Hospitable medicine

The renewal of generosity: illness, medicine, and how to live Arthur W. Frank, Chicago and London: University of Chicago Press, 2004 166 pp $34.50 ISBN 0-226-26015-1 (cloth)

Arthur Frank wastes no time in taking on the role of moral agent provocateur. He makes a bold entrance in the first paragraph of The Renewal of Generosity:

A physician once asked me if I had ever expressed “unqualified gratitude” to the doctors who treated me when I had cancer. I hadn't. The other side of the question is how often I felt that I was being cared for with unqualified generosity. Not often enough. I regret that, for us all.

It's a great lead to a book that cries, “En garde!” to physicians, especially those who are at all self-congratulatory in the realm of doctor–patient relationships.

As a physician and as a patient who has been treated for cancer, I felt doubly provoked. Even if I'm not one of the 46% of Canadian physicians in an advanced state of burnout, who among us in our busy offices and crowded hospitals has time for “unqualified generosity”? And is Frank telling me that the postcard I sent my specialist from a café in Avignon doesn't cut it as an expression of “unqualified gratitude”?

Frank's premise is that our relationships with those who come seeking our help should ideally be built on reciprocating expressions of generosity and gratitude. For Frank, the “foremost task” of modern medicine is not to devise new treatments; rather, it is “to increase the generosity with which we offer the medical skill that has been attained.”

Frank refers to his experience as a cancer patient often enough for the reader to see it as a catalyst for the writing of the book. In a sense, The Renewal of Generosity is the complex elaboration of an illness narrative. At one point, Frank describes how essayist Nancy Mairs, a woman with severely debilitating multiple sclerosis, “spin[s] personal experience into moral philosophy” — not unlike what Frank does himself.

Because The Renewal of Generosity is a work of moral philosophy it is hardly surprising that it is “populated by moral perfectionists.” Frank draws on the work of three in particular: Marcus Aurelius, the Stoic philosopher and Roman emperor; Mikhail Bakhtin, a literary critic; and Emmanuel Levinas, a contemporary philosopher. Using their various writings as the foundation of his inquiry, Frank proposes “a radical ideal of responsibility.”

Frank introduces us to the Dialogical Stoic, an imaginary persona who “brings together … two traditions of thought that have indispensable relevance for ill people and those who care for them.” The first tradition is one of communication through dialogue: “To exist as a human is to communicate with others.” In health care these days, Frank asserts, dialogue is too often replaced by the professional monologue, to the detriment of a healing interaction. The second tradition is Stoic philosophy. Stoicism, whether espoused by physician or patient, asks: “[W]ho are you choosing to be, regardless of where you find yourself, and is that your best choice?” It is the Dialogical Stoic who provides guidance in the crucial “how to live” part of the book's subtitle.

After our encounter with the Dialogical Stoic, we go on to meet a number of patients and doctors in chapters respectively entitled, “The Generosity of the Ill” and “Physicians' Generosity.” The stories of illness are often those of individuals suffering from cancer or longstanding chronic conditions. Through these stories, Frank calls for

More generous representations of the ill and disabled, generosity in expanding the scope of moral participation for the ill and disabled, and finally “health ecology,” which questions the boundaries of who, or what, is sick and needs healing.

With respect to doctors, Frank describes the work and writing of four physicians who “tell a collective story of how medical training and practice demoralize them.” Another concern of these physicians is summed up in the title of Rafael Campo's book of poetry, The Other Man Was Me. “[H]ow to be generous toward the other” — that is the problem. Each physician “is concerned with how to encounter patients who are radically different in the material, intellectual, and spiritual conditions of their lives.”

The philosophical concepts in The Renewal of Generosity can be difficult to grasp, partly because of the unfamiliar terms Frank uses to identify and discuss them. As I worked my way slowly through what is really a slim volume, I continued to imagine how my hospital colleagues would react to such jargon as dialogical, hypergoods, alterity, daimõn, remoralization, non self-sufficiency and unfinalizability. I also anticipate a skeptical resistance to Frank's proposal to substitute “guest–host” for the more familiar physician–patient.

All this may sound like one more onerous demand for harried physicians to give just a little more of themselves 30 or 40 times a day. Frank counters by saying that a reconsideration of the physician–patient relationship in the light of “moral possibility” rather than “moral burden” could ease the doctor's daily load. It is at this juncture — in what Frank cogently describes as “the contemporary medical moment” — where we doctors and patients come face to face with the considerable challenge of spinning moral philosophy into clinical practice.

Frank offers no tidy evidence-based algorithm or care plan on how this can be achieved. What he does, more through the collected stories in his book than through its philosophical framework, is alert us to the possibility that our interpersonal relationships in the examining room may not be as healthy as they could be. When the discussion gets a little ethereal, Frank brings it sharply down to earth through someone like Vanessa Kramer. She writes about her aunt's treatment for ovarian cancer, between her own recurrences of breast cancer:

Sometimes I think there's a regulation that we are not allowed to be real people. Sometimes I think professionalism is a handicap we all labor under. On really bad days, I have had the urge to tap on the shoulder of a particular nurse or doctor or technician and shout, “Hey! Is anybody in there?”

The Renewal of Generosity deserves a wider readership than I expect it will receive in our less-than-ideal world.