In discussions about the relationship between literature and medicine, it is often assumed that a literary education is a “good thing” for doctors. This perceived value has been one of the main reasons for the medical humanities becoming an acceptable core part of medical education in the USA and the UK over the past decade.1 2 However, in this article I would like to take a critical view of the instrumental role of a literary education for doctors through an analysis of Ian McEwan’s recent novel Saturday.3 In this novel, the value of literature for clinical education is specifically discussed by the characters and is illustrated in the narrative structure and in the persons of the characters themselves.

MEDICINE’S INTEREST IN LITERATURE

Why is it that clinicians might be professionally, rather than personally, interested in literature? There are a number of possible reasons. One is the view that literature is valuable because it can help doctors and medical students develop an empathetic response by nurturing the sensibilities. Through literature, we can vicariously experience the traumas in the lives of others and begin to understand how it feels to be bereaved, to have a marital break-up, to have a terminal illness.4 In addition, literature can remind doctors of the importance of the patient’s illness narrative for understanding the meaning illness has for that person, thus enabling doctors to treat the whole person.5 Focus on narrative has also led to the development of “narrative therapy”, which is based on the notion that if we are aware of the interpretations that patients may put on the stories of their lives, they can be helped, if these interpretations are destructive, to reshape them and see themselves in a more positive light.6 Medicine has adopted the notion of narrative as its own. As well as narrative therapy, there is “narrative-based medicine” (a foil to evidence-based medicine) and “narrative competency”.7 Professor Rita Charon runs a narrative competency course as part of the clinical skills programme at Columbia University. She refers to this as a “parallel chart” (parallel to the patients’ record charts) and developed it to enable her students to “better empathize with their patients” by keeping a record of their attempt to understand the patient’s experiences and the ways in which the patient reacts to explanations and information.8

These ideas are, of course, based on the premise that individuals can imaginatively respond to characters in literature (and in life) sufficiently to transfer that imaginative insight to other situations. Whereas this may work for some medical students, experience in UK medical education suggests that this response is not universal.9 My analysis of Saturday will also bear this out. Whatever our thoughts about literature enabling empathy, there is no doubt that literature can stimulate the imagination and can sharpen interpretive skills, important for doctors who have to make sense of patients’ stories.10

With some of these ideas in mind, and particularly the question of whether a familiarity with, response to and understanding of literature is necessary for a doctor to be a good doctor, I wish to examine the novel Saturday. Why choose this novel to consider the interaction between literature and medicine? The first and most important reason is that I enjoyed it: an important non-instrumental reason for reading literature. I was attracted to the central character as a person, and intrigued, as a doctor myself, in McEwan’s portrayal of him as a doctor. Second, having read Atonement, I knew that McEwan had an interest in doctors and their relationship with literature.11 Third, discussion about literature is an important theme in the novel, and the scene around which the narrative pivots hinges on the reading of a poem.

THE STORY OF THE BOOK

Let me briefly summarise Saturday. It tells of the events of a day in the life of Henry Perowne, a neurosurgeon, and his minute-by-minute thoughts in reaction to those events. The day is significant, as it is a real historical day, Saturday, 15 February 2003, the day on which London saw a huge popular demonstration against the likely commencement of the Iraq War. Perowne wakes early, alerted by a strange feeling of elation, only to see a plane seemingly on fire shoot through the sky. Thoughts of terrorist attacks come into his mind, but he discovers it was an innocent accidental fire. However, he is left with a heightened awareness of premonition for the day. While he is on his way to a squash game with a colleague, his car is hit by a trio of young men who have just emerged from a lap-dancing club. The accident turns into a confrontation in which Perowne is assaulted, but he notices that his assailant, Baxter, is showing the early signs of Huntington disease. It is this—and his discussion of it—that saves him from a worse assault but which demeans Baxter in front of his associates.

Perowne escapes to his squash game, shops in preparation for a meal he will prepare that evening and visits his mother, who has Alzheimer disease and is in a home. There is to be a family reunion, with his daughter, Daisy, returning home after 6 months in Paris with the proof copy of her first book of poetry in her hand. Also there will be his wife, Rosalind, a lawyer; son, Theo, a blues guitarist; and his father-in-law, John Grammaticus, a famous poet with whom Daisy has had a rift over his view of one of her early poems. However, the reunion is interrupted by the intrusion of Baxter and his sidekick. Baxter, with his knife, represents a threat to all that Perowne loves. A tense stand-off ensues, with the threat dissipated not by Perowne’s medical intervention, but by Daisy reading, ostensibly from her own book, but in fact reciting Matthew Arnold’s poem “Dover Beach”. Baxter is overwhelmed, is tossed down the stairs and ends up on Perowne’s operating table with a subdural haemorrhage.

BACKGROUND TO THE BOOK

Saturday thus contains one of the hallmarks of McEwan’s fiction: what one reviewer has called “the sudden ambush of the safe and smug”.12 In this case, unlike in The child in time, The innocent and Enduring love, horror is avoided in the end.13^–15 This was partly because McEwan was interested in writing about a “lucky” man. As he said in an interview about the book:

I got interested in the idea of a man who thought he was extremely lucky because the woman he loved also happened to be his wife and (because this is so rare) he was actually troubled that he was a freak of nature: “hey, there must be something wrong with me.”16

He also wanted to write about his character’s work, and in order to do this as accurately as possible, he spent a year watching a neurosurgeon at work in wards and in the operating theatre:

It is amazing how work is sorely missing in literary novels. People don’t seem to have jobs; they’re having affairs or having a terrible time with teenage children … I thought, “Whether he’s going to be a shipbuilder or an architect, I’m going to enter his world, watch and absorb.”16

In the novel, Perowne, thinking of his own work and how his skill as a surgeon has enabled his patients to return to their occupations, calls work “the ultimate badge of health”.3

McEwan could have chosen any world of work, but it is significant that he decided that his “happy man” should be a doctor, and a particular kind of “very medical doctor”: a surgeon doing some of the most technically demanding and dangerous surgery. Part of the reason for this may have been that the all-consuming nature of Perowne’s job, particularly in the training phase, helps to justify his lack of reading outwith medicine. For example, when he first meets his wife, Rosalind, he has never heard of his famous father-in-law’s poetry (p46).3 But another reason is that McEwan is interested in the relationship between literature and medicine. This relationship is explored in the book through discussions between Perowne and his poet daughter, Daisy, but it was also referred to in McEwan’s previous novel, Atonement.

In Atonement, Robbie Turner has returned from taking a first-class honours degree in English at Cambridge to his housekeeper mother’s cottage with a desire to go on to read medicine. This change of intellectual track is justified by Robbie in this way:

Despite his first, the study of English literature seemed in retrospect an absorbing parlour game, and reading books and having opinions about them, the desirable adjunct to a civilised existence. But it was not the core … (p91)11

He imagines himself at the age of 50, with medical experience behind him, a “weathered, knowing doctor … with secret stories” (p92) and thinks of the books he will have in his library, including Austen, Eliot, Lawrence and Owen:

For this was the point, surely: he would be a better doctor for having read literature. What deep readings his modified sensibility might make of human suffering, of the self-destructive folly or sheer bad luck that drive men towards ill-health! Birth, death and frailty in between. Rise and fall—this was the doctor’s business, and it was literature’s too. (p93)11

We never find out whether Robbie would have become such a doctor, but we suspect he might have been the kind of doctor who combined “an inconspicuously warm heart and cool judgement”, like Perowne. McEwan clearly approves of doctors: it is part of Robbie’s moral goodness that he wants to be a doctor, and part of Perowne’s that he is. In the tragic opening scene of Enduring love, the only one of five men to keep hold of the rope of the basket of an escaping hot air balloon carrying a young boy is the doctor, who thus forfeits his own life as the balloon is carried high into the sky by a gust of wind (p20).15 In Saturday, McEwan looks in more detail at the relationship between that quality of moral goodness and literature.

McEwan is also interested in the notion of empathy, a key concept in the claims made for the value of literature in medical education. It is no accident that McEwan chose as the novel’s “day” the date of the London demonstration against the Iraq war. This imbues the beginning of the novel with a sense of danger and draws the reader into the idea that the more we hear about the life of this happy man, the more we feel that his happiness may be under threat. Within the first few pages of the novel, the 9/11 attacks are called to mind, as Perowne watches a fiery plane plummeting towards Heathrow airport:

Everyone agrees, airliners look different in the sky these days, predatory or doomed. (p16)3

Like many writers, McEwan was moved to write a commentary on the attacks of 11 September on the World Trade Center and the Pentagon. The focus of his piece was the phone and answerphone messages sent by those in the twin towers and the hijacked planes to their loved ones when they knew that they were unlikely to survive. Most of them were sending messages of love: “Love was all they had to set against the hatred of their murderers”.17 In the heated emotion of that time, this was a very moving thought. But what McEwan went on to consider, as he imagined what it would have been like to have been one of these doomed passengers or workers, was the notion of empathy:

This is the nature of empathy, to think oneself into the minds of others. These are the mechanics of compassion: you are under the bedclothes, unable to sleep, and you are crouching in the brushed-steel lavatory at the rear of the plane, whispering a final message to your loved one. There is only that one thing to say, and you say it. All else is pointless.

…

If the hijackers had been able to imagine themselves into the thoughts and feelings of the passengers, they would have been unable to proceed. It is hard to be cruel once you permit yourself to enter the mind of your victim. Imagining what it is like to be someone other than yourself is at the core of our humanity. It is the essence of compassion, and it is the beginning of morality.17

McEwan identifies the capacity to feel what others are feeling, this ability to empathise, or this sensibility, as being a moral virtue; and in Atonement, he links the development of this capacity to a literary education. In Saturday, I suggest, he sets up the opportunity to examine this relationship in more detail.

THE CHARACTER OF PEROWNE THE MAN

Before considering how McEwan examines the relationship between empathy and literary education, I want to look at two aspects of the portrayal of the central character, Henry Perowne: as a man, and as a doctor. I think it is legitimate to consider these aspects of the character separately, as the second is a less successful portrayal than the first.

We learn a lot about Perowne in the first chapter of the book: a man happy and fulfilled in his work, his family and especially his wife: “What a stroke of luck, that the woman he loves is also his wife” (p39). But despite this he feels uneasy about himself. Even his fidelity to his wife causes him unease. He watches male friends’ adventures with younger women and thinks that his lack of interest indicates that there is something wrong with him. He fears “that he lacks an element of the masculine life force, and a bold and healthy appetite for experience” (p40). This unease is more forcibly felt when he considers his artistic children, particularly the guitar playing of his son:

There is nothing in his life that contains this inventiveness, this style of being free. The music speaks to unexpressed longing or frustration, a sense that he’s denied himself an open road, the life of the heart celebrated in the songs. (p28)

He has committed his young life to a punishing career and raising a family, with no time for such “parlour games”. But at this stage in his life, with some time to reflect, he feels “there has to be more to life than merely saving lives” (p28). This is the contrast between the experienced (not necessarily jaded) doctor and the young idealist in Atonement.

However, this unease is not fundamental. As one reviewer has put it, contentment is Perowne’s “default position”.18 Without this he would seem too bland, too happy. We are also told (p5) that he is a “habitual observer of his own moods”, and that he is a “dreamer sometimes” (p20), allowing “a shadowy mental narrative [to] break in” to his thoughts even during a consultation. And the structure of the book reflects this character trait. The style of the narration can be compared to Virginia Woolf’s Mrs Dalloway—stream of consciousness, without the consciousness in question ever transferring (as happens in Mrs Dalloway) to another person.19 We stick with Perowne and the links in his thought stream: flushing the loo, he remembers a magazine in the operating theatre suggesting that at least one molecule of his own urine will at some time fall on him as rain, to humming We’ll Meet Again, to thoughts of how much he likes a wet shave, to what William James wrote about recall, to his view that William wrote better than his brother Henry, to his daughter, Daisy, who would disagree, to what Daisy knows, to What Maisie Knew, the novel by Henry James—introduced to him by Daisy—which “baffled him” (p58).

The voice of the novel is Henry Perowne’s: the links, the inconsistencies of thought—he is “dreamer sometimes” (p20) but “dreams don’t interest him” (p4); the assumptions about what others are thinking—Daisy’s speeches on Iraq are seen affectionately by him (p186): “Is this the source of her agitated happiness?”. If McEwan wishes us to understand these thoughts to represent Perowne’s inner life, then this runs counter to the accusation by Daisy and some reviewers of the book that Perowne is “unresponsive to literature”.18 We find, for example, during an operation, the description of the tentorium cerebelli: “a pale delicate structure of beauty, like the little whirl of a veiled dancer …” (p11). If this is Perowne’s simile, then he is a poet. But I suspect that this is McEwan’s voice, a writer’s description of the brain which it is not possible for the workmanlike surgeon to express.

PEROWNE THE DOCTOR

This rather incongruous simile represents a problem with the portrayal of the central character. When we follow Henry Perowne into his workplace, and especially into the operating theatre, it seems that we are no longer viewing the world through his eyes, but through the eyes of an admiring bystander. The descriptions of the operations undertaken are textbook: nothing ever goes wrong; medicine is like magic, wonderful and strange. While still a young doctor in training, Perowne observes the removal of his future wife’s pituitary tumour, which was causing blindness:

To go right in through the face, remove the tumour through the nose, to deliver the patient back to her life … with her vision restored was a miracle of human ingenuity. (p45)

There are several pages also of detailed description of the operation on Baxter’s subdural haematoma, full of technical terms and the correct names for pieces of surgical instrumentation that make the account of the operation read like a textbook. We also have explanations of the technical terminology (“ataxia—unsteadiness”, p10). Whose voice is this? Is it Perowne’s? Why would he need to explain this term to himself? More likely, in these technical medical accounts, McEwan’s voice is intervening, the result of that year of observation. It seems as if, in portraying the perfect neurosurgeon, he gets a bit carried away. Even the account of Perowne’s chief at the time of his wife’s operation reads like the affectionate, admiring but exaggerated anecdotes doctors tell about their early days over a drink in the pub. The chief, Mr Whaley, “in three-piece pin stripe suit with fob watch and purple silk handkerchief” and “booming theatrical voice”, (p41) is a caricature. He recalls the picture painted of senior consultant surgeons by the actor James Robertson Justice in films such as Doctor in the House.

It is significant that when we follow Perowne on his visit to his mother’s home, we have a deeply moving and convincing account (from McEwan’s own experience and from the inside) of the deterioration of mind experienced by the person with Alzheimer disease. And when we move away from admiring and amazed accounts of operations, we do meet Perowne the doctor. Here is a convincing portrayal of a man who sees in his patients more than the technical task ahead of him. Observing the gathering crowds for the Iraq demonstration, he recalls that his own thoughts about Iraq have been influenced by treating an Iraqi professor of ancient history (p62). It is clear that Perowne has not just taken a standard medical history from this man but that he has spent time hearing about his experiences in an Iraqi gaol under Saddam Hussein. He “admires the spirit” (p10) of the difficult young girl whose astrocytoma he has removed (her adoptive parents hope her spirit is something to do with the effects of the tumour), and he is the kind of doctor who is sensitive to the dignity of patients and tries to avoid talking down to them:

He dislikes speaking with the forced cheerfulness nurses use on the wards, even on adult patients with no mental impairment. (p160)

He responds to his patients; practising what we might now call in the jargon “patient-centred care”. He does not stand on dignity, but will eat lunch between operations with the theatre cleaner (p9). This picture fits with the man we see at home, sensitive to the needs of his family and responsive to and aware of their moods.

THE LITERARY DEBATE

Thus, Perowne, a man happy and fulfilled in his life and work, is presented to us as someone who has had little time or inclination for a literary education. He is not sure what the word “stanza” means, and the word “scan” triggers a work worry about a £190 000 shortfall in his hospital trust’s budget for an MRI scanner, rather than the rhythm of a poem (p136). He does not recognise the names of contemporary poets (Hughes, Motion or even his own future father in law (p46)) and is unable to spot when Daisy, calming the savage Baxter, recites not one of her own poems, but Matthew Arnold’s “Dover Beach”.

Perowne has an ambiguous attitude to his ignorance. On the one hand, he is ashamed of it (he secretly looks up the word “stanza” to check its meaning); he admires his creative children, feels there is something missing from him and is “counting on Daisy to refine his sensibilities”. On the other hand, he

does [not] want to be a spectator of other lives, of imaginary lives … it interests him less to have the world reinvented; he wants it explained … (p66),

and he feels that his experience of life has given him more than literature can offer:

he thinks he has seen enough death, fear, courage and suffering to supply half a dozen literatures. (p6)

He attempts now to read poetry, less because of his shame, however, than because of his love and admiration for his poet daughter: having a father-in-law who was a poet did not galvanise him, but “fathering a poet” did (p129), and now that poet is trying to guide his literary education. Perowne at the same time thinks he should read but does not see it as necessary: he is “living proof” that people can live without stories (p68).

As his main critic, Daisy feels that her father is “ignorant”, has “poor taste” and is “insensitive” (p6). He has difficulty understanding what is meant by literary genius: reading Anna Karenina and Madame Bovary (under her instruction),

What did he grasp after all. That adultery is understandable but wrong, that nineteenth-century women had a hard time of it … (p67).

She thinks he “lacks an imagination” and is a “coarse, unredeemable materialist” (p134). As we have seen, it is clear that Perowne does not justify such harsh criticsm: he is responsive to his patients’ stories, is able imaginatively to enter into the experience of a passenger on a doomed plane (p16). He is impatient with fiction because his job requires not thought, but action. He is also vaguely aware that having too great a sensibility would be difficult in a surgeon “incapable of pity” (p98). He has mixed views about what literature can do for him. Daisy does not. She clearly feels that literature can save him: develop his imagination, assuage his poor taste and develop his sensitivity and sensibility.

John Carey, critic and retired professor of literature at Oxford University, argues (like Perowne) against Frank Palmer that literature is not necessary to develop our moral imagination.20 Palmer claims that reading Macbeth enables us to understand how awful murder is because we are able to step imaginatively into the shoes of Macbeth and feel how he feels about it (p229).4 But Carey counters that “genuine abhorrence of murder is not limited to readers of Macbeth” (p109).20 Carey also reviews work by psychologists and arts education experts to conclude that there is no evidence that a literary or artistic education affects a person morally (p101).20 In his book The arts and the creation of mind, Elliot Eisner draws no implications about how an arts education affects a person’s character and sensibilities. In his (significantly) short discussion of “How does learning in art show?” he lists four possible results: intrinsic satisfaction, refinement of perception, incisiveness of descriptive powers and good analytic and interpretative skills.21 As Carey paraphrases, he is essentially saying no more than that “work in the arts evokes, refines and develops thinking in the arts” (p101).20 We know of the well-rehearsed argument about the Nazis and their love of music. Even Palmer admits to being baffled by the fact that “a man of fine artistic sensibilities may, in other respects, remain a swine (p240).”4

And we do have a couple of swine in the novel who would seem to contradict the view that literature develops our moral sensibilities. Compare the character of Perowne with that of his father-in-law, the famous poet John Grammaticus. The poet is grotesquely self-centred: he trashes an award-winning poem of Daisy’s out of envy and is prone to sudden and unexpected mood swings that can make his family’s lives a misery. When we actually meet him in the flesh rather than in Perowne’s memory, the picture of him is ridiculous. Expecting his granddaughter, not Perowne, to open the door to him he appears posing:

… with long belted woollen coat, fedora and cane, head tipped back, his features in profile caught in the cool white light from the lamps in the square. (p196)

The comparison implies that the doctor is a man of greater sensibility than the literary man.

Even more convincing than this is what happens at the tense high point of the story, when the criminal Baxter, on the point of raping Daisy Perowne, jokingly asks her to read a poem to him from her book. He is so moved by the beauty of the poem she reads (“You wrote that. You wrote that”, (p223) that he draws back from attacking her (“It makes me think about where I grew up”) (p222), and is sufficiently put off guard to allow Perowne and his son to disarm him and trip him down the stairs.

Thus, it turns out that Baxter the thug has the literary sensibility that Perowne, the saver of lives, lacks. Perowne’s explanation for this is the effect of the disease on his brain; the poet’s (Grammaticus’s), that Daisy moved Baxter so much he fell in love with her. The suggestion here is that literature is less able to influence character, but has rather the power to move and affect us; to make us see things differently. But from here there is another huge step to achieve moral transformation. Baxter is capable of this initial response; Perowne is not. Despite his rationalist explanation, he suspects that the poets might be right: that it was love that transformed Baxter from a beast, not the activity of the neurotransmitters in his brain. The end of the novel suggests that it is this attribute in Baxter that leads Perowne to save his life.

Daisy recited a poem that cast a spell on one man. Perhaps any poem would have done the trick, and thrown the switch on a sudden mood change. Still, Baxter fell for the magic, he was transfixed by it, and he was reminded how much he wanted to live. No one can forgive him the use of the knife. But Baxter heard what Henry never has, and probably never will, despite all Daisy’s attempts to educate him. Some nineteenth-century poet … touched off in Baxter a yearning he could barely begin to define. That hunger is his claim on life, on mental existence, and because it won’t last much longer, because the door of his consciousness is beginning to close, he shouldn’t pursue his claim from a cell, waiting for the absurdity of his trial to begin. (p279)

McEwan shows us a happy man—but in the end the happy man senses something grand in Baxter that he himself has not got and is humbled before it: “there has to be more to life than merely saving lives.” Perowne saves Baxter so he can enjoy his superior consciousness for as long as it can continue.

CONCLUSIONS

Saturday does not make a convincing case for the efficacy of a literary education for doctors. Perowne can live without fiction and is clearly able to be responsive to his patients’ stories without first having his sensibilities refined by literature. McEwan is interested in the notion of empathy, but this book suggests that, at least for some doctors, literature fails and experience of life more than literature is necessary—and sufficient—to develop the sensibility required for an empathetic response. Perowne does not lack this response, although one might suggest that his poet father-in-law does. The debate here is less to do with whether literature is necessary for medicine than with whether it is necessary to feel complete as a person, fully responsive to what life has to offer. Literature is here presented as important not for its instrumental value, but for its intrinsic worth. Here, McEwan suggests, Perowne is wanting, not as a doctor, but as a man.