrip,butRatchedfrightensthemen.TheChief reallywantstogobut

knows he will blow his cover by indicating so. Acting deaf has allowed him to

hear. It started as a child when outside people who saw an American Indian as

invisiblequitlisteningtohim.WhenIndianlandwasseizedtomakeahydro-

electric dam, the government had his white mother, instead of his father, sign

the deal. The Chief begins to emerge from his silence one night when Mack

offers him some gum, and he replies, “Thank you.” A conversation ensues,

and Mack works on the Chief ’s ego to convince him to throw the tub room

control panel out of the window for escape.

Mackpushestoarrangeadeep-seashingtrip,signinguptheChief asthe

only Chronic going. With great effort, because Ratched had tried to “damp

themanoutof them,”Mackgetsthequotaneededforthetrip.But,when

only one chaperone shows up, the prostitute Candy Starr, Dr. Spivey must

step forward as the second chaperone. All the way to the dock, the men show

bravado and courage, and instinctively manliness once derailed returns. They

surpass manyobstacles on theirroad trip tothe sea;in the end,without a

properlysignedwaiver,theyevenhijackaboat.Theshingtrip,completewith

victoriousshingandheartycamaraderie,hasreturnedanaturalmasculinity

to formerly emasculated men. The laughter “started slow and pumped itself

full, swelling the men bigger and bigger.” Mack watches as the men appear to

slowly take back their lives. Billy and Candy become smitten, and Mack invites

her to the mental institution on Saturday.

At the mental institution in Part 4, Ratched plots to discredit Mack by

disclosing to the patients how much money he is making on them from gam-

Illness and Culture 81

bling and arranging games and trips. Her ploy seems to be working, until Mack

andtheChief defendGeorgeSorensoninastghtwiththeblackorderlies.

As punishment, they receive ECT in the Disturbed Ward, which Mack com-

pares to electrocution. Because he will not relent, but rather acts heroically,

Ratched orders more ECT for Mack. When he begins to attain legendary sta-

tus, Ratched brings him back to her ward where she works on making him

appear weak.

Still rebellious, Mack arranges for Billy to lose his virginity to Candy dur-

ing a drunken night on the ward. The other patients urge Mack to escape, rath-

er than face further repercussion from Ratched. But, drugged and drunk, he

falls asleep. In the morning, Ratched takes it all in and threatens to tell Billy’s

mother about his encounter with Candy. After Billy cuts his own throat, Mack

attacksRatched.Inretaliation,shehashimlobotomized.TheChief humanely

releases Mack from his vegetative state by suffocating him, and then escapes

back out into his life.

Literary Analysis

One Flew Over the Cuckoo’s Nest,oneof themostinuentialnovelsof thetwen-

tieth century, derives from Ken Kesey’s observations at a mental institution.

Although it is a popular myth that Cuckoo’s Nest sprung full-blown from Ke-

sey’s drug-induced state, he admits only some of it was inspired that way. Writ-

ten during the post-World War II era of the psychedelic 1960s, when the U.S.

faced a Communist threat, he wanted his black satire’s good versus evil plot,

rich with symbols, literary allusions, and bioethical and medical issues, to show

howindividualsmuststanduptoauthoritysotheirrightsarenotquashedby

government control. As a prototypical depiction of mental illness, Cuckoo’s

Nest describes how the mentally ill were treated, and this analysis focuses on

the effects of the therapies applied at the time.

The Chief ’s observations as narrator make him the most important char-

acter in the novel. The “deaf and dumb” American Indian, who has seen his

lands taken away to build a hydroelectric dam and his family destroyed, tells

thestory,at rstin a ashback sequenceand then inhallucinatory visions.

It is possible to trace throughout the novel his passage out of the fog of

schizophrenia.Theactioncentersonthefree-spiritedRandle P.McMurphy

(Mack),whopersoniesthecountercultureBeatGeneration.He“wasagiant

come out of the sky to save us from the Combine,” the Chief believes. Mack

82 Bioethics and Medical Issues in Literature

facesoff againstNurseRatched,whopersoniesgovernmentalauthorityand

repressionandinwhomTheCombine(evilgovernmentforcesseekingcon-

formity)culminates.

The Combine includes Ratched’s network of hand-picked and personally

trainednurses,doctors,andaides.Mack,“crazylikeafox,”hascapitalistintent

in feigning mental illness to leave a prison work farm. However much of a

con man he appears to be, though, in setting up gambling opportunities, his

antiauthoritarian rebelliousness makes him an imperfect antihero. Because he

has been involuntarily committed by the prison, Ratched has absolute power

to hold him until she deems him cured. But most of the other Acute patients

who are deemed hardcore and seek institutional discipline can release them-

selves.Inhisbattlewithhisnemesis,NurseRatched(symbolicallyaratchet,

atoolcontrollingbydegree),heappearstobebothaclassicpsychopathand

acockycomicbookgure.Regardlessof theimpurityof Mack’sself-serving

hustlinginstincts,hisantagonizingRatchedallowshimtogrowandtheother

patients to be liberated. Considering the complexity of mental states, it is am-

biguouswhether heextendedhis stay (breakingthenurses’station window

twice)forhisgreedorforsolidaritywithpatients.Ishethevictimof anill-

conceived plan or a martyr?

WhileMack“walksoutof step;hearsanotherdrum,”aliteraryreference

to Henry David Thoreau that is a leitmotif symbolizing individualism, the

Chief stands for the vanishing American Indian, an invisible man diminished

by white society. Kesey goes into great detail about how the Chief ’s disinte-

gratingculturehasparalyzedhimintocatatonia,effectingasplitpersonality

andsporadiclossof reality.TheChief hasbeenonthewardthelongest;Mac

is the new patient. Each is putting on an act: the Chief’s hallucinatory in-

sightsonhospitalactivitiesreecthissilentsavvy;Mack’snoisybravadoeither

agitates or rallies patients by challenging Ratched’s matriarchal authority. Con-

trasting the Chief and Mack is interesting, with the ingenious part of the novel

havingtheabilitytotraceMack’sinuenceontheChief.Inextricablylinking

mentalprowessandphysicalsize,theChief inhismind’seyeappearstogrow

physicallybiggerashebecomesmentallyreleasedfromhisschizophrenicfog.

In an example of the complexity of Mack’s motives, he uses the Chief to lift

the control room panel as the basis of a bet, but at the same time it empowers

the Chief.

The mental institution culture in Cuckoo’s Nest reveals how the lines be-

Illness and Culture 83

tween sanity and insanity are often blurred. It describes many types of illness,

divided between the Acutes and the Chronics, and includes the obsessive-

compulsive disorder(OCD)patientwhocannotgetdirty,twoepilepticswith

opposing drug administration problems, cowering depressives, self-mutilating

passive-aggressives,hallucinatingschizophrenics, and troublemaking psycho-

paths. In a group therapy meeting Mack sets out to challenge authority by

persuading most of the patients to vote to watch the World Series during

their work detail. Although a democratic vote is taken—modeling the type of

behavior needed on the outside—Ratched wields her authority and cuts the

power to the set. The patients then gather in front of it in a rebellious sit-in.

The Chief tacitlyobservestheywouldallappear crazytoan outsider.Talk

therapies based on ward log entries are run like confrontational pecking par-

ties, with the patients acting like scared rabbits. Harding and others both fear

Ratched, viewed as a surrogate wife and mother, and want her to keep them in

their place. Throughout the novel women are mostly portrayed as dominating

“ballcutters” or submissive pleasure-givers.

DaleHarding, symbolizingthevoiceof reason aspresidentof  the Pa-

tients’ Council, explains the system and treatments like ECT and lobotomy.

What may be inexplicable, though, are the therapeutic roles of nature and the

healing power of laughter seen throughout the novel. In a classic road litera-

turescenario,Mackandthe otherpatientson a shingtrip learnandgrow

along the way as they face challenges and overcome obstacles. Mack laughs at

shingtripmishaps,theChief tellsus:

Becauseheknowsyouhavetolaughatthethingsthathurtyoujust

tokeepyourself inbalance,justtokeeptheworldfromrunning

youplumb crazy. He knows there’sa painfulside; he knowsmy

thumb smarts and his girlfriend has a bruised breast and the doctor

is losing his glasses, but he won’t let the pain blot out the humor no

more’n he’ll let the humor blot out the pain.

The contagious laughter pumped the men up, as it “rang out on the water in

ever-widening circles.” Laughter, as a proponent of the mind-body-spirit ap-

proach to health and healing, may relieve pain and renew hope. As referenced

in the literature of alternative therapies, it gives back control to life.

Mack’s therapeutic role—if it can be called such—demonstrates the im-

84 Bioethics and Medical Issues in Literature

portance of levity as well as of maintaining some self-respect in institutional

living.Unfortunately,inRatched’stherapeuticcommunityherdehumanizing

ways belittle all men, including Dr. Spivey. Contrary to today’s conventional

wisdom, she controls the population by diminishing the men’s self-esteem.

She also administers drugs daily. Her threats of using electroshock therapy

and lobotomy as punishment would now be seen as unethical, at the least.

Mackprogressivelybuilds up the men’s masculine condence.But then he

lets them down, until in one last hurrah he puts his personal interests aside

whenheandtheChief protectGeorgeinastghtwiththeblackaideswho

try to give him an enema. Although Ratched gives Mack a chance to get out

of ECT as punishment by admitting he has been wrong, in a pivotal show of

selesssolidarity,herefuses,feelingitwouldbethesameasconfessingtoa

“plot to overthrow the government.” As he undergoes a series of ECT in the

Disturbed Ward, his bravado creates a heroic legendary status that Ratched

fears. In a psychological ploy to regain control, she brings him back to the

ward where she can watch him—and plot.

Sexuality is a part of life—even in an institution. Mack arranges for Billy

Bibbit, 31 but mentally an adolescent controlled by his mother, to lose his

virginity to a smuggled-in prostitute during a drunken evening on the ward.

Mack’s attempt to restore a manly independence in the men may release some

from psychosomatic illness; however, for Billy, things are not that simple.

Ratched,inherzealtokeepthingsundercontrol,shameshimintoextreme

guilt.Fearfulof hismother,hecommitssuicide.Atthispoint,KeseyllsCuck-

oo Nest’s with rich literary references to Melville’s Billy Budd’s in a suggestion of

the stuttering, innocent protagonist, as well as imbuing it with the good versus

evil overtones in Moby Dick.

Applying Darwinian reasoning to the pecking order of the mental ward,

Ratched’s “ballcutting” approach mandates that only the ttest survive. So

MackviciouslyattacksRatchedforBilly’ssuicide,leadingtohernalretalia-

tion:hislobotomy.WhatmakesKesey’sdramatizationsocompelling,however,

isthewayChristianimageryusedthroughoutthenovelcoalescesintohisnal

redemption: Mack is the martyred Christ who has compromised authority and

released the patients from The Combine’s control of them. In fact, Cuckoo’s

Nest’sgrotesquedescriptionissocompellingittooklobotomyastherapeutic

psychosurgery underground.

In the end, the Chief ’s releasing Mack from his vegetative state and es-

Illness and Culture 85

caping out into a new life show the healing power of individuals. Nonetheless,

life is messy, and Kesey’s ambiguous conclusion causes speculation that The

Combine, bigger than Nurse Ratched and her mental institution, cannot be so

easily defeated.

The allegorical title, One Flew Over the Cuckoo’s Nest, comes from a nursery

rhyme the Chief recites in Part 4:

Ting.Tingle,tingle,trembletoes,she’sagoodsherman,catches

hens, puts ‘em inna pens . . . wire blier, limber lock, three geese inna

ock...oneeweast,oneewwest,oneewoverthecuckoo’s

nest . . . O-U-T spells out . . . goose swoops down and plucks you

out.

The cuckoo’s nest is the mental hospital; Ratched “tremble toes” pecks at

themen;theBullGooseLoonyMack“plucksout”theChief,whoembodies

Mack’s spirit as he makes his hopeful escape into the moonlight.

Kesey’s cautionary tale, a metaphor for how society socially constructs

itsattitudestowardmentalillness,makesusquestion,conversely,howmen-

tal illness derives from culture as well as from disease. What is more clearly

understood, however, is that views of insanity change generationally in our

culture, and that therapies go in and out of fashion. We are left to wonder

how we should balance mental healthcare’s need to control and conform with

maintaining individual rights. In Kesey’s novel, the psychiatric staff are not

always the good guys, and the patients are often more complicated than they

rstappear.Itmakesitnecessarytoask,bywhoseideaof normalshouldwe

be measured?

Topics for Oral and Written Discussion

• What roledidthe rebelliousMerry Prankstershavein deningthe

counterculture into which Cuckoo’s Nest is set?

• What psychological characteristics make the Chief an effective

narrator?

• How does the individual versus the Combine encapsulate the book’s

conict?

• Throughsceneanalysisdeneincidentsof insanityaswellasgender

and racial bias.

86 Bioethics and Medical Issues in Literature

• Howistheshingtriptherapeuticforthepatients?

• As seen through the eyes of the Chief, whose mental illness may de-

rive from a cultural schism, relate Christian imagery to Mack as he

goesfrommavericktoself-sacricingsaint.

• Describe Ratched’s ward in totalitarian terms, incorporating a discus-

sion of her authoritarian ways and the patients’ loss of civil liberties.

• Discuss the psychological effect of domineering women in Cuckoo’s

Nest.

• As described in Cuckoo’s Nest, would the ECT and lobotomy adminis-

tered as therapy and/or punishment be ethical now?

• Throughoutthenovel,traceMack’sinuenceontheChief ’spassage

outof thefogof schizophrenia.

Bibliography

Kerouac, Jack. On the Road. New York: Viking, 1957.

Kesey, Ken. One Flew Over the Cuckoo’s Nest. (40thAnniversaryEdition).New

York, Viking, 2002.

Robinson, Mary Frances and Walter Freeman. “Glimpses of Postlobotomy

Personalties.” Psychosurgery and the Self. New York: Grune, 1954: 15-32.

Shorter, Edward. A History of Psychiatry. New York: Wiley, 1997.

Suggested Further Reading

Chekhov, Anton. “Ward Number Six.” Ward Number Six and Other Stories.

Trans. Ronald Hingley. New York: Oxford UP, 1974. Written in 1892,

thisattackoninvoluntarymentalhospitalizationshowsthedarkerside

of psychiatric history.

Green, Hannah. I Never Promised You a Rose Garden. New York: Holt, Rinehart,

andWinston,1964.Theanguishandhope,fromtherstperson,of a

schizophrenicmentalpatient.

Kesey, Ken. The Further Inquiry. New York: Viking, 1990. Screenplay on 1964

bus “voyage.”

Jamison,KayRedeld.An Unquiet Mind: A Memoir of Moods and Madness.

New York: 1995. A clinical psychologist suffers from manic-depression.

— Night Falls Fast: Understanding Suicide. New York, Vintage, 1999.

Sheehan, Susan. Is there No Place on Earth for Me? Boston:HoughtonMifin,

1982.Arst-handaccountof lifeasaschizophrenic.

Illness and Culture 87

Styron, William. Darkness, Visible: A Memoir of Madness. New York: Vintage,

1992. First-person account of severe depression.

Wolfe, Tom. The Electric Kool-Aid Acid Test. New York: Farrar, 1968.

ALICE WALKER’S

POSSESSING THE SECRET OF JOY(1992)

There are those who believe Black people possess the secret

of joyandthatitisthisthatwillsustainthemthroughanyspiritual

or moral or physical devastation.

—Alice Walker, Possessing the Secret of Joy

Historical Context

While Kesey’s One Flew Over the Cuckoo’s Nest and Walker’s Possessing the Secret of

Joy are both cultural representations of mental and physical illnesses, they are

asdiverseintime,setting,andcharacterizationas thebackgroundsof their

authors. Alice Walker(b.1944),therstblackwomantowinboththePulitzer

PrizeandtheAmericanBookAward,forThe Color Purple (1983),wasbornin

Eatonton, Georgia, the last child of eight to poor sharecropper parents. Her

mother’s grandmother was mostly Cherokee Indian. At the age of nine, Walker

wasblindedintherighteyewithaBBgunpelletandfaciallydisguredwhile

playing cowboys and Indians with her brothers. She retreated into books.

Walker excelled despite the partial loss of eyesight, and at her high school

graduation in 1961 she was valedictorian and prom queen. She received a

scholarship at Spelman College in Atlanta, Georgia, but before she left her

mother wisely gave her three gifts: “asewingmachineforself-sufciency,a

suitcase for independence, and a typewriter for creativity.” While in Atlanta,

Dr. Martin Luther King, Jr. invited her to his home, and later Walker attended

the Youth World Peace Festival in Helsinki, Finland. These two events im-

mersed her in the Civil Rights Movement and gave her greater understanding

of other cultures. In 1963 Walker took part in the March on Washington for

Jobs and Freedom where she heard Dr. King’s “I Have a Dream” speech.

After two years at Spelman, Walker received a scholarship to attend the

88 Bioethics and Medical Issues in Literature

prestigious Sarah Lawrence College in Bronxville, New York. During her senior

yearshebecamepregnantandconsequentlysufferedfromsuicidalthoughts

and depression. She pored her feelings out into poetry and a short story, “To

Hell with Dying,” which was published with the endorsement of the famous

poet Langston Hughes. With the help of classmates, Walker arranged to safely

abort the pregnancy, which was illegal at the time. Following college gradu-

ation in 1965, Walker increased her civil rights activism by the door-to-door

registering of poor voters in Georgia. She married Mel Leventhal, a Jewish law

student in New York City, who later worked for the NAACP. They moved to

Mississippi where threats of violence tested their interracial marriage. Walker

became pregnant again, but lost the baby during the frenetic time following

King’s assassination. She later delivered a healthy daughter. After receiving a

number of grants and fellowships, Walker taught at Wellesley College, one

of thecollegesthatinthenineteenthcenturychampionedwomen’srights(a

movementbornoutof abolition),includingvotingandpropertyrights,educa-

tion,andhealthreform.Whilethere,Walkercreatedoneof therstwomen’s

studies courses. In the mid-1970s she divorced Leventhal.

AfterWalkernishedhermostfamouswork,The Color Purple, she trav-

eled to Africa to research the oppressive practice of female genital mutila-

tion(FGM),whichalsooccursintheMiddleEastandinpartof theWestern

Hemisphere. Her work turned into Possessing the Secret of Joy, which focuses

on one woman’s traumatic experience with FGM. Later with collaborator

Pratibha Parmarshelmedadocumentarywithacompanionbook,Warrior

Marks (1993). Walker draws from a deep reservoir of personal experiences

to write realistically about many issues in her novels and poetry. For instance,

she cares very much about poverty, racism, and the health issues that emanate

fromglobalviolenceagainstwomen.Herworksdramatizetheoppressionof 

women, in particular, and lately have addressed bisexual and father-daughter

relationships. As a former teacher, she hopes to educate her readers on the

brutalityof misogyny;thedangersof silenttaboos;andtheeffectsof rituals.

Her activism, which started during her college days at Spelman, now addresses

other causes such as protecting indigenous cultures in their natural environ-

ments. Walker, a California resident, continues to write and to lecture.

The main topic Walker addresses in Possessing is how the female genital

mutilationritualinaspecicAfricantribeaffectsthemind,body,andspiritof 

its bicultural protagonist, her family, and her countries. It is important to note

Illness and Culture 89

that Walker’s literary representation of FGM applies to only a small percentage

of African tribes, and that the surgical ritual is conducted in many different

ways, in hospitals as well as in huts, for many different reasons. For these pur-

poses,theprocedureismoredescriptivelycalledfemalegenitalcutting(FGC)

because, by degree, it ranges from a slight ceremonial nicking of the clitoris

todrawbloodtothemoreradicalexcision(removingsomeorallof theouter

genitals)andinbulation(sewingupthevaginaandleavingasmallopeningfor

urinationandmenstrualow).Theritual’sendresultspansthegamutfroma

proud youth who has experienced a spiritual initiation into adulthood and el-

evatedtribalstatustoascaredyounggirl’sagonizingpainandlingeringdeath.

A woman who has had the more radical procedure often has very painful

intercourse and child delivery. Even the newborn may be harmed mentally

and physically from passing through the narrow opening. After childbirth, the

womanisreinbulated,orsewnbackup.

The origin of FGC goes back as far as Aristotle’s thinking that women

wereunnishedmen;consequently,themalformedanduncleanfemaleparts

needed altering. It is believed Queen Cleopatra of Egypt had undergone phara-

onic circumcision to, theoretically, ensure a union that could extend her realm’s

interests. Historically, only a virgin who could protect the paternal bloodline

was marriageable, and therefore FGC (euphemistically “having a bath” or

“cuttingtherose”)effectedasortofchastitybelt.Thosewhoshowcowardice

(“cryingtheknife”)aresociallyostracized.Thegirls,whosometimesdescribe

their experience as spiritual ecstasy, prove their bravery by transcending physi-

cal pain and have more control over their tribal lives. It became a mother’s duty

to keep her daughter pure until marriage, and therefore a prospective bride’s

excised and inbulated vagina became aestheticallydesirable. Inaddition, a

desexed girl was more likely to keep chaste until and during marriage. Thus,

African mothers who force FGC on their daughters help maintain their status

and that of their daughters’. In a few tribes, the tradition includes boys who

vie for leadership by a test of their courage. They must be stoic while, without

anesthesia, their penises are circumcised and ritually mutilated.

Anthropologists and missionaries have known about FGC for many cen-

turies. Christian missionaries were trying to eradicate FGC in Africa at the

same time Puritan moralists in America believed clitoridectomy was a neces-

sary surgery to control nymphomania and masturbation and to cure hysteria

and melancholia. While some argue that there is no sound medical reason for

90 Bioethics and Medical Issues in Literature

male circumcision, in the Western world and elsewhere it is still done both

for hygienic purposes and as a powerful religious ritual. However, for males,

circumcision(theremovalof theforeskin)isrelativelytrivial—unlessitgoes

awry—compared to its female counterpart (clitoridectomy, at its worst), in

which sexual pleasure is replaced by pain.

Putting FGC into a cultural context is helpful. Historically, menstruation

and menopause myths declaring women unclean or undesirable, respectively,

havemandatedisolationandsubjugation.AncientChinesefootbindinghob-

bled women into a helpless desirability, while recent headlines report female

infanticide where sons are desirable. Whether these practices are considered

heinous or not is a matter of perspective, though, since to many around the

worldtheAmericandeathpenalty(anancientformof justicestemmingfrom

“aneyeforaneye”)isconsideredbarbaric.

FGC was brought to the popular consciousness in a 1980 Ms. Magazine

article by Gloria Steinem and Robin Morgan titled “The International Crime

of Genital Mutilation.” Later Representative Patricia Schroeder of Colorado

shocked Congress with the reality of FGM, and eventually it passed the Fed-

eral Prohibition of Female Genital Mutilation Act in 1996, making it a federal

crimepunishablebyuptoveyearsinprison.AliceWalker,whoctionalized

the issue in Possessing, and others who wrote about their private ordeals have

horried Americans.What followed these revelationswas aWestern media

blitztendingtowardsensationalism and polemics. Can we claim moral superi-

ority in a country where increasing incidents of rape, sexual assault, wife bat-

tering, and sexual harassment against women made it necessary for us to pass

the Violence Against Women Act in 1994?

Whether or not First World countries can claim moral superiority, it is go-

ing to take the hard work of an international community, including the support

of  Amnesty International, the World Health Organization, and the United

Nations, as well as local and international human rights and women’s organi-

zations,todebatetheviolationof humanrightsandhealthissues.Thepolar

positionstakenare:1)extremeculturalrelativism—FGC practiced on girls is

tiedupwithnationalidentity,andwecannotjudgeanothercountry’smorals

andinterfere;or2)weshouldwithholdaidfromcountriespracticingFGC.

Thedireconsequencesof FGCstirthepublicconscience,causingtheworld

community to become involved, as it has been in trying to eradicate slavery,

genocide, and infanticide. The two million girls each year who undergo FGC,

Illness and Culture 91

andespeciallyinbulation,riskamyriadof mentalandphysicalhealthprob-

lems,includingshock,trauma,andhemorrhage;bacterialandHIVinfections;

incontinenceandmenstrualproblems;sterility,frigidity,andchildbirthprob-

lems.Manywilldie.TheWorldHealthOrganizationsaysitwilltakeeducating

three generations to eradicate FGC.

Part of the world feels it is contentious to call their venerable female cir-

cumcision rite “mutilation”;nevertheless, for most Americans Secretary of 

State Madeleine Albright put it best: “When people are mutilated, it is criminal,

not cultural.”

Synopsis of the Novel

In Walker’s Possessing the Secret of Joy there are seven main characters, and ev-

ery few pages the viewpoint changes with each new speaker. Tashi, who is a

peripheral character in The Color Purple, has shown allegiance to her Olinkan

people by having the tribal marks cut onto her face and by having the female

genitalcuttingceremony.Thebookbeginsinaashbackwhentheimaginative

Tashi,whoisnowanAmerican,reectsonwhatherlifehasbecome.Telling

the parable of the panthers, Tashi sets the tone for the whole book, and she

moves the plot along by intermittently telling myths and stories.

Raised in Olinki, Tashi’s sister, Dura, died after a ceremonial genital cutting

ritual. The African-American missionary’s children, Olivia and Adam, befriend

Tashi. Adam becomes her lover, breaking tribal taboos. Adam also meets Li-

sette, a white French Algerian missionary, with whom he shares stories of

the Olinkan culture. Tashi, in the name of Olinkan pride, has the circumciser

M’Lissaexciseandinbulateher,abovetheprotestsof herChristianmother,

Adam,andOlivia.Bydoingthis,sheintendstojoininsolidaritywiththeother

women. She sees them as strong and invincible African women.

Days after the operation, Tashi is told to sit up and walk a few steps—

herownproudwalkhasbecomeapermanentshufe.Ittakes15minutesto

urinate now. Her menstrual cramps last half the month because it is nearly

impossibleforowtopassthroughsotinyanaperture.Theresidualowthat

doesnotnditswayoutandisnotreabsorbedintoherbodyhasnowhereto

go;sotheodorof souredbloodfollowsheraround.Tashi’sfriendOliviaob-

serves, “That her soul had been dealt a mortal blow was plain for anyone who

dared look into her eyes.”

Adam marries his friend, the once proud and lively Tashi, who is now

92 Bioethics and Medical Issues in Literature

heartbreakingly slowed by pain, and takes her back to the United States. Living

biculturally, Tashi cannot rationalize the emotional anguish sheexperiences

daily in the name of her tribal leader’s call for Olinkan pride, so she sees sever-

alpsychiatrists.TherstonetellsherNegrowomencannotbecured“because

they can never bring themselves to blame their mothers.” Tashi still thinks of

herself as an African woman, not an American Negro. Another psychiatrist,

Lisette’swhiteuncle(theOldManorMzee),triestohelpTashiinSwitzerland

witharttherapyandbyanalyzingherdreams,whichshecannotsharewith

her husband. When the Old Man dies, the black feminist Raye becomes her

therapist.

Tashi explains to Raye how her African leader mandated FGM from one

generation to the next through a sacred tribal code, there being a strong cul-

tural taboo against speaking of it to outsiders. The act was designed to keep

the female body pure by cutting out the dual female soul that interferes with

male domination. If a woman is not circumcised, the myth goes, her unclean

parts will grow long and touch her thighs. Unremedied, warn the elders, who

act as if they have recently witnessed this evil, no man can enter this mascu-

line woman, who arouses herself. The circumcised women do not remember

havingvaginallipsoraclitoris,sotheylaughandjeeratthemonstrous“tail”;

circumcisedgirlsrunfrom“thedemon.”Thetribepassesonunveriedbeliefs

because the old ways must be kept. Tashi, who had been a young orgasmic girl

with Adam, gave up her sexuality to preserve the old ways.

In America, Adam and Tashi have a son, Benny, born retarded from pass-

ing through the birth canal narrowed by FGM. Unable to bear further pain,

Tashithenabortsasubsequentpregnancy.Adamlaterbecomesreacquainted

with the free-spirited Lisette, and they become lovers, seeing each other on his

biannual visits to Paris. Together they have a child, Pierre, which enrages the

dispiritedTashi.Pierre,unlikeBenny,isbrightandinquisitive;hestudiesBlack

American Literature and decides to go to school in America. His mother has

died, and he wants to become closer to his father. Tashi feels threatened and

attacks Pierre.

Tashi returns to Olinka when she reads about M’Lissa’s becoming a vener-

ated symbol of Olinkan pride. In an elaborate scheme, the tortured Tashi, now

in advanced middle age, plots her revenge. She seeks an audience with the ven-

erated circumciser M’Lissa, and over a period of several weeks they talk. Tashi

ritually washes her intended victim, who taunts her for foolishly submitting to

Illness and Culture 93

circumcision. M’Lissa is prepared to become a martyr, and Tashi smothers her

with a pillow as she attends her. She is indicted for murder.

Tashi is imprisoned in Olinka and put on trial for killing M’Lissa. Her fam-

ilyandfriendsaretheretosupporther,andAdamreectsonhowhehaswit-

nessedhiswife’shellonearth.Theprisonalsohousesawholeoorof AIDS

patients waiting to die. Many believe they contracted AIDS in an experiment,

like the Tuskegee Syphilis Study, when scientists vaccinated them for polio.

In the end, Tashi grows weary of the plodding trial and confesses to the

murder;nevertheless,thetrial,amediacircus,goeson.Atherexecutionbyr-

ingsquadonthesoccereld,Tashiisreleasedfromhertorturedsoulfor“kill-

ing someone who, many years ago, killed me.” Adam, Olivia, Benny, Pierre,

Raye, and Mbati, their friend, hold a banner: resistance is the secret of joy!

Literary Analysis

In PossessingtheblackliberalfeministAliceWalkerdramatizeshowhermain

character, Tashi, in an act of tribal allegiance, gets facial scarring and circum-

cision“becausesherecognizeditastheonlyremaining denitivestampof 

Olinka tradition.” The tribe’s leader, who is compared to Nelson Mandela and

even Jesus Christ, has instructed the people “not to neglect ancient customs.”

He has been imprisoned by the white regime. Walker explores the effects of

FGMinadazzling stylethat simultaneouslyseemsto contrastand totran-

scend cultural differences. The various viewpoints are artfully integrated into

dialogue and ashbacks, intermixed with myths, symbols, and psychology.

Walker uses the narrative device of renaming Tashi relative to her changing

culturalandpsychologicalstateof mind;forexample,whenreferringtoher

evolving American self she is “Tashi-Evelyn.” In this way, Walker conveys the

essenceof Tashi’sjourney.

Tashi is not a sympathetic character, however, because she was circum-

cised against the wishes of her Christian mother whose other daughter died as

a result from FGM. Furthermore, because Tashi was sexually responsive with

Adam, she knows the operation will result in a loss of pleasure. Even after

Tashi’ssparklingyouthfulnessturnsintoaat-eyedpassivity,Adammarries

her, and she emigrates with him to America. Only then does she understand

her physical and emotional loss and explode into rage. This analysis, in particu-

lar, shows how Walker creates in Possessing a bicultural lens through which we

can examine Tashi’s African soul and warring American consciousness.

94 Bioethics and Medical Issues in Literature

The title, Possessing the Secret of Joy,reectedintherstepigraph,derives

more fully from a passage in Mirella Ricciardi’s 1982 memoir African Saga. Ric-

ciardi was a French-Italian woman born and raised on a farm in Kenya, then

a colony of British East Africa, who wrote, “Black people are natural, they

possessthesecretof joy,whichiswhytheycansurvivethesufferingandhu-

miliationinicteduponthem.Theyarealivephysicallyandemotionally,which

makes them easy to live with. What I had not yet learned to deal with was

theircunningandtheirnaturalinstinctforself-preservation”(Ricciardi147).

The condescending tone of Ricciardi’s colonial remembrance highlights how

nationalistic backlash plays into Tashi’s mindset when she undergoes FGM.

In Possessing’s scenario,aFirstWorldorganization’sattemptstochangeaThird

Worldculturecausedeantanticolonialacts.

Walker’s second epigraph/proverb further sets the story into its bicultural

context, prophesying Tashi’s state of being torn apart from within: “When the

axe came into the forest, the trees said the handle is one of us.” Walker’s plot

borrows further from Ngugi wa Thiong’o’s novel The River Between(1965),in

which two lovers living across the river from each other play out the drama

of Christian converts clashing with African traditionalists. Like River, Walker’s

theme in Possessing argues that female circumcision destroys not only individual

women but their country as well. Tashi endures pain to prove her devotion to

tribalheritage;shesymbolizesritualsacriceandtheultimatehopeforchange.

Likewise,thecircumciserM’Lissa,a“monument,”symbolizesancientbeliefs

and keeping the old ways.

Possessing is a vehicle for Walker’s own feminist agenda. By putting Tashi

into a particular context, Walker is able to develop her human rights and health

issues as well as argue for political change. Tashi’s story becomes part of Walk-

er’s own. For instance, the autobiographical elements are clear when Walker

refers to FGM as “sexual blinding,” a reference to her brothers shooting her

in the eye and swearing her to silence. Both Walker and her character Tashi

aborted a pregnancy and bridged cultures in search of an identity. They are

storytellerswhosemythsteachlessons,llingthenovelwithstoriesof repres-

sion,of struggles,andeventuallyof self-actualization.

Walker’sstrongfemalecharacter,Adam’sloverLisette(Walker’salter-ego),

is an altruistic white woman who, as the voice of reason, contrasts with the

emotional Tashi. As a youth Lisette had visited Olinka with a church youth

group, and her family members were colonists in Algeria. As an adult she is a

Illness and Culture 95

high school French teacher in Paris who studies her ”co-wife” Tashi from afar.

The novel’s opening parable of the panther foreshadows the Tashi-Adam-Li-

sette love triangle and even foretells the outcome. Adam’s child with Tashi, the

American-born retarded Benny, during his birth becomes a painful sideshow

forWesterndoctors;hischildwithLisette,theParis-bornprecociousPierre,is

the result of a natural, orgasmic home birth. The autonomous Lisette starkly

contrasts with the fractured Tashi.

After Lisette dies from cancer, Pierre “continues to untangle the threads

of mystery that kept his stepmother Tashi enmeshed.” He reports that FGM

may have been a reaction to “the Hottentot apron,” or, as described by early

European anthropologists, the unusually elongated labia on uncircumcised

Khoisan women with enlarged buttocks (steatopygia). The bisexual and

biracial Harvard-educated Pierre explains how some tribes eventually decided

a woman’s dual genitalia needed modifying because she could not perform

both female and male roles.

The interesting parade of “shrinks” that try to help Tashi begins with a

white “son of Freud” couch analyst who gawks at her as a publishable case

history. He simplistically declares that healing is impossible because Africans

cannot blame their mothers. Tashi’s next analyst is Lisette’s uncle, the Old Man

orMzee.Clearly, as Walker references in her afterword, her Old Man charac-

ter is Carl Jung(1875-1961),theSwissanalyticalpsychologistwhoopposed

Freud’sideathatthelibido(sexualinstinct)alonedriveslife.Jungdifferedfrom

Freudbyespousinganinterestintheoppositesinnature(thedividedself),

even expressed in the way Jung, unlike Freud’s couch analysis, sat in a chair

opposite his patient to actively engage in dialogue.

Applying the Old Man’s Jungian psychology to the bicultural/divided

Tashi, she must reconcile her conscious ego with her unconscious, repressed

experiences through interpreting her dreams, stories, and art. For example,

duringarttherapy,afterTashidrewalarge,evilrooster(“ahumongousfeath-

eredcreature”),shefeltshewas“seeingthecauseof heranxietyitself forthe

rsttime,exactlyasitwas.”Itwasabeast-sizedindicationof herpsychosis,

the “emotions that had frightened her insane.” All at once Tashi remembered

hiding in the grass and witnessing her sister’s murder: “No longer would my

weeping be separate from what I knew.” The insidious tribal taboo demanding

silence and repression had subverted her childhood memory.

That Walker, herself, underwent Jungian analysis is evident in how she

96 Bioethics and Medical Issues in Literature

develops its tenets in Possessing.Jung’sarchetypalelementsof theego(central

consciousness), shadow (unpleasant unconscious—Dr. Jekyll to Mr. Hyde),

animus(Tashi’smasculineunconsciousmind),andSelf (wholeregulatingcen-

ter of the psyche, transcending theego) help identifyTashi’s psychological

process toward wholeness or individuation. Simplyput,WalkerequatesJung’s

psychic ideal—harmonizing the conscious and unconscious; decentralizing

theego;andacknowledgingtheshadowandanimus—withTashi’scomingto

terms with her past, at last bringing her discovered Self spiritual peace. Even

Walker’snalchaptertitle,“TashiEvelynJohnsonSoul,”cuesthereaderthat

Tashi’s fragmented mental state is at last reconciled.

After the Old Man dies, Tashi’s new analyst, the black American feminist

Raye, only understands Tashi’s physical pain after having her own periodontal

surgery. Tashi opens up to her, breaking her silence and referencing her shad-

owordarkself,andself-acceptancefollows.RayeandPierreanalyzeTashi’s

dream of being the Queen termite with broken wings imprisoned in a dark

tower.InAfricanculture,theprotrudingtermitehillsymbolizesanelevated

clitorisbarringmaleentry;thehillbeingcutdownsymbolizestheritualdesex-

ing. Because the girl’s male soul is in the clitoris, it must be excised to rid her

of the dangerous duality.

But Tashi’s personal anguish cannot be assuaged by Pierre’s anthropologi-

cal facts, the Old Man’s analytical psychology, or Raye’s empathy alone, so she

premeditates killing the old circumciser M’Lissa. Tashi returns to Africa with

a banner that reads, “If you lie to yourself about your own pain, you will be

killedbythosewhoclaimedyouenjoyedit.”Ironically,M’Lissaisunremorse-

fulaboutherancientpracticeof excisingandinbulatingtheOlinkangirls;

she even expects to be martyred, robbing Tashi of satisfaction. Walker, as

embodied in Possessing, speaks directly to the tribal mothers who she believes

subjecttheirdaughterstoperpetuallies,tofamiliartortures,andtothemur-

ders of the spirit.

Detractors say Walker’s novel is overwrought sensationalism and polem-

ics and should not be read as a fact-based anthropological study of FGM, in

decline since 1920. They say that while Walker’s feminist ideology in Possessing

has impacted FGM legislation here and cultural interventions abroad, it tends

to subsume the myriad of issues facing African women into the reduction-

ist’s view they are only mutilated genitals. Hence, the “yuck factor” eclipses

productive debate. On the other hand, the cultural relativists believe tribal cus-

Illness and Culture 97

toms are an integral part of each society and should be observed but not inter-

fered with. In the mid-twentieth century their controversial views superseded

the late nineteenth-century Social Darwinians whoclassiedsocietiesonthe

basis of race.

Regrettably, when First World organizations attack tribal practices per-

ceived as objectionable, nationalistic backlashes occur, as seen in Possessing.

Furthermore, the notion of women as oppressed victims of men becomes

questionableinsomecultureswherethesocialinteractioninFGCbuildssis-

terhoods and elevates their tribal status, says Efua Dorkenoo in Cutting the Rose.

Critics contend that Walker created an explosive topic with some misrepresen-

tation and started a mass media trend toward First World voyeurism, leaving to

be desired practical approaches to address the issues it raises.

In sum, Possessing is about one woman’s struggle with her African heri-

tage and her right to self-determination beyond cultural constraints. It is not

a factual anthropologist’s case study but rather has the emotional power of

literature.Evenassensationalizedculturalcriticism,ithasaddedtothegeneral

dialogue on human rights and health issues. In principle, it foregrounds a num-

ber of issues of cultural, medical, and legal importance. It shows women com-

plicit in a world run by male ideologies, culture intersecting with gender and

health issues, and Walker’s ethical basis for a controversial worldwide stance. In

a postscript Walker claims Tashi as her sister, even though she does not know

where her own African ancestors came from. While Possessing powerfully ad-

dresses FGM and highlights AIDS, for some her Western feminist approach

remains problematic.

Intheend,Tashi’sfriendMbatireectsonthecolonialistmemoir,Ric-

ciardi’s African Saga, underscoring Walker’s interpretation of possessing the

secretof joy:“Oh,Isay.Thesesettlercannibals.Whydon’ttheyjuststealour

land, mine our gold, chop down our forests, pollute our rivers, enslave us to

workontheirfarms,fuckus,devouroureshandleaveusalone?Whymust

theyalsowriteabouthowmuchjoywepossess?”AtTashi’sexecution,her

friends and family hold a sign: “resistance is the secret of joy!” And only af-

ter dying, when her divided selves unite into her whole Self, has Tashi resisted

whatisevil(thepoweroverher)topossessthesecretof joy.

98 Bioethics and Medical Issues in Literature

Topics for Oral and Written Discussion

• Compare and contrast Kesey’s Chief and Walker’s Tashi as examples

of howmentalandphysicalillnessderivesfromaspeciccultureas

well as from disease. How have Cuckoo’s Nest and Possessing had the

power to change the system?

• With increasing global awareness of human rights violations effected

throughliteratureandorganizationssuchasAmnestyInternational,

theWorldHealthOrganization,andtheUnitedNations,whydocer-

tain cultural practices like FGM continue? What are cultural relativism

and Social Darwinism?

• Reecting on Tashi’s painful physical abnormalities, describe how

it affects her mental state, as she describes it to her various mental

health professionals. How in particular does the Jungian analytical

psychologist work with her to ultimately achieve her Self?

• While the Olinkan male leader appears to mandate FGM, how and

why are the tribal women complicit in maintaining the ritual?

• Compare and contrast the tortured Tashi and the free-spirited Lisette.

How do these two women interrelate?

• Discuss how Pierre and Benny represent their respective mother’s au-

tonomyandinadequacies.

• How does Walker, an imaginative storyteller, use symbols (Tashi,

M’Lissa, termitehill, clay),parables,and mythsto tellTashi’s story

and to teach a lesson?

• As highlighted in Possessing, how has the Tuskegee Syphilis Study im-

pactedthequestionof trustintreatingAIDSinAfrica?

• What is M’Lissa’s perspective on FGM and her actions, as told to

Tashi, before her death?

• On Tashi’s journey toward wholeness, what is her resistance to, in

teachingusaboutthesecretofjoy?

Bibliography

Baartman,Saartjie.SpecialSouthAfricanBiography.http://zar.co.za/

baartman.htm

Dorkenoo, Efua. Cutting the Rose: Female Genital Mutilation, the Practice and Its

Prevention. London: Minority Rights Group, 1994.

Jung, Carl. Man and His Symbols. New York: Dell, 1968

Illness and Culture 99

Ngugi wa Thiong’o. The River Between. New Hampshire: Heinemann, 1965.

Ricciardi, Mirella. African Saga. London: Collins, 1982.

Understanding Violence Against Women. National Research Council. Washington:

National Academy Press, 1996.

Walker, Alice. Possessing the Secret of Joy. New York: HBJ, 1992.

— and Pratibha Parmar, eds. Warrior Marks: Female Genital Mutilation and the

Sexual Blinding of Women. New York: Harcourt, 1993. Book and video.

WorldHealthOrganization.FemaleGenitalMutilation.

http://www.who.int/mediacentre/factsheets/fs241/en/index.html

Suggested Further Reading

Atwood, Margaret. The Handmaid’s Tale. New York: Fawcett, 1986. Power

relations;scienceandsexuality;women’shealth.

Chase, Cheryl. “‘Cultural Practice’ or ‘Reconstructive Surgery’? U.S. Genital

Cutting, the Intersex Movement, and Medical Double Standards.” Genital

Cutting and Transnational Sisterhood: Disputing U.S. Polemics. Ed. Stanlie

M. James and Claire C. Robertson. U of Illinois P, 2002: 126-51. Is it a

double standard to call FGM a barbaric ritual and sexual reassignment

surgery a necessity?

Chopin, Kate. The Awakening. New York: Bard-Avon, 1972. A desperate

woman swims out to sea.

Conrad, Joseph. Heart of Darkness. New York: Penguin, 1999. Marlow travels

to the dark interior of Congo searching for his European self in Mr.

Kurtz.

Eugendies, Jeffrey. Middlesex. NewYork:Farrar,2002.WonthePulitzerPrize.

Hemingway, Ernest. “Hills Like White Elephants.” E-text available.

Kassindja,Fauziya.Do They Hear You When You Cry? New York: Delacorte,

1998.

Kristof, Nicolas and Wudunn, Sheryl. Half the Sky. New York: Knopf, 2009.

Robertson, Claire C. “Getting Beyond the Ew! Factor: Rethinking U.S.

Approaches to African Female Genital Cutting.” Genital Cutting and

Transnational Sisterhood: Disputing U.S. Polemics. Ed. Stanlie M. James and

Claire C. Robertson. U of Illinois P, 2002: 54-86.

Thiam, Awa. Speak Out, Black Sisters: Feminism and Oppression in Black Africa.

London:Pluto,1978.Graphicdescriptionsof FGM;cultural

perspectives.

100 Bioethics and Medical Issues in Literature

Walker, Alice. “Advancing Luna—and Ida B. Wells.” You Can’t Keep a Good

Woman Down: Short Stories. New York: Harvest-Harcourt, 1981: 85-104.

A white woman raped by a black civil-rights leader remains silent to

advance the cause.

— The Color Purple.NewYork:WashingtonSquareP,1982.

Whitney, Ruth Linnea. Slim. Dallas, Texas: SMU P, 2003. Novel about AIDS

in Africa.

Chapter Five

End of Life—Disease and Death: An Analysis of

John Updike’s Rabbit at Rest and Margaret Edson’s

Wit

Introduction

While chapter 4 shows clashing cultural extremes, chapter 5 focuses more on

ourcommonalityof movinginexorablytowarddeath.Thequalityofourpas-

sage may depend on how we care for our bodies, minds, and spirits.

JohnUpdikechronicleshismaincharacter’slifestyleanditsconsequences

inaquartetof famousnovels:Rabbit, Run(1960),Rabbit Redux (1971),Rabbit is

Rich(1981),andRabbit at Rest (1990).ByupdatingRabbit’slifeeverydecade—

from his 20s to mid-50s—Updike portrays his high school basketball star’s

turning into a self-indulgent car salesman. Updike’s everyman lives through the

1960s “decade of discontent,” the 1970s “Me Decade,” and the AIDS-plagued

1980s,emphasizingthehealthconsequencesof thesexualhabitsof thetime.

Years of self-abuse lead to Rabbit’s rapid decline during the last years of his

life, leaving him little reason to live.

In Rabbit at Rest Updike artfully dissects middle-class dysfunctional life,

givinga powerfulculturalcritiqueof  America. Hejuxtaposestechnicaland

metaphorical language to describe Rabbit’s various diseases, symptomatically

expressed as morbidly depressed, chest pains, and a bloated body worn “like

a set of blankets the decades have brought one by one,” all leading to a fatal

heart attack. Rabbit at Restilluminatesspecicallyhowuntimelydeathsoccur

when contemporary medicine records life expectancy at an all-time high. Other

topics it covers are cocaine addiction, patient experience, family relationships,

and American hedonism.

Dr. Vivian Bearing’s courageous and protracted death from cancer in

Margaret Edson’s play WitcountersRabbit’sself-inictedearlydemisefrom

102 Bioethics and Medical Issues in Literature

heart disease in John Updike’s Rabbit at Rest. InthePulitzerPrize-winningplay,

poetry, science, and death interrelate for Bearing, a John Donne professor and

stage4metastaticcancerpatient.Shebecomesaresearchsubjecttocontribute

to knowledge, even without therapeutic value for her. During eight months

of chemotherapy the dedicated scholar turns from erudite to vulnerable.

She has only one hospital visitor, having valued ideas over personal relation-

ships. Special insights on the medical professional-patient relationship come

through two supporting characters: the compassionate nurse who knows how

to emotionally nurture and the unfeeling young research doctor with so-called

detached concern.Theplaygivesscenariosthatdeneempathy and compassion.

It asks, how do you treat the dying patient? What do you say to soothe rather

thanaddinsulttoinjury?

Edson puts the American medical system on trial in Wit by boldly looking

at doctor paternalism, patient autonomy, and human rights in clinical trials.

She shows how hope, kindness, and a sympathetic touch can interface with

research ethics. In a layered approach using metaphysical poetry to shed light

ontwenty-rstcenturymedicalresearch,Wit also ponders serious philosophi-

calandreligiousquestions,askinghowcanweliveafulllinglifebygivingand

receivinglove?Furthermore,inourmedicalizedsystemof dying,howcanwe

realizeagooddeath?

Wit dramatically evokes a spirituality to bring catharsis: “And death shall

benomore,Deaththoushaltdie”(JohnDonne,Devotions upon Emergent Occa-

sions, London1624).Notwithstandingthepoeticrevelationthateverlastinglife

follows death, the play’s themes underscore the present-day need for better

trained end-of-life and palliative-care medical professionals. Lastly Wit, by

evokinglaughterandtears,allowsustotakeanuninchinglookatdisease,

dying, and death.

End of Life—Disease and Death 103

JOHN UPDIKE’S

RABBIT AT REST(1990)

Food to the indolent is poison, not sustenance.

– Life and Times of Frederick Douglass

(Rabbit at Rest epigraph)

Historical Context

John Hoyer Updike was born in Reading, Pennsylvania, in 1932 but grew up

in nearby Shillington. His mother, an unpublished writer, encouraged him to

readandtowrite;hisfatherwasamathteacher.InhisyouthUpdikesuffered

fromanembarrassingstutteranddisguringpsoriasis(“FromtheJournalof 

aLeper”).

Updike, president and covaledictorian of his Shillington High School class

of 1950, said he entered Harvard “a true tabula rasa,” absorbing whatever

it offered. He drew cartoons for its famous humor magazine, the Harvard

Lampoon. After he graduated with an English degree in 1954, he and his wife

Mary Pennington moved to Oxford, England, where Updike studied art at

the Ruskin School of Drawing and Fine Arts. In 1955 his rst jobwas as

a New Yorker staff writer. Two years later Updike became a full-time writer,

movingtoIpswich,Massachusetts.Hisrstbook,The Carpenter Hen and Other

Tame Creatures, a collection of poetry, was published in 1958. The next year he

publishedhisrstnovel,The Poorhouse Fair (1959). During the 17 years Updike

lived in Ipswich, he keenly observed its suburban couples, writing about their

sexual antics in Couples(1968).Adulteryanddivorcecontinuedasathemein

his Rabbit tetralogy.

The prolic John Updike published more than 50 volumes, including

poetry,essays,novels,andshort stories,muchof it scrutinizingcontempo-

rary American culture.Herendered theawsof  hischaractersin eloquent

language, often writing autobiographically, as most authors do. He received

two PulitzerPrizesforction:Rabbit is Rich(1982)andRabbit at Rest(1991).In

2003 Updike was honored with the National Humanities Medal. After Updike

andhisrstwife,MaryPennington,divorced,hemarriedMarthaBernhardin

1977. He was the father of four children and lived in rural Massachusetts, near

Boston, until his death in 2009.

104 Bioethics and Medical Issues in Literature

Updike gives a powerful cultural critique of  American life in Rabbit at

Rest.Thespecicmedicalissueitaddressesishowhiseverymanprotagonist,

Harry “Rabbit” Angstrom, has abused his body, mind, and spirit for most of

his life, culminating in a fatal heart attack. When the average life expectancy

exceeded82(IRSTableI),hediedat55.To understand Rabbit’s plight, study

theamazingfour-chamberedhumanheartwith its complex of arteries, veins,

and valves. It is a dynamic double-pump action organ with an all-important

pace-making sinoatrial node, beating 100,000 rhythmic beats a day. The right

sidereoxygenatesthebloodinthelungs;thentheleftsidereturns14,000pints

of blood daily to the entire body from head to toe. Indeed, a healthy heart,

looking like a valentine, is a masterwork of nature that we relate to feelings,

often referring to it as the seat of the soul.

When the heart for any number of reasons fails to deliver its oxygen-laden

and nutrient-rich blood all over the body, including to the lungs, liver, kidneys,

and the brain, it causes a number of systems’ failures. In particular, when the

brain has been deprived of oxygen for as little as two to four minutes, brain

death occurs, as partly determined by an electroencephalogram(EEG)read-

ing. Brain death, pronounceable by a doctor, is a legal term.

Some medical context, focused specically for discussing this novel, is

useful. Heart attack warning signs for males, as described in Rabbit at Rest, are

listed by the American Heart Association:

• Chest discomfort. Most heart attacks involve discomfort in the center

of the chest that lasts more than a few minutes, or that goes away

andcomesback.Itcanfeellikeuncomfortablepressure,squeezing,

fullness or pain.

• Discomfort in other areas of the upper body. Symptoms can include

painordiscomfortinoneorbotharms,theback,neck,jaworstomach.

• Shortness of breath with or without chest discomfort.

• Other signs may include breaking out in a cold sweat, nausea or light-

headedness.

Theafictedalsomayexperienceanirregularheartrate,paleness,andfeel-

ing an impending sense of doom. The signs may come and go, as Updike

chronicles in Rabbit at Rest, and not all of them may appear in every attack.

If thereisnobreathingorpulse(cardiopulmonaryarrest),cardiopulmo-

End of Life—Disease and Death 105

naryresuscitation(CPR)mustbestartedimmediatelyand911emergencyhelp

called.If anautomatedexternaldebrillatorisnearbywithatrainedoperator,

it should be used immediately to restart the heart. Only a doctor will make the

actual diagnosis of a heart attack after a physical examination including patient

medical history, an EKG that ascertains heart abnormalities, and a blood test

detectingabnormalenzymelevels.Americanssuffer1.2millionheartattacks

every year and many of them die.

There is good news. Studies of centenarians show how to extend longev-

ity. The Living to 100 Life Expectancy Calculator relates ways to a healthier,

longer life: keeping an optimistic attitude to manage stress, avoiding tobacco

and excessive alcohol, and maintaining an ideal weight. Obesity, the silent epi-

demic,isdenedas20percentaboveidealweightoraBMIof 30ormore.It

affects over 30 percent of adults and 25 percent of our children. Even one in

four pets is overweight. Rabbit at Rest describes one man’s indolent lifestyle and

how his obesity, stress, and depression culminate in a fatal heart attack.

Synopsis of the Novel

It is the end of December 1988. Harry “Rabbit” Angstrom is a white, middle-

class, married male with a dysfunctional family, whose years of self-abuse

surface in this last novel of Updike’s famous Rabbit series. Now 55, he is a

grandfather who has lived anxiously through the end of the Cold War and into

the War on Drugs with both his family and country still in crisis. The social

backdrop includes political references to the Ronald Reagan and George H.W.

Bush administrations and multiple death references, including to AIDS, Roy

Orbison, and Pan Am 103 exploding over Scotland. Thus, the novel’s tone is

elegiac, echoing the past decades of discontent and foreshadowing Rabbit’s

demise.

Rabbit and his wife, Janice, meet their son, Nelson, and his wife, Pru, and

theirtwochildren,Roy(4)andJudy(almost9),attheMiamiairport.Right

away the family situation becomes stressful when Rabbit takes Judy to buy

candyandthencannotndhiscar;latertherearemorequarrelsovernixinga

Disneyland trip and making sleeping arrangements. Additional problems arise

because the drug-addicted Nelson has taken over the family car sales business

inheritedbyJanice,buthelacksthecompetencytomanageit.Oneconict

afteranotherstressesRabbit’splaque-narrowedarteries.

Three days later Rabbit saves Judy from drowning after their sailboat cap-

106 Bioethics and Medical Issues in Literature

sizes;hehasamildheartattackandistakentothehospital.Whileoating

in a world of Demerol, Rabbit learns he has a typical American heart: “tired

and stiff and full of crud.” The whole family visits him. The doctor explains

the diagnosis, and then he discusses interventions like angioplasty and bypass

grafting surgery. He recommends a new dietary plan. Nelson’s family returns

home to Brewer, Pennsylvania.

In Part 2 it is mid-April, and Rabbit and Janice return to springtime

Brewer.WhileJanicelooksforajob,Rabbitreectsonhisdismalpast,visit-

ing his ill former lover, Thelma, whose disease, systemic lupus erythematosus,

has depleted her family’s income and spirit. He learns from her that Nelson

is a cocaine addict, causing Rabbit additional worry about AIDS. He visits

Springer Motors, discovering Nelson has taken down his old basketball star

photosandhashiredawoman.ThehomosexualAIDS-inictedbookkeeper,

Lyle, refuses to show him the books.

Janice takes Penn State extension real estate courses, while Rabbit frets

about Nelson. They talk about Nelson’s drug addiction and his bleeding the

company. They receive threatening calls from his unpaid drug dealers. They

are guilt-ridden for raising Nelson to be so troubled. Rabbit asks his friend,

Charlie Stavros, for advice, and they discuss Brewer’s drug problem at large.

Late one evening after the drugged-up Nelson attacks Pru, she calls Janice and

Rabbit for help. They are divisive in their approach to Nelson.

In mid-May Rabbit undergoes a hospital angioplasty, fully described in

the novel, to widen the narrowing arteries to his heart. He feels sandbagged

when he learns that what was described to him as a simple Mickey-Mouse

procedure requires the surgeon, two attending nurses, and a bypass team

standing by. His nurse may even be his illegitimate daughter. Rabbit resents

CharlieStavrosforadvisingandconsolingJanice.Janiceresthebookkeeper,

and Rabbit feels threatened by her taking charge of the business rather than

managing their household. Dr. Breit tells Rabbit his angioplasty was not totally

successful because there is still 80 percent blockage in his right coronary artery.

Also,becausehemayhavesufferedapostoperativemyocardialinfarction(MI),

Dr. Breit strongly recommends the more drastic coronary artery bypass graft.

“They split you right open like a coconut and rip veins out of your legs,” Rab-

bit tells his sister, Mim, during a depressing phone call.

Rabbitis distrustful of Dr.Breit, suspectinghehas asurgical quotato

achieve. Janice, too busy with classes, has not visited him in the hospital, but,

End of Life—Disease and Death 107

when she does, she relates how the car lot revenue has gone to Nelson’s drug

habit and Lyle’s AIDS medicines. Thelma and her husband, Ronnie, visit Rab-

bit.Sheisdemoralizedfromdealingwithherdisease.Nelsongoestoanearby

rehabfacility,learningtheNarcoticsAnonymousrstprincipleof “admitting

you’re powerless and dependent on a higher power.” Rabbit, released from the

hospital into Pru’s care because Janice is busy taking real estate tests, makes

love to her. Back running the car lot, Rabbit uncovers Nelson’s malfeasance

and reinstalls his own enlarged high school basketball photos on the wall. Rab-

bit, whose strange brand of religion has been replaced by cynicism, reluctantly

attends family counseling. To Rabbit’s chagrin, Nelson, who reminds him of

Hitlerandsoundslikeaminister,hugshimforthersttimeintheiradultlives.

In part 3, appropriately called “MI,” Rabbit marches as Uncle Sam in the

Mount Judge Fourth of July parade. He attends Thelma’s funeral, where her

husband Ronnie argues with him. In early August the Toyota representative

visits Rabbit on the lot and cancels the franchise. Janice warns Rabbit about

his health habits, and Nelson returns from rehab, his life plan being to change

“a day at a time with the help of a higher power.” Janice and Nelson dash

Rabbit’s high expectations about running the business again. They want to get

grant money to turn it into a drug treatment center. The Toyota loan is paid

with a second mortgage on the property. When Janice talks of moving in with

Nelson and Pru to save money, the latter tells Janice of her affair with Rabbit,

who then takes off on a marathon drive to their Florida condo.

Eatingjunkfoodalongtheway,helearnsontheradiothatBartGiamatti,

thebaseballcommissionerwhodealtwiththePeteRoseasco,hasdiedatage

51. Alone in the condo, Rabbit becomes depressed and makes an appointment

with Dr. Morris who advises him on a health plan: eat right, walk, and get

absorbed in “something outside yourself and your heart will stop talking to

you.” Nelson, Pru, and Janice are moving forward with their lives, while Rabbit

reectsonthepast.Thehealthyfoodshetriesareunpalatabletohim,andfor

anexerciseregimenhechooseswalking.Onatrekoneday,hejoinsayoung

black man in a pickup basketball game and suffers a massive heart attack.

JaniceiestoFloridatoforgivehim;aremorsefulNelsonbegshimnottodie.

But Rabbit assures his son, “It isn’t so bad,” and thinks laconically to himself:

“Enough.”

108 Bioethics and Medical Issues in Literature

Literary Analysis

Larry“Rabbit”Angstrom,thectionalantiherointheRabbitquartet,andJohn

Updike, his creator, led parallel lives. Both were born in the early 1930s and

grew up around Reading, Pennsylvania. There, however, the similarities end.

While Rabbit was a “beautiful brainless guy” whose glory days peaked at 18,

Updike became a world-famous author, an ability seeded in a Harvard educa-

tion.

The Rabbit series derived from Updike’s early blank verse poem, “The

Ex-Basketball Player,” in which the speaker mocks the title character with

no appreciable talents to transfer into the bigger world. The ex-jock Flick

Webb accepts his mediocre fate as a small town gas station pump-jockey.

The townspeople who once lived vicariously through his high school

accomplishmentsnowgivehimonlyeetingafrmation.Updike’sskillfuluse

of gurativelanguageandimagesbuildsthecontrastbetweenFlick’slackluster

adult life and his short-lived fame. The poem, replete with sports analogies,

correlates Flick’s cut off, bleak future with having never learned a trade—the

idiotjustexists.AfterUpdikewrotethepoeminthe1950s,heimaginedFlick’s

life further into the future, becoming the Rabbitquartet.

This analysis focuses on how Rabbit, an everyman middle-class, white

Protestant male, embodies late twentieth-century American culture. He

experienced adolescent and young adult sexuality during the postwar boom of

the mid-1940s through the 1950s. He was a married man and adulterer with

afamilyduringthehippie1960sandthefeminist1970s(alsocalledtheage

of discontent).Infact,authorTomWolfe coined the term the Me Decade to

describetheselshseventiesmentality,whichUpdikeappliedtotheimpulsive,

sexually-obsessed Rabbit who shirked commitment. By the time we catch up

to Rabbit in Rabbit at Rest, it is now the AIDS-plagued 1980s, foreshadowing

Updike’s deep theme, “the blossoming and fruition of the seed of death we

allcarryinsideus”(Oates449).Thenovelcoversthelastnine-monthperiod

in the life of Rabbit Angstrom, who has a lot of baggage. He is all of these

things: racist, xenophobic, misogynist, and homophobic. It is all described in

three chapters titled after his states of being: “Florida,” “Pennsylvania,” and

“MI”(myocardialinfarction).

Intherstchapterthe6’3”Rabbitis55yearsoldand40poundsover-

weight, making him late middle-aged and obese. He and his long-suffering

wife, Janice, are semi-retired in Florida. After they pick up their estranged son

End of Life—Disease and Death 109

and his family at the airport “a sense of doom regrows its claws around his

heart.” Thereby, right from the beginning at their unpleasant and stressful

family reunion, Updike artfully interweaves into the scene a classic symptom

of heart disease, following it with a description of the gluttonous lifestyle

supporting it. That is, Updike’s omniscient narrator speaking for the brooding

Rabbit fully orients descriptions of his stress, overeating, and depression to

his angina pains, bloated body, and the frightening sensation there is “nothing

under you but black space.”

Rabbit becomes a focal point around which an understanding of an era

develops. Having lived through the Cold War, Rabbit bursts with pride when

President Ronald Reagan tears down the symbol of communism, the Berlin

Wall. Readers who have seen the American and Russian Presidents, Bush and

Putinrespectively,embraceinsolidarityinthetwenty-rstcenturyarefasci-

nated to hear descriptions of students’ duck-and-cover desk drills during an

age of nuclear bomb threats. Rabbit also lived into the war on drugs, unsafe

sex, and AIDS concerns, leaving him with a sense of impending doom. A

sexually promiscuous antihero, he embodies the free-love culture and its con-

sequences.Thenovel,withitsreferencestoairdisasterssuchastheexplosion

of Pan Am 103 over Scotland, foretells the age of terrorism.

The many cultural threads woven throughout the novel, namely historical,

political, economic, religious, and social, provide a backdrop for the emphasis

Updikeplaces onRabbit’s lifestyle withits consequentialmedical issues. In

particular, Rabbit is best understood by looking at what he relates to the most:

food, sex, and sports. Once an admired high school athlete, he is now an

indolentagingjunk-foodaddict.Hisxationonsportsheroes,suchasfootball

and baseball player Deion “Prime Time” Sanders, helps him vicariously relive

his glory days of being the star of the show.

In the spring Rabbit’s egotism transfers wholly to baseball, as American

as apple pie and heart disease. The Philadelphia Phillies all-star third baseman

Mike Schmidt, a has-been, as reported in the media, hits two home runs in the

rsttwogamesof theseason.ItreinvigoratesRabbituntiltheinjuredSchmidt

retires at 39.

Moreover,the PeteRoseascoagitates Rabbit.Baseball Commissioner

Bart Giamatti imposed a lifetime ban from baseball on Rose for gambling on

his own team. Rabbit, whose muscle has turned to fat, is leading the type of

lifestyle that caused Giamatti’s massive heart attack death at 51. But, without

110 Bioethics and Medical Issues in Literature

changing his bad habits, he rationalizes that, unlike Giamatti, he is a non-

smoker. When his son, Nelson, removes the old Rabbit basketball photos at

Springer Motors, the slender thread by which Rabbit’s fragile ego is tethered

snaps. He feels, “nothing matters very much, we’ll all soon be dead,” evoking

a chronic depressive state.

As the last book in the tetralogy, Rabbit at Rest fascinates by showing Rab-

bit and the century winding down together. Riding the cultural tides until his

energy gives out, he is “too oldfor ux.”He is also too close to his own

predicaments for self-awareness and too shortsighted to view change as an

opportunity for renewal. Sadly, he even sees the birth of his granddaughter as

anothernailinthecofn.

Suffering from hardening both of the arteries and of ideology makes

Rabbit an average aging American male, in Updike’s view, who tends to react

instinctually rather than to act rationally with forethought. His actions in the

sexually promiscuous climate lead to adultery and an illegitimate child. In addi-

tion to living hedonistically, he feels spiritually alienated, fearing his own death

in a godless culture. Inhismid-fties,Rabbitmustfacetheconsequencesof 

his past to live out a mediocre life with implacable regret. There will be no

golden years.

ThedesolateRabbit,afteratrystwithhisdaughter-in-law,eestoFlorida.

The smell of death is all around. Having no reserve, he is now “ready to

succumb to the heaviness of being.” Janice, on the other hand, embraces a

new feminist independence. Disinterested in her philandering husband, she

becomes a successful realtor. After running Springer Motors into the ground,

Nelson attends rehab for cocaine addiction. He achieves a new life despite his

enabling mother and his father’s refusal to continue family therapy.

But for Rabbit, his lack of inner resources causes his inability to change

and to embrace life, leaving him in a state of perpetual male angst. Note the

surname “Angstrom.” There is no redemption. The fourth part of an epic

American tragedy, Rabbit at Rest portrays not only an unsympathetic, aging

American malebut a disintegrating societyat large.It istting that Rabbit

unsentimentallyacceptshisfateanddiesjustafterthinkingonelastthought:

“Enough.”

Life goes on in Brewer without Rabbit, as Updike explains in the novella,

“Rabbit Remembered,” a postscript to the series published in Licks of Love

(2000). Now approaching the new millennium, Janice has married Rabbit’s

End of Life—Disease and Death 111

nemesis, Thelma’s former husband, and Nelson is a divorced father and a

drug-free social worker. Through them Updike somewhat redeems a culture

seen in decline, thereby expressing hope the old and new generation can

change for the better.

Inthenalanalysis,Updiketreatsthesubjectof diseaseanddeathinRab-

bit at Rest so artistically that he triumphs over its dire reality enough to make

Rabbit exemplar of a deteriorating body, teaching healthcare and ethics. It is

too late for Rabbit, whose rapid decline is metaphorically America’s story, but

there will be readers who identify with Rabbit’s downfall. And, as in the realm

of all great tragedy, they may be transformed by the novel’s events enough to

achieve catharsis and to embrace change. Otherwise, if Rabbit represents the

average man (or woman) who does not take personal responsibilityfor his

health, the real American tragedy extends beyond the pages of Updike’s book.

Topics for Oral and Written Discussion

• Describe how Rabbit is an antihero like Kesey’s Mack and how his

self-image and existential angst contribute to his unfortunate lifestyle

and health problems. Add to your discussion Updike’s poem “The

Ex-Basketball Player.”

• CorrelateRabbit’slifestyle(diet, exercise,stress)withhis increasing

cardiac symptoms in a study of how it contributed to his cardiac

arrest. Use medical terms and apply the saying, “It’s time to pay the

piper,”toRabbit’snaloutcome.

• How did the decades through which Rabbit lived culturally acclimate

him to bad personal habits? In particular, how does Tom Wolfe’s

description of the Me Decade apply to Rabbit?

• In Rabbit at Rest, an American tragedy, apply the term free will to

Rabbit. If you were a medical professional who observed someone

like Rabbit, not your patient, who exhibited heart disease symptoms,

would you tell him to see a doctor?

• Describe how Nelson’s cocaine habit affects his family relationships

with his wife, children, and his mother and father. Who enables him?

Who helps him?

• DenethetraitsUpdikeattributesRabbitwith,suchasnarcissistic,

hedonistic, bigoted, misogynistic, xenophobic, and homophobic, then

argue both sides, that either he is or he is not the product of his times

112 Bioethics and Medical Issues in Literature

and typiesan average agingAmerican male with apropensity for

heart disease.

• Describe, medically, the effects of Rabbit’s hedonism and indolence

onhisbody(heart),thendiscuss:1)the rstmedicalprocedure he

underwent,2)themoreaggressivemedicalprocedureanotherdoctor

recommended,and3)thedoctor-patientrelationshipineachevent.If 

Rabbit’sbypassdoctorhasaquotatomeet,asRabbitsuspects,would

this be ethical?

• Because Rabbit vicariously relates to various sports heroes, how do

they,andspecicallythePeteRose-BartGiamattidebacle,affecthis

well-being?

• How does isolation in Florida affect Rabbit’s failure to recover from

myocardial infarction?

• Describe how rehabilitation and feminism help Nelson and Janice,

respectively, reclaim their lives.

Bibliography

American Heart Association. www.heart.org.

The Living to 100 Life Expectancy Calculator: http://www.livingto100.com/

Oates, Joyce Carol. “A Beautiful Brainless Guy.” Books of the Century (The New

York TimesBookReviews),ed.CharlesMcGrathetal.NewYork:Three

Rivers P, 2000: 449-51.

Updike, John. “The Ex-Basketball Player.” The Carpentered Hen and Other Tame

Creatures. New York: Knopf, 1982. [E-text]

— “From the Journal of a Leper.” Problems. New York: Fawcett, 1981: 201-

18.

— Rabbit at Rest. New York: Fawcett, 1990.

— “Rabbit Remembered.” Licks of Love. New York: Knopf, 2000.

Suggested Further Reading

Gawande, Atul. “The Man Who Couldn’t Stop Eating.” Complications: A

Surgeon’s Notes on an Imperfect Science. New York: Holt, 2002: 162-83.

Nuland, Sherwin B. How We Die: Reections on Life’s Final Chapter. New York:

Knopf, 1994.

Wolfe, Tom. “The ‘Me’ Decade and the Third Great Awakening.” New York

Magazine(August23,1976):26-40.

End of Life—Disease and Death 113

MARGARET EDSON’S

WIT(1999)

Once I did the teaching, now I am taught.

— Dr. Vivian Bearing, Wit

Historical Context

Margaret Edson was born on July 4, 1961, in Washington, D.C. Her medical

social worker mother and her newspaper columnist father encouraged her high

school drama interests. After she received a bachelor’s degree in Renaissance

history, magna cum laude, from Smith College in 1983, she traveled for two

yearsworkingatoddjobs.Forthenextfewyearsshewasanoncology/AIDS

patient clerk and volunteer social worker at the National Cancer Institute in

Bethesda, Maryland. She witnessed protocols being developed to treat patients

for ovarian cancer and HIV.

In 1991, from observing the medical teams and patients on the ward and

from listening, she wrote Wit (alsoknownasW;t),initiallyaregionaltheatre

and off-off Broadway production. Edson received a master’s degree in English

from Georgetown University in 1992, and then she taught English as a second

languageandrstgradeinaD.C.publicelementaryschooluntil1998.While

shewasanAtlantakindergartenteacher,in1999,hercareerwasbrieyinter-

ruptedwhen sheaccepted thePulitzerPrize forDrama. Todayshe livesin

Atlanta with her partner, art historian Linda Merrill, and their two sons.

Withastherarequalityof beingsimultaneouslyfunnyandheartbreaking

as it deals with thesubject of  ovarian cancer,an often fatal disease if  not

caught in its early stages. The play also reviews clinical trial methods, includ-

ing the effects of experimental drugs administered to terminal patients with-

out offering any hope of cure. It dramatically depicts medical science in its

hustle-and-bustleattempttondbettertreatmentsandcures,subordinating

theresearchsubject’shumanneeds.Therefore,theplayscrutinizesthedoctor-

patient relationship, especially relating to respect shown for or withheld from

the patient whose palliative care may therefore be lacking.

Although there is no possibility of healing Wit’s protagonist, Dr. Vivian

Bearing, of stage 4 cancer, avoiding medical mistakes is also at issue. Patients

achieve autonomy, or the right to self-determination, in part when their medi-

114 Bioethics and Medical Issues in Literature

cal professionals learn to listen to them, a skill that can be modeled in narrative

literature as illustrated here. Lastly, as a practicum in clinical trial methods, Wit’s

analysisdescribeshowinstitutionalreviewboards(IRBs)taketheirethicalphi-

losophy from The Belmont Report and follow Federal Drug Administration

(FDA) regulations in drug studies. They oversee methods for ensuring the

study participant’s informed consent and privacy as well as work to avoid doc-

toranddrugcompanyconictsof interest.Managingthepatient’spainand

utilizinghopeforincreasingthequalityof lifearealsohands-ondoctor-patient

issues. In the mid-twentieth century One Flew Over the Cuckoo’s Nest sharply

criticizedmentalhealthcare;nowintothetwenty-rstcenturyWit casts a light

on end-of-life issues.

Cancer is a leading cause of death in Americans, second only to heart

disease. While breast cancer kills the most women, many gynecological cancers

are part of the overall cancer statistic. Ovarian cancer, the so-called whispering

disease because of its insidious nature, is detected in one in 70 predominantly

perimenopausalandpostmenopausalAmericanwomenandoftenmetastasizes

undetected. Risk factors include family history of ovarian and breast cancer,

high dietary fat, delayed menopause, and no or late childbearing. The use of

oral contraceptives appears to decrease risk. Ovarian cancer often presents

itself with a cluster of three persistent and severe symptoms: a swollen abdo-

men, a bloated feeling, and urgent urination. Other symptoms associated with

the disease include gas pains, anorexia, backache, and indigestion.

Unfortunately, most women seek medical advice when their ovarian cancer

is in the advance stage because the symptoms might be associated with other

gynecological conditions. A routine pelvic exam or sonogram can detect an

abdominalmass;however,becausebenigncystsarecommon,acancerantigen

blood test such as CA 125 and/or exploratory surgery may be needed to rule

out malignant tumors. The ovaries of postmenopausal women are small so an

enlargedmassisof signicantconcern.

Legislation proposed in 2003 as The Gynecologic Cancer Education and

AwarenessAct(HR3438),calledJohanna’sLawafterJohannaSilverGordon

who died from ovarian cancer, outlines a national early detection and awareness

program to give women and their healthcare providers the latest information

on the symptoms and risk factors of gynecologic cancers, with ovarian cancer

being the deadliest. The American Cancer Society estimates that in 2013 about

22,240 new cases of ovarian cancer will be diagnosed and 15,500 women will

End of Life—Disease and Death 115

dieof  itinthe UnitedStates.Therelativeve-yearsurvival rateisonly 44

percent, depending on the stage of diagnosis. At the U.S. National Cancer

Institute clinical trials are underway on a breakthrough proteomics diagnostic

test for detecting bloodstream proteins produced by early stage cancer cells.

This exciting news builds hope for early diagnosis followed by new treatments

in development such as the anti-angiogenesis drugs that shut off a tumor’s

blood supply causing it to shrink.

With 1,600,000 cancer diagnoses in America in 2012, numerous clinical

trials help to develop other diagnostic tests and treatments beyond surgery

and chemotherapy. Researchers who enroll about two percent of adult can-

cerpatientsintodrugstudiesgetvaluabledata;desperatepatientshopefora

miracle.However,therealityof clinicaltrialsconductedrstinnonhumans

and then in humans often results in pure research promising no therapeutic

valuefortheparticipants,whichbringsintofocusthequestionof theirrights.

The process begins at hospital admission, when patients are asked about any

advance directives they have signed, including living wills, healthcare powers

of attorney,andorgandonation.Apatientadvocateisalwaysavailabletoeld

general complaints. The attending doctor reviews the patient’s medical history,

performs a physical examination, and presents a plan for healing. Along the

way, the patient may seek an ethics consultation, which is a reasoned conversa-

tion with a professional about the values and choices made in healthcare.

When the patient enrolls in a drug study, as Wit’s Dr. Bearing does, in

realityaninstitutionalreviewboard(IRB)actsasadisinterestedpartytoover-

see research protocol. IRBs take their philosophy on what ethical research

is from The Belmont Report commissioned by the Department of Health

and Human Services. In 1974 the National Research Act created the National

CommissionfortheProtectionof HumanSubjectsof BiomedicalandBehav-

ioral Research. The Nuremberg Code, derived from the World War II war

crimes, was a prototype for the commission’s guidelines.

For this discussion, the ethical principles and guidelines for the protec-

tionof humansubjectsincludedeninghowparticipantsareselected,how

informed consent is obtained, how to assess risk-benetratio, and howto

avoid conict of interest. The boundaries between practice and research

are dened.Thebasic ethical principlesit sets out are: respectfor persons

(acknowledging autonomy and diminished capacity), benecence (securing

well-beingandabidingbytheHippocraticmaxim,“rst,todonoharm”),and

116 Bioethics and Medical Issues in Literature

justice(observingfairnessinwhobearstheburdenorreceivesthebenets).

Besides monitoring these practices and obtaining legally effective informed

consentfromthesubjectorhisorherlegalrepresentative,IRBsmustcare-

fully observe privacy regulations created by the Health Insurance Portability

andAccountabilityActof 1996(HIPAA).Therefore,respectforthepatient’s

autonomyandguardingagainstanypossibilityof deceitorundueinuence

in a potentially vulnerable participant is paramount. Furthermore, in drug tri-

als an IRB must carefully apply various titles of FDA codes of regulation.

Investigational new drugs (IND)go through three graduated phasesin the

investigational process, as determined by the FDA, before FDA approval is

sought and physician labeling procured.

Vivian Bearing is probably enrolled in a Phase 3 frontline drug study to

evaluate the effectiveness and safety of the drug. It may be deemed proper to

push the dosage. The distinction must be made between suffering the patient

would have as a part of her disease and that which may result from research

participation. Any toxicity in the full dosage given Bearing could be evalu-

ated by laboratory values and the parameters determined that could kill her.

That is, administering the full dose may not be necessarily painful. In particu-

lar, the duties of IRB watchdogs include giving the research participant the

opportunitytoaskquestions.Pertinentinformationmustbeexplainedsothat

theparticipantfullyunderstandstermsandrisk-benetratios,allunderFDA

regulations.

When a patient becomes a study participant, like Wit’s Dr. Vivian Bear-

ing, facing illness—especially disease and dying—may take the courage of

a lion-tamer, to borrow from Virginia Woolf in “On Being Ill.” While such

studies are vital to medical training and can affect the future care of patients,

often they are not in the best interests of the terminal patients. In addition,

distraught family members may insist on keeping a patient alive through heroic

measures, merely prolonging their loved one’s suffering.

Therefore, economics becomes another primary concern in a healthcare

system in crisis. Ongoing interdisciplinary talks between clinicians and phi-

losophersaddresswhatitmeanstodieinthetwenty-rstcentury,withtech-

nology altering our conception of death. These concerned individuals assess

the implications for end-of-life caregiving to determine a reasonable duration

in the dying process. Until assisted-suicideislegalized,state-by-state,inthis

country, fortifying the doctor-patient relationship is one solution to enable

End of Life—Disease and Death 117

private, apolitical end-of-life decisions.

Besides all of the above, Edson’s Wit incorporates topics such as having

hope, even in the terminal, and the importance of kindness, listening, and

touching by healthcare professionals, making for a better end-of-life experience.

Synopsis of the Play

ProfessorVivianBearing,aliteraryresearcher,isnowherself thesubjectof 

cancerresearch.Thesetwodissimilareldsof studyformthefoundationof 

a moving play looking at the boundaries of the intellect and the expanses of

the heart. Primarily set in a University Hospital Comprehensive Cancer Center

room, there are no action breaks between scenes and no intermission in the

90-minute play. Therefore, lighting changes signify important transitions.

Dr. Bearing enters an empty stage pushing an IV pole, giving immediacy

to her dire situation. She wears two overlapping hospital gowns for modesty

andahospitalIDbracelet;shecoversherbaldnesswithabaseballcap.Outof 

a cast of nine, Bearing carries the play, intermittently breaking the fourth wall

by addressing the audience: “Hi. How are you feeling today?” Then, slightly

mocking,shebecomesawarethatitisarhetoricalquestion:nooneislistening.

In a ashback scene, Chief  of Oncology Dr. Kelekian dispassionately

announcestoDr.Bearingin medicaljargonthatshe hasstage4 metastatic

ovariancancerwithtumorsspreadingquickly.Shewillreceiveeightmonthsof

aggressivebutexperimentalchemotherapy,takingthefulldosetosignicantly

contribute to knowledge. She must be very tough, he says, as she signs an

informed consent. Given this drastic news, Bearing retreats into her intellect,

making a mental note to create a bibliography for studying her disease. Both

doctors, as academics, commiserate on the state of their students’ scholarship.

Bearing learns the treatment for her insidious cancer will have pernicious side

effects, but she views her plight as a challenge, taking comfort in applying her

life-long discipline of exploring mortality in Donne’s Holy Sonnets.

Twenty-eight years earlier, Bearing’s mentor, E.M. Ashford, berates her

foremotionallyanalyzingDonne’s“HolySonnetSix,”ratherthanreadingit

critically, with a correctly punctuated line: “And death shall be no more, Death

thou shalt die.” In this uncompromised version a mere comma, a breath, sepa-

rates life from everlasting life. A future academic, Bearing eagerly returns to

thelibrary,althoughProfessorAshfordsuggestsshejoinfriends.

Back in the present, Bearing deals with the impersonal hospital regimen,

118 Bioethics and Medical Issues in Literature

saveforthattreatmentgivenbyhercompassionatenurse,Suzie.Theemotion-

ally detached young doctor, Jason, once Bearing’s student, oversees the study

protocol. Bearing answers his battery of  questions, her famous wit intact,

describingherprogressivesymptoms.ThenJasoninadehumanizingmanner

performsapelvicexamination,excitedlyconrmingherovarianmass.Tests

and treatments ensue, aligned with Bearing’s nausea and vomiting. Her only

visitors are medical students on rounds.

Inanotherashback,Dr.Bearingisve,readingBeatrixPotter’sThe Tale

of the Flopsy Bunnies toherfather,whoexplainstheword“soporic”(sleepy)to

her. Hence, her love of words began early and extended into the wonders of

metaphysical poetry, as it does now less evocatively to medical terms. She has

endured her outpatient chemotherapy but now rushes to the hospital shaking,

feverish,andweak.SuziesuggestsBearing’sdosebelowered;Jasoninsistson

the full dose, which paradoxically may imperil her health but is done in the

interest of knowledge.

The scene shifts, putting Dr. Bearing in the spotlight as she lectures on the

metaphysical doctrine that teaches God forgives overweening intellect. Then

Suzieisbroughtbackintothescene,takingBearingformoretests.Growing

weaker,Bearingvisualizesthistobetheend,orinDonne’swords:“theplayes

last scene.” However, Jason enters. He explains his enthusiasm for studying

cancer, but acknowledges he lacks the bedside manner he says only “troglo-

dyte” clinicians are trained for. Bearing tries to tap Jason’s emotions but is put

off.Nowavulnerablepatient,sherealizestheybothhaveexaltedresearchat

the expense of humanity. Thinking her confused, Jason denies the touch of

human kindness she needs.

Bearing’s own inhumanity to her students is highlighted in her teaching

methods. A student who sees Donne as afraid, “so he hides behind all this

complicated stuff, hides behind this wit,” is put down. A consistently uncom-

promisingteacher,Bearingatlydeniesastudent’spaperextensionduetoher

grandmother’s death. This lack of compassion haunts her.

It is now the hospital’s graveyard shift, and the agitated Bearing is sun-

downing,soshecreatesalittleemergencytogetSuzietocomeseeher.Bearing

isafraid;sheisinneedof comfort.SuziesharesaPopsiclewithBearing,and

they talk about her advancing cancer and code status, noted in her chart as no

heroic measures to restart her heart. Only palliative care managing her pain

helps now. Jason enters the room as Bearing lapses into a drug-induced sleep.

End of Life—Disease and Death 119

AsBearing’sformerstudent,hetellsSuziethathehadtheorizedDonnewas

never released from his salvation anxiety, and then he hastily adds, the senti-

mental meaning-of-life garbage is not for him.

In the all-important penultimate scene, retired Professor Emerita Ashford

visits the semi-conscious Bearing, crawls into her hospital bed, holds her, and

reads The Runaway Bunny,abookforherve-year-oldgrandson.Ashfordgen-

tly kisses the sleeping Bearing and softly says upon departing, “It’s time to go.

Andightsof angelssingtheetothyrest.”

Then Jason stridently enters the room, notes his patient’s lack of vital signs,

and without checking her chart calls code blue. He frantically pounds her chest

andperformsmouth-to-mouthresuscitation.Suzieentersandannounceshis

mistake:Bearingisnocode.Buttheteamhecalledswoopsin,atrstdeaf 

toSuzie’spleastostop.Atlasttheviolentactivityceases,andJasonfeelstrue

humility from making a medical mistake. The audience focuses on the bed

asSuzieliftstheblanketfromherpatient.Thesurpriseending,asBearingis

envelopedintoGod’sgrace,mustbeexperiencedintheplay(orbook).House

lights fade to black.

Literary Analysis

There is no mistaking who is in charge. Right from the beginning Wit’s pro-

tagonist, Dr. Vivian Bearing, a tough-minded Renaissance literature professor,

addresses the audience directly: “Hi. How are you feeling today?” This meta-

theatrical device, breaking the fourth wall, makes the audience self-consciously

aware of its role while preserving the illusion of unfolding action. Then Bear-

ing abruptly says, “I think I die at the end.” Such a declaration might reduce

dramatictensionexceptherstoicalwitllsthevoid,drawingtheaudienceinto

the story in a way whimpering could not.

This analysis focuses on how Wit isaplayaboutBearing’sjourneytoward

deathandhowthroughthesimplehumankindnessofothersshendsmean-

inginlife.Edsonsaysherintentwastoshowapersongraduallyacquiringself-

knowledge through the capacity for love, then ultimately receiving God’s grace.

Indoingso,Edsonwalksthenelinebetweenheartbreakingandhumorous,

knowing when something is funny you hear the truth a little louder. Wit is used

to teach lessons on humanity in medical practices and procedures.

Bearing,a50-year-old,postmenopausal,childlesswoman,tstheprole

of an ovarian cancer patient, who typically ignores the disease’s vague physi-

120 Bioethics and Medical Issues in Literature

cal symptoms. Now in stage 4 with metastatic spread to distant organs, late

detection means virtually no possibility of recovery. The play begins in medias

res with Bearing, a researcher herself, signed up for an eight-month research

protocol involving chemotherapy and high-dose experimental drugs given

ctionalnames.Toshrinkhergrapefruit-sizetumorhealthycellswilldiealong

with the cancer. By consenting to the study she contributes to knowledge but

suffers harsh side effects including hair loss, nausea and vomiting, compro-

mised immunity, fatigue, and pain. Cancer in a no-nonsense university profes-

sor,nowaresearchsubjectdetachedfromtheoutsideworld,causeshertofeel

vulnerable.

Wit, a teachingplay beneting both actors and audiencealike, at rst

portrays Bearing unsympathetically. She is a disciplined professor who has

sacricedfriendshipforintellectualachievement.Onceill,shewagesaper-

sonal battle for survival by drawing on the only resources she has built up:

the metaphysical poetry of John Donne(1572-1631). Donne was a seven-

teenth-century Anglican priest who became the dean of St. Paul’s Cathedral in

London in 1621. Family deaths—including his wife, Anne More, and several

children—and his own extended illness caused him to write a series of spiritual

meditations, Devotions Upon Emergent Occasions. In these essays and in his earlier

Holy Sonnets,salvationanxietyquestioninghisfaithisprevalent.Hediedaftera

lingering illness, but hope of salvation swept into his later years.

Bearingseesthesesonnetsasanintellectualexercise,analyzingtheircon-

ceits, complex poetic devices including simile, metaphor, puns, hyperbole, and

paradox. By integrating metaphysical poetry into the structure of her whole

play, Edson creates some surprising comparisons, as well as elaborate parallels

betweendissimilarthingsindisparateeldsof knowledge.For example, Bear-

ing compulsively researches her medical condition, as she had Donne’s Holy

Sonnets,bycompilingabibliography,analyzingdata,andsoforth.Herrunning

dialogueonmetaphysicalwit contrastswiththe scienticjargon of  ovarian

cancer protocols, showing how Bearing tries to understand her illness through

language. Set into the framework of the interrelated disciplines of literature

and medicine come lessons on kindness and detachment, hope and grace, and

ultimately life and death.

Wit is also a character-driven quest narrative. The others on Bearing’s

illness journey include cancer specialist Dr. Harvey Kelekian, an academic

professor like Bearing who mirrors her emotional distancing from students.

End of Life—Disease and Death 121

They have an intellectual exchange that soon collapses under the stark reality

of her dire situation. Told her prognosis, she signs an informed consent for

the full dose of an investigational drug. Paradoxically, while this protocol may

help to distinguish useful from useless treatment, contributing to knowledge

andbenetingothers,itmightharmher.

Kelekian is obligated to inform Bearing fully about the drug, including

whether it is FDA approved and has possible side effects. There is an ethical

dilemma,groundedinHippocrates’“rst,donoharm,”of deliveringanon-

benecialdosetoohightotolerateandkeepingBearingalivetoreapmedical

data.Periodicreviewof Bearing’spainlevelandqualityoflifeisimperative.At

rst,BearingisaseagertohelpresearchersasshehasbeentosolveDonne’s

intractablementalpuzzle.Butalongthewaytechnicianstreatherinhumanely,

as a number rather than a person, causing her to become cynical. Bearing is

terminally ill, in intractable pain from the cancer and its treatment, and alone.

Like Kelekian, his research fellow Dr. Jason Posner is in a relentless pursuit

of knowledge,alsoforgettinghissubjectisapersonlikehimself.Jasonmind-

lesslyasksher,“Howareyoufeelingtoday?,”arhetoricalquestionindicative

of detached concern, or a medical professional’s learned ability to compart-

mentalizethefearandanxietythatproximitytodeathbrings.Thisformulaic

greetingdefensivelydisconnectshim froma patientto maintainobjectivity.

Bearing feels proud that Jason, once her undergraduate student, is a dedicated

researcher also. But as a scientist he is more interested in his patient’s cancer

cells than he is in her emotions, humiliating her during a disrespectful pelvic

exam. He callously observes and records Bearing’s suffering without offering

solace.

Underneath it all, Bearing tries to mask her loneliness with bravissima rep-

artee. For example, after taking her medical history Jason remarks, “Well that

about does it for your life history,” to which she wittily replies: “Yes, that’s all

there is to my life history.” The sarcasm is lost on the busy doctor who had not

chosen his words carefully. In the beginning both Bearing and her like-minded

young doctor are dispassionate, but with increasing pain her arrogance gives

way to fear. For Edson, once a hospital worker herself, kindness and humility

needtobalanceoutthefervorof scienticendeavor.

In stark contrast to the detached, fact-oriented Jason, nurse Suzie,

althoughportrayedasadimbulb,epitomizesacompassionatecaregiver.Pro-

fessor Bearing is a master teacher of the highest intellectual order with an

122 Bioethics and Medical Issues in Literature

unsurpassedcuriosityforwords;however,havingreadaboutdeathherentire

professional career, she does not have a fundamental understanding of com-

passion.ItismodeledwhenSuzie,herunofcialpatientadvocate,meetsher

needs by listening and by showing simple human kindness. Of course, there

is no way to know when given the bad news how anyone, whether the most

learned theologian or a cancer-stricken child, will face a date with mortality.

But with hope of recovery lost—the cancer is not in remission and only pal-

liative measures are undertaken—Bearing appears to subsume her fear and

acceptherfatewithequanimity.Inthecomfortof Suzie’sarms,sheisgetting

“the medicine of friendship,” as put by Jerome Groopman’s patient in The

Anatomy of Hope(135).

ToassuageBearing’sfear,Suziecallstheonceeruditeprofessorthefamil-

iar“sweetheart.”Sheappliesskinlotion,adjustsherbaseballcaptohideabald

head, and splits a Popsicle with her while having a talk about codes. Bearing

signs a do-not-resuscitate order, thus taking some control over her life. It is

indeanceof Jason’sandKelekian’sdesiretokeepheralivetocollectmore

research data. Ironically, in so doing Bearing has deprived death of its power

overher,justasDonnehopedmeditatingonmortalityandsalvationwould

do for him. Suzie’s time-consuming interactions with Professor Bearing of

coursebeliethefactthatanynursehasatleastveotherjobstodoatonce.

ButEdson’sportrayingcharacters,likethekindSuzieandtherationalJason,

in extremis, shows how, combined, they become an ideal caregiver. That is, the

faculties of reason are not weakened by the growth of compassion and need

not be mutually exclusive.

There is a moment of dramatic irony when Professor Ashford comes to

visitBearing.Ina28-yearashback,Ashfordtalkswithherstudent,ayoung

Vivian Bearing, about Donne’s “Holy Sonnet Six” and its profoundly simple

meaning. Citing the authentic text, “And death shall be no more, Death thou

shalt die,” Ashford states that “nothing but a breath—a comma—separates

life from life everlasting.” How can a simple human truth and uncompro-

mising scholarly standards inform each other, Bearing wonders. Her lifelong

immersion in the Holy Sonnetssparkedheruseofwit,certainly;however,other

than providing an intellectual challenge, it did not engage her in real life.

From the beginning it is clear Bearing is terminal. Feeling secure in life, she

hadignoreddeathuntilherillnessbecameashortjourneyof self-discovery.In

the play’s most sentimental, albeit realistic scene, Ashford crawls into bed with

End of Life—Disease and Death 123

the dying Bearing. Nestled in her mentor’s arms, Bearing has regressed from

intellectual posturing into childlike trust as Ashford reads to her not Donne

but an uncomplicated child’s tale, The Runaway Bunny. Simply put, no matter

wherethebunnyrunstoorhides,itsmotherwillndit.Itisalittleallegoryof

the soul that shows God’s love.

Eight months of cancer treatments seemed interminable, but Bearing’s

death is swift. Now others must tell her story. Jason enters Bearing’s room, and

seeingnovitalsignstriestoresuscitateher.Suzieknowssheisnocodeand

pleads for him to stop. Compassion dictates it is time to stop intervening. In

hermemorabledeathbedscene,redemptioncomestotheawedintellectual.

As the soul departs the body in a transcendent scene that surprises, Bearing

experiences grace through her ability to give and to receive love.

Margaret Edson’s play is both intellectually challenging and emotionally

immediate. Bearing is an unforgettable character whose intractable pain and

dehumanizing end-of-life isolation is not unusual. She goes from being an

intellectual scholar, vociferously in charge, to being friendless and quietly

vulnerable.Donne’s“deathbenotproud”isamajorthemeillustratinghow

humility precedes her courageous death. Other themes are preserving human-

ityinthequestforscienticknowledge,asearchformeaninginlife,and,of 

course, how wit, the play’s salient characteristic, evokes both verbal skill and an

ability to understand.

Besides wordplay that delights, surprises, and lightens the mood, Wit’s

metatheatrical elements and dramatic devices drive the play. An important

storytellingfeature,ashbackstoBearing’schildhood,toherstudentdays,and

tothelineartrajectory—research,teach,publish—of herbusyprofessor’slife,

contrast with seeing what her life is like during the last months and hours.

Friendless, she is embroiled in a struggle for her life. Bearing’s repeatedly

addressing the audience is powerful, “Hi. How are you feeling today?,” becom-

ing a leitmotif that mocks detached concern, inbred into medical professionals

who may not be listening anyway. Later her silence makes it necessary to shift

tootherstorytellers.Onesceneowsintothenext—therearenointermis-

sions—with the hustle and bustle of diurnal medical schedules to be met,

realistically portraying what a patient endures. A play of opposites—hope

and kindness are revealed by showing characters without them—Wit’s layered

literature-and-medicine approach ultimately pits life against death.

Wit has been called sentimental and melodramatic, as well as been criti-

124 Bioethics and Medical Issues in Literature

cized for portraying stereotypical medical professionals. Unfortunately, it is

notunrealistictothedegreearecentstudycites“woefullyinadequate”care

for end-of-life patients, including lack of respect, failure of physicians to com-

municate,andinsufcientpainmedicineandemotionalsupport(Teno,etal.

291:88-93).

At rst Bearing appears one-dimensional as a prideful professor, until

cancer drains the life out of her. It is fully ironic that a scholar who studies

illnessanddeathseemsnottohavegainedaniotaofwisdomfromhersubject

matter;rather,onlyBearing’sobsessionwithlanguageandretentionof asem-

blance of Donne’s wit are easily communicated to the audience. Arguably, she

learned from Donne’s writings neither courage nor his faith and beliefs. Only

a caring nurse can tap into Bearing’s emotions to assuage her fears.

The hospital’s busy environment, with beeping technology and rushed

medical personnel, is incongruently lled with silences, both metaphorical

and literal, that disease and dying create. Critically ill patients need answers to

end-of-lifehumanrights’questions,whichcandidlyaddressedcanlladark

room with light. In particular, the medical issues and ethics Wit evoke concern

specicguidelinesinresearchstudyprotocol.Forinstance,Bearingistoldshe

must be tough, then without further counsel she signs the informed consent.

This is not a clinical research study report, but rather a play, so there is no men-

tionof therisk-benetratioforheraggressivetreatmentnoranassessment

of anyconictof interest.But,lateron,insufcientdiscussionsof palliative

caremeasuresresultinincreasedpain,lesseningthequalityof hershortlife.

All institutions have their own ethics policies, and, hypothetically, readers

might imagine a scenario in which Drs. Kelekian and Posner try to further use

VivianBearing’sbodytocontributetoscienticknowledge—exceptSuzie,her

last friend on earth, wants to retain her dignity and will not let them. However

much Wit talks about death, though, it focuses more on Bearing’s struggle

to reassess her life, and within rising life-to-death plot action many ethical

questionsareprobed.TherebyWit maintains its momentum from the begin-

ning even through Bearing’s death. Wordplay provides relief, offsetting the

comitragedy’s paradox that Bearing had to experience dying before kindness

brought meaning to her life.

End of Life—Disease and Death 125

Topics for Oral and Written Discussion

• What different healthcare lessons do Rabbit Angstrom and Dr. Vivian

Bearing teach? Apply the sayings memento mori and carpe diemspeci-

cally to each.

• Describe the medical professional-patient relationship that Vivian

BearinghaswithDr.KelekianandSuzie.Whohelps?Whoaddsinsult

toinjury?

• Correlate Jason’s and Bearing’s personality characteristics to show

rsttheirsimilaritiesandthentheirgrowingdifferences.Whatevents

cause each to turn pride into humility?

• Describe how Wit denes the role of  communication in treating

patients, specifying how listening, empathy, hope, humor, and silence

relatetomedicalmistakesand/orpatientquality.

• Distinguish detached concern from compassionate care in research

protocols.

• DiscussDonne’smeditationonhumilityanddeath,amajorthemein

Wit, and relate it to Bearing’s saving grace.

• Describe ovarian cancer and the tests and legislation hoping to elimi-

nate this silent killer.

• Thesubjectof diseaseanddeathisdoneartfullyinRabbit at Rest and

Wit, but the latter work is uplifting. Describe the literary devices, wit,

dramatic irony, and audience metatheatrical self-consciousness, that

keepthereaderentertainedsothediresubjectremainspalatable.

• In clinical trials doesusingexperimentaldrugsthatmaynotbenetthe

study participant and may even eliminate the last peaceful moments,

sacrice patient autonomy to advance research? Review IRB rules,

regulations, and philosophies as set out in The Belmont Report and

FDA regulations. Argue both sides.

• Atlast,whatspecicissuesdoes Wit illuminate to help bring reform

in end-of-life care, as One Flew Over The Cuckoo’s Nestcriticizedmental

institutions to bring sweeping changes?

Bibliography

TheBelmontReport:http://ohrp.osophs.dhhs.gov/humansubjects/

guidance/belmont.htm

Donne, John. Devotions upon Emergent Occasions and Death’s Duel: New York:

126 Bioethics and Medical Issues in Literature

Vintage Spiritual Classics, 1999. Meditations on illness and recovery.

Edson, Margaret. W;t. New York: Faber, 1999.

Federal Drug Administration: www.fda.gov

GeneralRequirementsforInformedConsent.Title45Codeof Federal

Regulations Part 46.116. http://www.hhs.gov/ohrp/policy/

ohrpregulations.pdf

“Gynecology and Obstetrics.” The Merck Manual of Diagnosis and Therapy.

http://www.merck.com

LeadingCausesof Death(CDC):http://www.cdc.gov/nchs/fastats/

lcod.htm

Ovarian Cancer National Alliance: http://www.ovariancancer.org

Teno, Joan M., et al., eds. “Family Perspectives on End-of-Life Care at the

Last Place of Care.” JAMA 291(2004):88-93.

Woolf,Virginia.“OnBeingIll.”Asheld,MA.:ParisP,2002:5.

Suggested Further Reading

Albom, Mitch. Tuesdays with Morrie. New York: Doubleday, 1997. A teacher’s

dying lesson.

Broyard, Anatole. “Doctor, Talk to Me.” On Doctoring. Ed. Richard Reynolds,

et al. New York: Simon, 1995: 175-81. Pathography.

Butler, Sandra and Barbara Rosenblum. Cancer in Two Voices. Spinsters Ink,

1996.

Kübler-Ross,Elizabeth.On Death and Dying. New York: Macmillan, 1969.

Olsen, Tillie. Tell Me a Riddle. New York: Dell, 1977. Woman’s cancer affects

family.

Nuland, Sherwin B. “Hope and the Cancer Patient.” How We Die. New York:

Knopf, 1994: 222-41.

Tolstoy, Leo. The Death of Ivan Illych. New York: Bantam, 1988. Emotions of

dying man.

Williams, W. C. “A Face of Stone.” The Collected Stories of William Carlos

Williams. New York: New Directions, 1996: 167–76. Paternalistic doctor

lashes out.

Glossary of Terms

Literary,Medical,andScientic

ThesetermsapplyspecicallytothereadingsineachchapterandtoWestern

medicine;therefore,thedenitionsarelimitedinnature.

abortion.Theterminationof apregnancy.(SeeRoev.Wade1973.)

absurdism. Philosophy espousing that human life is irrational, morally

indifferent, and rendered meaningless by death.

advancedirectives.Signedauthorizationsincludingmedicalpowersof attorney

in living wills designating another person, or proxy, to make healthcare

decisions in your stead.

affective family. The family entity evolving from freely expressed emotions.

agriterrorism.Usingagriculturalweaponsagainstlivestockorgrainelds.

AIDS.  Acquired immunodeciency syndrome.  A human immune-system

disease caused by HIV infection transmitted through blood and

bodily secretions, rendering its victim susceptible to life-threatening

pneumonia and Kaposi’s sarcoma. See also HIV.

allegory. A narrative with a primary and secondary meaning. Related to fable

and parable, it is understood on two levels. After reading an allegory,

ask yourself, What is the story also about?

alphamale.Thetopdog;exempliedby“BullGooseLoony”inOne Flew Over

the Cuckoo’s Nest.

alterego. The second self or other side of the personality.

alternative medicine. A mind-body-spirit approach to self-healing.

amalgamate. Integrate, fuse, merge.

amoral. Existing outside of a standard moral code of right and wrong.

angina. Sharp, spasmodic pain attacks, indicative of heart disease. See also

arteriosclerosis.

angioplasty.  An artery-clearing procedure (also known as cardiac balloon

catheterization)tounblockcloggedarteriesthatreducebloodowto

heart muscle, followed by clot-busting drugs.

anthrax. An acute infectious disease caused by spore-forming bacterium

Bacillus anthracis, infecting warm-blooded hoofed animals like cattle

128 Glossary

and sheep but transmittable to humans. Characterized by external

ulcerating nodules or lung lesions. See also bioterrorism.

apriori.Latin,meaning“fromtheformer.”Derivedfrompreviousanalysis;

that is, deductive.

archetype.Primordial,structuralelementsof thehumanpsyche(Jung).

ars moriendi. Latin, meaning “the art of dying.”

ars vivendi. Latin, meaning “the art of living well.”

arteriosclerosis. Arteries progressively blocked or narrowed by cholesterol

plaque,causingachronicoxygenandnutrientshortagetotheheart,

generating a “protest” or angina pain.

asylum. A mental institution or a sanctuary and inviolable place of refuge.

attentiondecithyperactivitydisorder(ADHD).Aconditioncharacterizedby

behavioral and learning disorders.

autonomy. Each person’s individual right to respect and self-determination.

babyboomers.Americansbornbetween1946(afterWorldWarII)and1964

(whenthebirthratepeaked).

back shots. Painful spinal taps used to procure neurological evidence for study.

bad blood. The vernacular, or common term, for syphilis-infected blood.

bariatrics. From the Greek baros, meaning “weight” and –iatrics, meaning

“medical treatment.” A branch of medicine relating to obesity and its

treatments, including surgery.

Beat Generation. An American post-World War II literary and social movement

promoted by 1950s writers Allen Ginsberg, William Burroughs, Jack

Cassady, and Jack Kerouac, who attacked capitalism, the military,

racism, consumerism, and the destruction of the environment. At the

end of the 1960s hippies replaced beatniks as an alternative American

culture.

bildungsroman. A novel about the main character’s moral and psychological

growth.

bioethics.Forbiomedicalethics.Itconcernsethicalissuessituatedinscientic

and healthcare disciplines. Van Rensselaer Potter coined the term in

1970 to describe “a new discipline that combines biological knowledge

with a knowledge of  human value systems” (Jonsen, The Birth of

Bioethics).

biotechnology. The use of biological processes to produce a product or

processforhumanuseandbenet.Forexample,inmolecularbiology

Glossary 129

itmightincludeusingmicroorganismstoperformspecicindustrial

processes such as making beer and cheese as well as producing

genetically altered bacteria to solve a horticulture problem or altering

genes for recombinant DNA in an attempt to cure human diseases or

inhumanreproductionprocesses.Oftenthestuff of sciencection,

it merges science and engineering. See Schacter, Issues and Dilemmas of

Biotechnology.

bioterrorism. Terrorist acts using biological weapons like anthrax or smallpox.

blacksatire.Agenreridiculinghumanviceswithaturntowardthegrotesque.

blank verse.  Common, unrhymed verse (usually in iambic pentameter

[vefeetperline,stressingthesecondbeatof eachfoot]).Seenin

Shakespeare’splays.Donotconfuseblankversewithfreeverse(vers

libre)thatcommonlyhasnoxedmeterandnumberof feet.

blood pressure. A pressure cuff placed around a patient’s arm measures

the“push”of the circulationsystem (i.e.,thetop,systolic,number

measuresthepressureof theheartpumpingbloodout;thebottom,

diastolic, number measures the pressure in between pumps. A reading

over 120 systolic means the heart is working too hard, stressing

arteries, leading to heart disease, stroke.

botulism.  An inhaled or eaten bacterial toxin causing a muscle-paralyzing

disease.

braindeath.AsdenedbytheUniformDeterminationof DeathAct,brain

death is “irreversible loss of all functions of the entire brain, including

the brain stem.” However, these activities of the brain may continue:

1)evokedpotentialsof auditoryandvisualpathways;2)brainwave

activity; and 3) neurohormonal regulation producing the arginine

vasopressinhormonekeepinguid-electrolytesbalance.

bubonic plague. From Greek boubon, meaning “groin.” A disease caused by the

bacterium Yersinia pestisthatisspreadtohumansbyeasfrominfected

rodents and that causes swelling of lymph glands. Early symptoms

include headache, nausea, vomiting, and aching joints, followed by

fever and chills. In advanced cases the skin turns black, hence the

alternate name Black Death. See also plague.

Calvinism. The theological system of John Calvin and his followers, marked

byemphasizingthesovereigntyof God,thedepravityof mankind,

and the doctrine of predestination.

130 Glossary

cardiac arrest. Sudden stoppage of the heart resulting in heart damage and

death unless immediate resuscitation is achieved.

cardiac death. The irreversible loss of circulatory and respiratory functions, as

denedbytheUniformDeterminationof DeathAct.Thetraditional

cardiopulmonary criterion of death is when blood stops circulating.

Non-heart-beating protocols determine the exact time an organ can

be harvested for transplantation to reduce degradation.

cardiopulmonary resuscitation. CPR. An emergency procedure involving

external cardiac massage and articial mouth-to-mouth respiration,

attempting to restore blood circulation and prevent brain damage.

Also know as “the kiss of life.” Consult American Heart Association

forspecicdetails.

carpe diem.Latin,meaning“seizetheday.”Enjoymentofthemomentwithout

concern for the future.

catch-22. Derived from Joseph Heller’s novel, Catch-22; a contradictory

situation, paradox, or absurdity in which the only solution is denied

by a circumstance inherent in the problem and is therefore impossible

to achieve.

catharsis.Anartisticpurgingof emotions(pityandfear,forexample),bringing

about renewal.

chagrin.Tobevexedorunsettledby;disappointed.

cholera. An acute diarrheal illness caused by intestinal bacterial infection.

cholesterol. A type of liver-produced fat found in the blood and used by the

body to make hormones and build cell walls. Elevated cholesterol

levels may increase the risk of heart disease. Cholesterol became a

common household term in the 1970s.

chronic. Having a long duration or always troubling.

cingulotomy. Psychosurgery in which the trigeminal cranial nerve and

intracranial lesions are targeted, often with a noninvasive Gamma

Knife in an outpatient procedure to relieve intractable depression,

obsessive-compulsive disorder (OCD), chronic pain, and other

disorders.

civilrightsand liberties. Every U.S.citizen isentitledto protectionagainst

infringement by the government; other specic rights include

freedom of speech, press, religion, and assembly, as well as having

propertyrightsandequaltreatmentunderthelaw.RefertotheU.S.

Glossary 131

Constitution’srst10amendments(Billof Rights)andCivilRights

Acts of 1957, 1960, 1964, and 1968.

cloning. Creating a genetic duplicate through somatic cell nuclear transfer

(SCNT).

code blue. A signal for calling a hospital resuscitation team.

colonialism.Thestateof beingcolonial;thatis,acolonyissubjecttoanother

government’s policies, which may involve cultural oppression and the

domination of one country over another.

coma.Astateof unarousableunconsciousnessrequiringamedicalevaluation.

Combine,The.Acombination,especiallyinbusinessorpoliticalinterests;also,

in agriculture, a grain-threshing machine. In Cuckoo’s Nest the Chief

believestheomnipotentCombineisahugeorganizationrunningthe

world, both inside and outside of the institution. A metaphor for

repressive America.

comitragedy. A dramatic mixture wherein comic elements offset the tragic.

compassion. From Latin com + pati, meaning “to bear with” the consciousness

of another’s distress, together with a desire to alleviate it. Syn. Pity.