This essay is a reflection on the doctor–patient relationship from the perspective of two medical students, which draws on the ideas of 20th-century philosopher Martin Buber. Although Buber never wrote about medicine directly, his ‘philosophy of dialogue’ raises fundamental questions about how human beings relate to one another, and can thus offer valuable insights into the nature of the clinical encounter. We argue that Buber's basic word pairs, ‘I–You’ and ‘I–It’, provide a useful heuristic for understanding different modes of caring for patients, which we illustrate using examples of illness narratives from two literary works: Tolstoy's Ivan Ilych and Margaret Edson's Wit. Our essay demonstrates how the humanities in general and philosophy in particular can inform a more humanistic practice for healthcare trainees and practicing clinicians alike.
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All actual life is encounter.
—Martin Buber, I and Thou (1923)
Last month, as part of our clinical skills course, we were asked to interview a 50-year-old woman who was admitted to hospital with a diagnosis of advanced pancreatic cancer. Having recently completed our gastroenterology block, we readied ourselves to apply the pathophysiology we had learned to the clinical setting. When we walked into the room, we saw an emaciated woman with deeply sunken cheeks and yellow-tinged skin. As we stood by her bedside and began naming pertinent findings—prominent zygomatic arches secondary to cachexia, visible jaundice due to biliary obstruction—she interrupted us and said, “I'm dying. Do you know what that feels like?” We froze. Although we understood the facts of our patient's diagnosis, we could not answer her question. We stood silent as she stared straight at us. Silence was our only honest response.
We left our patient's room feeling defeated. In that moment, we were unarmed—suddenly neither our biomedical knowledge nor our clinical skills could help us provide our patient with the care that she deserved. The following day, we were asked to reassess her. When we walked into the room, she was sitting on a chair next to a window and motioned for us to have a seat on her bed. As before, we began the interview with a general inspection. From our new vantage point, however, we noted certain findings that had escaped our previous observations. We noticed that despite her skeletal appearance, she was using what remained of her strength to sit in an upright posture, with her arms folded neatly across her lap. From this perspective, she appeared dignified and elegant. We wondered if she was a dancer when she was younger. We also observed that on the shelf next to her bed was a photograph of a young man who appeared to be in his twenties. Was this her son? When she noticed us looking intently at the photograph, she sighed deeply and told us that he was her only child. Noticing the sadness in her eyes, we invited her to continue. As we sat on her bed, she began to share her story, which we absorbed with an openness and curiosity that was absent during our previous encounter. This time, we left the room feeling that we had experienced something more meaningful, something more human.
As second-year medical students preparing to embark on our clerkship years—when we will exit the theoretical world of the classroom and enter the ‘real’ world of the hospital—we can be confident that after studying the mechanisms and management of disease, we have the necessary tools to become competent technicians. What we can be less certain of, however, is whether we have the appropriate skills to become humane healers. Our experience with the patient previously described shocked us into the realisation that something crucial is missing in our preclinical medical education. It became clear to us that we are learning how to cure disease but not how to effectively care for patients, how to decrease physical pain but not how to alleviate suffering.
Is the ‘human’ side of medicine something that can be learned and, if so, how? We believe that one way is by turning to the humanities in general and to philosophy in particular. Although 20th-century philosopher Martin Buber never wrote about medicine directly, his philosophy raises essential questions about how, at the most basic level, human beings relate to one another, and thus offers valuable insights into the doctor–patient relationship. In I and Thou (1923), Buber argues that there are two basic modes of human interaction: the ‘I–You’ and the ‘I–It’.1 The I–You is a dialogical relationship wherein human beings encounter one another in their holistic existence. As Buber writes,
When I confront a human being as my You… then he is no thing among things nor does he consist of things. He is no longer a He or a She… nor a condition that can be described, a loose bundle of named qualities… Even as a melody is not composed of tones, nor a verse of words, nor a statue of lines—one must pull and tear to turn a unity into a multiplicity—so it is with the human being to whom I say You.
The I–It, on the other hand, is a relationship between subject and object. It is a ‘detached’ interaction, in which the ‘I’ sees the other as something that is ‘describable, analysable, classifiable’. In Buber's words, “The man who… says I–It assumes a position before things but does not confront them in the current of reciprocity. He bends down to examine particulars under the objectifying magnifying glass of close scrutiny…”.
As we enter clerkship and continue to gain knowledge and build technical skills, will there be room for I–You patient encounters, or will we fall all too easily into the I–It? Unfortunately, the prospects are not optimistic. Studies have documented a marked decline in students’ empathy and ability to relate to patients as they progress through medical school.2 ,3 Are we resigned to this fate? Or is there a way to achieve a meaningful balance of I–You and I–It clinical encounters? In search of answers, we looked to literature for narratives of physician–patient interactions. Two works, written over a century apart, Tolstoy's The Death of Ivan Ilych (1886) and Margaret Edson's Wit (1999), seemed to us especially telling. Both works highlight different ‘modes of existence’ in medicine—instantiations of the I–You and the I–It—and in so doing provide important lessons about the nature of person-centred care.1
In The Death of Ivan Ilych, the encounter between high court judge Ivan Ilych and his physician serves as a powerful example of an I–It interaction. As Ivan Ilych notes, ‘It was all exactly the same as in court. As he put on airs before the accused in court, so the famous doctor put on airs before him’.4 The doctor's objectifying demeanour—his seeing Ivan Ilych as an ‘It’—prevents him from addressing Ivan Ilych's true concern:
For Ivan Ilych only one question mattered: was his condition dangerous or not? But the doctor ignored this inappropriate question. From the doctor's point of view… there existed only the weighing of probabilities—a floating kidney, chronic catarrh, or appendicitis. It was not a question of Ivan Ilych's life, but an argument between a floating kidney and the appendix.
Throughout the examination, amid ‘the tapping, and the auscultation’ and deliberation over differential diagnoses, the doctor denies Ivan Ilych's humanity—and therefore his mortality—and fails to ease his suffering.
Where Ivan Ilych does derive comfort is from his interaction with the peasant boy Gerasim. As the text notes, ‘Ivan Ilych felt [Gerasim's] presence such a comfort that he did not want to let him go’. Ivan Ilych ‘saw that no one felt for him, because no one even wished to grasp his position’ and that ‘only Gerasim recognized it and pitied him’. Gerasim's presence, along with his simple act of elevating Ivan Ilych's legs to alleviate his pain, brings Ivan Ilych a true sense of relief. This interaction is telling, and is one of the few instances in the novella where the I–You becomes apparent.
Like Ivan Ilych, Margaret Edson's Wit offers a powerful contrast between I–It and I–You encounters with terminal illness. Like the ‘famous doctor’ in Ivan Ilych, the physicians in the play shield themselves from their patients’ suffering. The clinical fellows are so blinded by theory that when they are asked to identify ‘problem areas’ with Vivian's treatment, they list ‘myelsosuppression’ and ‘nephrotoxicity’ but fail to identify the most obvious sign: hair loss.5 Over the course of her illness, Vivian begins to feel that ‘what [the doctors] have come to think of as me is, in fact, just the specimen jar, just the dust jacket, just the white piece of paper that bears the little black marks’. As Vivian faces her own mortality, she wishes that her caretakers ‘would take more interest in personal contact’. Vivian finds this ‘touch of human kindness’ in a nurse by the name of Susie. Like Gerasim in Ivan Ilych, Susie treats her patient a ‘whole being’.1 Although Vivian wonders why Susie's simple acts of calling her ‘Sweetheart’ and offering her an orange popsicle bring her a deep sense of relief, she realises that “It can't be helped… Now is not the time for wit and detailed scholarly analysis… Now is the time for simplicity. Now is the time for, dare I say it, kindness.”5
Perhaps as an attempt to avoid confronting their patients’ mortality, the doctors in both Ivan Ilych and Wit hide behind layers of abstract knowledge and clinical expertise. Indeed, the demands of clinical medicine often require that physicians adopt a detached disposition in order to function effectively. In his candid memoir Do No Harm, neurosurgeon Henry Marsh describes the tension between empathising with patients and assuming an ‘objective’ disposition. He writes of a ‘necessary detachment from patients’, suggesting that ‘[i]t would be impossible to do the work if you felt the patients’ fear and suffering yourself’.6 Marsh views this detachment as a strategy employed by practitioners—which becomes reinforced throughout their training—to avoid facing their own vulnerabilities and to cope with the suffering of the patients for whom they are responsible. However, Marsh explains that as he progressed in his medical career, he came to realise the limitations of purely detached patient interactions. Reflecting back on his practice, Marsh writes: “Now that I am reaching the end of my career this detachment has started to fade. I am less frightened by failure … I can dare to be a little less detached … I can no longer deny that I am made of the same flesh and blood as my patients and that I am equally vulnerable.”6
Marsh's observations are consistent with Buber's remark that in the ‘ordered world’ of the I–It, one ‘can live comfortably’.1 Entering into the patient's world and existing in the I–You, on the other hand, ‘pulls us dangerously to extremes, loosening the well-tied structure, leaving behind more doubt than satisfaction, shaking up our security’. It would seem that existing in the I–It is the simpler approach. Indeed, in our own experience, seeing our patient as a case of end-stage pancreatic adenocarcinoma—as an It—was far more comfortable than stepping into the frightening reality of a middle-aged woman who was dying quickly of an incurable disease. Although seeing our patient as a whole person—as a You—was a jarring reminder of her suffering and of our own fallibility—it injected a critical dose of meaning that was missing in our initial clinical encounter. Marsh's memoir, along with Tolstoy's Ivan Ilych and Edson's Wit, capture an inherent tension in clinical medicine. Ultimately, medicine cannot do without the I–It, yet a medicine that exists solely in this mode threatens to lose its humanity. As Buber warns: “without It a human being cannot live. But whoever lives only with that is not human.”
Contributors AM and BCY both contributed equally to this work.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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