Instrumental benefits from the humanities

A number of educational benefits are said to result from studying the humanities, including broader perspectives on medicine and the health professions, and an understanding of the patient within her particular circumstances and milieu.9 The humanities are occasionally spoken of as ‘humanising’ medicine,10 11 although the term has a variety of meanings including that the humanities “provide a different viewpoint” and a “critical and questioning attitude”,11 broaden the medical curriculum,10 and bring patients being back into focus “as unique persons living with an illness” within “particular cultures or communities”.9 The expression also refers, on occasion, to developing self-awareness within the trainee health practitioner by giving attention to their own human-ness in the sense of feelings for others and understanding of their own limitations, concerns and prejudices.11 However, the notion of the arts ‘humanising medicine’ has been criticised more recently.6 9 12 It is also noted that the reference to “humanities related to medicine” in Tomorrow's Doctors published in 2003 by the General Medical Council in the UK, was not included in the revised 2009 document.13 14

Perry observes an underlying assumption in the medical humanities that the “arts can assist in the development of the student as a communicative doctor”.15 Macnaughton suggests that literature, drama and painting offer insight into the “nuances of communication between people, both verbal and non-verbal”.4 Downie claims that the humanities provide “transferable skills” such as “sensitivity to nuances, ambiguities, and hidden meanings”.5 Chen et al consider that the “attitudes and behaviour of a holistic and compassionate practitioner” can be “experienced vicariously through the medical humanities”.16 Some claim that studying the humanities promotes empathy,15 although many commentators are sceptical about this claim8 17–20 (also see p 216 in Downie5). Little argues, for example, that the arts only influence those already open to them.8 17 From a review of the literature, Perry et al found some evidence that arts programs in medical courses lead to changes of attitude and the acquisition of some skills but no evidence to indicate whether these changes are long lasting and bring about behavioural change.15

There is a more general concern about instrumental justifications for the medical humanities. Gillis describes the approach as “product oriented” and presents it as an argument that “through the humanities we make physicians more understanding people—and by extension, more effective physicians… and for this reason [the humanities] should be a part of the medical curriculum”.18 This highlights a concern that the humanities and the arts are used as mere instruments to the end of producing effective practitioners.

The allusion here to Kant's categorical imperative (that we should not use another human being ‘merely as a means’ to our own ends) is deliberate as it helps to isolate what it is about the instrumental justification that is troubling (Kant, p 37).21 The concern is that we may be treating the arts as mere instruments to effect an end—a point that Macnaughton and Downie also address.4 5 While the humanities and the arts may provide an instrumental benefit to medical education, they are more than this in that they potentially offer benefits to individuals beyond their capacities as medical students.4

Macnaughton, and Downie and Macnaughton, are careful to note that the medical humanities “also have an intrinsic value in their own right” and they consider that this value is itself essential to “what it means to be ‘educated’ as distinct from simply ‘trained’” (Macnaughton, p 192).4 22 This provides a further justification for including the humanities because, without them, a course in medicine is an insular vocational ‘training’ rather than an education.4 Warner observes that this idea has been a “persistent refrain” since the early 1900s when some leaders of the USA medical establishment “warned that the allegiance to science driving the profession's technical and cultural success was endangering humanistic values fundamental to professionalism and the art of medicine”. Many of these leaders argued for teaching the history of medicine as an antidote in order to maintain the “liberal education, civility and moral wisdom” of the profession and as a means for attaining the “ideal of the ‘gentleman-physician’ well versed in the classic liberal arts”.23

Personal development and enrichment

‘Personal development’ and ‘personal enrichment’ are broader justifications for teaching medical humanities.4 8 Unlike the instrumental rationale, the humanities are justified, even if they do not make people better doctors, because they enrich and bring greater pleasure to their lives and because “the education process touches the student more deeply at a personal level” (Macnaughton, p 195).4 Little (a surgeon and published poet), for example, writes that the “humanities offer an experience of the world of feelings and values, which can be as profound as people allow it to be” (Little, p 170).17 He cautions however, that “[t]hose who hope to make better clinicians by teaching poetry may make some of their students into better or happier people, but I doubt that they will enhance their clinical skills”8 (see also p 38 in Scheper-Hughes24). For ‘teaching poetry’ we could equally read ‘music’, ‘theatre’, ‘film’ or ‘dance’. Marcel Proust appears to agree:

This mysterious gift [flair in diagnosis] does not entail any superiority in the other departments of the intellect, and a creature of the utmost vulgarity, someone who admires the worst pictures, the worst music… may perfectly well possess it. (Proust, p 380)25

While personal enrichment may justify electives drawn from the medical humanities, this is not sufficient reason to institute a compulsory course, especially as “there are some who will always be indifferent to aesthetics, and yet be competent physicians” (Little, p 164).17

The instrumental and the enriching depictions of the relationship treat the arts and humanities as providing support to medicine and comfort to practitioners. If this was the extent of the relationship, then the medical humanities would be solely justified by a health professional's benefit, edification or entertainment. While I do not mean to deny a potential beneficial role for the humanities, or for the arts as entertainment and edification, the arts and humanities offer, and are, more than this. An aspect of this wider potential lies in their capacity to engender critique.

The arts as dangerous

Rees is critical of the medical humanities for being tame. He promotes a more interventionist approach by “refusing the ends given to” the humanities and promoting “ethical questioning” that is “genuinely open-ended”. His concern is that:

Literature, art, poetry, music, film, are… too often engaged as if they are non-critical resources which can be deployed in the service of the ends determined by the medical and medical ethical powers that be.12

He argues that there is an “ethical imperative” to positively reform the medical humanities. As an example he advocates an “existential reflection” about “caring for persons”—the predominant rationale of all the health professions—and proposes that the humanities advocate “caring for nothing” in order to address ultimate meaninglessness. This is an idea akin to Buddhist sunya: a recognition that at the core of any experience of being is a void or no-thing-ness (although Rees makes no direct reference to Buddhism).12 He acknowledges that this is a ‘radical’ proposition. However, it may be too radical to be taken seriously as it attacks a core value of the healthcare professions and of many working within the humanities. In any case, there is no obvious reason for positioning “caring for persons” and reflections on “ultimate meaninglessness” as being in opposition to each other.

This should not, however, deflect us from his cogent critique of the medical humanities. Rees's central argument is that conceptions of the arts as non-critical resources belittle the roles of the arts and artists. It is to treat the medical humanities as a “tool of medicine and medical ethics”. “Portentously elided”, he writes, “is the possibility that medical humanities is also dangerous”.12 Rees believes that the humanities have gained entré into medical education by adopting the ends of medicine and medical ethics and the result is to “defang all the potential criticisms… that literary and other sources can generate”. To illustrate the point he writes that:

One reads Shakespeare or Emily Dickenson, watches Lorenzo's Oil or Wit, considers the late paintings of DeKooning or Rembrandt, in order to become a better doctor or improve the work of doctors, and not to question the work of doctors and the associated administration of medicine as an ethical profession.12

In this manner lions from the Serengeti become domesticated cats for a warm place in front of the fire. Left to themselves, and appreciated in an appropriate setting, the arts may be challenging, but in this context they are pacified. In my view, however, this is a pedagogical issue to do with the manner in which the arts are employed by each humanities teacher. There is no inherent reason that the films, paintings and literature Rees refers to might not lead to “question[ing] the work of doctors and the associated administration of medicine as an ethical profession”. Nevertheless, there may be more general societal perceptions of the value of the humanities that incline teachers to present a subdued and limited account of these materials.

At the nub of this issue is a perception of the humanities as marginalised in relation to science-based knowledge. In a medical context, rather than confronting this marginalisation, the response has been to emphasise the utility of the humanities. Slouka, however, decries this tendency and mounts a muscular defence:

The humanities, done right, are the crucible within which our evolving notions of what it means to be fully human are put to the test…. They are thus, inescapably, political. Why? Because they complicate our vision, pull our most cherished notions out by the roots, flay our pieties. Because they grow uncertainty. Because they expand the reach of our understanding (and therefore our compassion), even as they force us to draw and redraw the borders of tolerance…. The humanities, in short, are a superb delivery mechanism for what we might call democratic values. There is no better that I am aware of.26

In a similar vein, Bleakley et al wrote that “One of the primary functions of art is surely to challenge the basis upon which we are civil. Art often sets out to shock our sensibilities and question our limits to taste”.27 This is to draw “attention to the transgressive nature of art” and artists who “challenge societal norms working with and against the boundaries of taste and expectation”.28 The role of the humanities is not therefore to “tiptoe through the minefield, leaving the mines intact and loaded” but to accept that provocation and discomfort (if not explosions) play a valuable role in learning.26 There is something antithetical about treating the arts as a mere resource for a specified purpose when their strength lies (in part) in their capacity to break bounds and to lead to unanticipated freedom of thought and appreciation.

The medical humanities as critique

One of the more compelling arguments for a role for the humanities in medicine is to provide critical reflection on assumptions and predominant ‘taken-for-granted’ metaphors of medicine and the healthcare professions more generally. However, the medical humanities have shied away from this role. Bishop is critical of the medical humanities for acting as a “compensatory mechanism for the mechanical thinking that has dominated and continues to dominate medicine”. His point is that the very attempt to humanise medicine in an instrumental way, has served to reinforce and perpetuate a dualism that already exists between the humanities and medicine, a dualism that is founded on an erroneous distinction. More importantly, it misses the possibility of the arts finding “human being at the margins of what it is always a struggle to say”.6 Davis and Morris also challenge a “science/humanities, facts/values divide” by refusing to accept any “hard and fast boundary” between “biology” and “culture”.29 To put this in the positive, as Davis and Morris do in their ‘Biocultures manifesto’, “[s]cience and humanities are incomplete without each other”. As a consequence, “the biological without the cultural, or the cultural without the biological, is doomed to be reductionist at best and inaccurate at worst”.29 The essence of these criticisms is that medicine, with the connivance of bioethics, assumes a dubious distinction between fact and value as if medicine is about fact (and aligned with science) and ethics and the humanities are about questions of value.

Shapiro et al raise the “problem of how certain biomedical narratives are privileged”.1 Of particular concern are the “prevailing metaphors” which are “mechanistic (the body as machine), linear (find the root cause and create and effect) and hierarchical (doctor as expert)” and the “dominant narrative” which is a “story of restitution” in which the “patient becomes ill; patient is cured by physician expert; patient is restored to preillness state”.1 Anyone engaged (as I am each year) in interviewing incoming medical students will know that the ‘body-as-machine’ and a ‘story of restitution’ are dominant narratives of students even before entry into a medical course. As many of my clinician colleagues acknowledge, these are inaccurate and misleading portrayals of medical practice, yet the metaphors have been remarkably resilient. One of their effects is to marginalise the humanities. On the hopeful side, however, as Shapiro et al note, there are “many reflective physicians and medical educators” who support “an expanded vision of medicine and medical education”.1 For this expanded vision to have any effect, it needs to be “nurtured and enlarged” and displace (or at least be taken as a serious challenge to) the pre-eminent biomedical model in medical education.1

Provocative art as critique

As one of the ways to explore and question assumptions of medicine, including the metaphor of the ‘body-as-machine’, I examine the work of two leading international performance artists, the Australian Stelarc and the French artist Orlan, who have subjected their bodies to modifications and extensions. Their work deliberately challenges conceptions of the body, along with medicine's relationship with technology in a number of ways.30 31 What their projects have in common is technological or surgical augmentation of their bodies. Both of them intentionally confront the notion that individual corporeality is intrinsic to identity.

Stelarc for example, in performances of THIRD ARM, has allowed internet audiences to activate electrodes in his body to effect movements of an additional prosthetic arm. In MOVATAR, the machine itself prompted movements of his body. He has described himself as “intrigued about identity, the self, free will and agency in these performances” when “his body becomes, or is partly, taken over by an external agency”.32 Unlike science fiction, this is not a thought-experiment but a direct physical experiment with his body incorporating (or being altered to include) technological extensions.

Orlan's face has been surgically sculpted on numerous occasions to embody icons of feminine beauty including “the nose of Diana, the mouth of Boucher's Europa, the chin if Botticelli's Venus, and the eyes of Gerome's Psyche”.33 These operations have been broadcast live to galleries around the world as “baroque theatrical performances… in which she and her medical attendants wore fashion-designer costumes”.28 Poetry reading and music accompanied the surgery, in an operating theatre decorated with large bowls of grapes. There is an apparent intention both to invert the usual power relationship between patient and doctor, and to shock. Jane Goodall has commented that:

Both artists… are creators of scandal in the original sense of the term as… a trap or stumbling block, metaphorically interpreted as a moral snare causing perplexity and ethical confusion (OED). Some forms of risk-taking may be scandalous, but scandal in this sense tests the moral ground and puts morality itself at risk.34

She interprets the work of Stelarc and Orlan as “good scandal—one which generates complex confusions around high-intensity issues and cannot be resolved through the simple assertion of precepts”.31 For Zylinska, this goodness results “from the impossibility of providing a consistent, totalizing narrative about the events in question”.32 The point I wish to pick up on is this capacity of these works to generate controversy and debate about the meaning and implications of the work without “providing a consistent, totalizing narrative”.

Both Stelarc and Orlan have positioned their work as speaking of the “posthuman body”, the “body as obsolete” and a “postmodern and cybercultural body”. The idea of our bodies as extensions of technology leads Joan Broadhurst Dixon to describe the human as fluid and in question, and to conclude that “We are losing touch with our bodies, our human physical dimensions, and with it our meaty morality (or ethics)”.35 Indeed there is now a genre of post-human literature of which Stelarc and Orlan's work has become a part.36–42 However, I am not examining their work as an adherent to a new of canon of thought about post-human beings, but rather, for its capacity to generate controversy and questions. Some of these questions will inevitably be about the value of the works themselves and their underlying presuppositions, and about the relationship between the artists and their medical attendants. Others may relate to the artists' claims about the body as obsolete and the ‘cyborg’ blending of body and machine. This in turn draws attention, potentially, to the assumptions of the ‘body-as-machine’ within both medicine and art.

Others observing performances of Orlan and Stelarc have not seen an obsolete body but are drawn to the meaty and suffering body. For Jones and Sofia, the artists' bodies “in the here and now” are bodies that “bleed and pulsate” and experience “the reality of pain”.43 Both Stelarc and Orlan deny or downplay that pain is a significant element in their projects. However, Jones and Sofia observe that “[d]uring her operations Orlan tries to show no distress, but this doesn't mean that the pain disappears [it] is displaced onto the audience… something she herself acknowledges”. They note similarly that “Stelarc asserts that the intrusions he makes on his body are a means to an end and are only coincidentally painful”. Yet, for their audiences, “witnessing of pain is an important part of the performance of both artists, and one that not all can endure, especially when surgery is performed”. Jones and Sofia consider that there is a “redemptive value from the audience's viewpoint” in that “their bodily suffering spares us the greater agony of having to find out more directly what is entailed in transforming ideals into flesh”.43

These are just some of the controversies surrounding the work of Orlan and Stelarc. As provocations in the context of medical education, their work raises many questions concerning the role of medicine; whether we are indeed moving to a technologically augmented cyborg body; and ethical questions about whether any of this is ethically acceptable for art, or medicine, and on what basis.28 Art is not immune from demands for social and ethical responsibility (Zylinska, p 149–74).44 45 Neither the art work itself nor commentaries by the artists (and others) presuppose any particular answers. The works themselves, and the commentaries, are however powerful provocations for students' own enquiry.

Beyond Orlan and Stelarc, there are other potentially challenging possibilities in the work of current artists. Catts and Zurr (from SymbioticA) have used tissue culture as “an effective methodology to confront the complexities and to contest dominant ideologies”.45 46 In their installation ‘Tissue Culture & Art (ificial) Wombs (AKA the Semi-Living Worry Dolls)’, they cultured cells on polymer scaffolds as ‘worry dolls’, in a series from ‘A’ to ‘G’, with the promise that the dolls would take those worries away. Doll ‘A’, for example, represents “the worry about Absolute Truths and people who think they hold them”.47 This artwork is “both ‘tongue-in-cheek’ and serious in attempting to draw attention to assumptions and ethical conventions within art, science and culture and open these up for critique and deeper understanding”.28 Similarly, Julia Reodica cultivated her own vaginal cells for a 2004 project ‘hymeNextTM’ to produce a series of artificial hymens that “aim to confront modern sexuality, and provoke thought on the female body and the emphasis placed on virginity” (Zylinska, p 161).45 48 Eduardo Kac is renowned for his GFP Bunny Alba, the green fluorescent rabbit made by using transgenic materials (Zylinska, p 150–2).45 49 Bioart of this kind raises many questions about the danger of artists working with biological materials to culture, clone and generate new life forms, and—more fundamentally—about the relationship between science and art (Zylinska, p 149–74).45

I have focused on the work of artists working ‘at the edge’ (so to speak) of their art, and in particular, provocative performance art involving alterations and extensions of the body, and bioart which makes use of new biological technologies. Equally, work in other genres of the arts gives rise to controversies. For example, David Foster Wallace's last novel The Pale King addresses the issue of boredom with “little resembling an over-arching narrative”, no plot, just something sketched “here and there” like “shards in the tornado”.50 Ross, in his The Rest is Noise, listens to the 20th century through its music in a journey into atonality, discordance, and beauty in surprising moments, glimpsed against the backdrop of the politicians, wars, demagogues, dictators and genocide.51

The point I am endeavouring to make is that recent work in any of the arts tends to defy easy understanding and resist instrumental application. It also resists the artist's interpretation (as discussed above in relation to Stelarc and Orlan) and is resistant to a ready translation into a teaching medium to make a particular point. New art of this kind demands to be taken seriously on its own terms (or not at all).

Another reason for suggesting this approach is that students in the health professions are conspicuously young (obviously so in medicine and dentistry, and true of the majority of students in nursing, social work and psychology). My impression of medical students (in Australia, Singapore and England at least) is that 19th and early 20th century art, literature and music has little interest for many of them. Current and more risqué artwork may be more appealing. Moreover, exploring current art is more likely to be a genuinely shared enquiry between the teacher and student, both of whom may experience similar responses. Using material that we as teachers are struggling to make sense of is not as conspicuously manipulative as drawing on classics to make particular (pre-determined) points about issues—whether about medicine, or death, or living in poverty. We are comfortable with the classics—and have views about them—in a way in which we may not be with recent film, art, music or literature from artists who are playing with and against the boundaries of their own genre.

A further reason is that, rightly or wrongly, medicine and the health professions are projected and perceived as gung-ho, heroic, unlocking nature's secrets with promises of laboratory grown organs from our own cells, pushing the limits of human finitude, and rendering the secret codes of our genes open to scientific code breakers who promise to eradicate cystic fibrosis and diseases of old age. These ideas are strong provocations in themselves. They need to be met with equally strong images and responses from the arts.

However, I am not proposing that this should be the only approach. My underlying concern is with a manipulative and clumsy use of the humanities and the arts as instruments to achieve a specific purpose. This occurs when students are expected to read a novel to gain a particular understanding—where the teacher has a prescribed agenda in mind. The value of the arts and humanities is in their open-ended support of questioning, and their potential to “enliven and animate… and develop new forms of engagement that allow for participation and discovery through enactment and embodiment and not just through abstraction or theory”.28 It derives (in part) from a capacity of art to generate controversy and debate about the meaning and implications of the work and the subjects referred to. This is still an instrumental use of the arts, I acknowledge. The difference is that art is used not merely as a means, but with respect for each work of art in and of itself. The same respect can be extended to the classics—and is by good teachers. Even when familiar, the classics need to be read for the surprise, the delight, or listened to attentively for that exquisite or devastating moment. They too resist easy translation. They can be discussed as works open to many interpretations. Art needs to be allowed its own impact and not be exploited solely, or predominantly, for some other purpose.

The humanities, arts and healthcare education

If art and the humanities are to play a more critical role, rather than “attempting to ‘produce’ humanistic attributes widget-fashion” (to use Shapiro et al's term), it raises the question of how this may be possible in healthcare education.1 For reasons of space I am constrained to offer the barest sketch of an answer to this question.

There is a good argument for offering humanities electives to medical students. However, arguments based on the “intrinsic value in their own right” of the humanities and their being “essential components of the educated mind” (Macnaughton, p 192)4 are insufficient to substantiate compulsory courses in the humanities in my view. These arguments only have cogency if we accept as valid medicine's place as an elite profession and a concomitant need for “the ‘gentleman-physician’ well versed in the classic liberal arts”.23 Little is correct, I believe, in observing that there are many competent clinicians indifferent to aesthetics and that the arts only influence those already open to them.8 17 It may be counterproductive to insist on teaching the humanities to those not interested, at least in the context of traditional medical courses.

In my view there needs to be a shift in the foundational assumptions of medicine and the metaphors by which medicine is taught if the arts and humanities are to contribute more fully to medical (and other healthcare) education. To persist with a metaphor of ‘body as a machine’ and ‘medicine as a science’ offers little space in which the arts and humanities can contribute in an appropriate way, other than as electives for those students with a special interest. The metaphors and myths of biomedical medicine are obviously limited, but like many such simplifications they have been effective in medical education for the last century. I claim, however, that the discontinuities and disjunctions have become too many and too great to persevere with these oversimplified models.

Shapiro et al go some of the way toward this conclusion in suggesting that there needs to be a lessening of the “ubiquitous divide between scientific/clinical medicine” and recontextualising of medicine to place the “medical humanities close to the core rather than on the periphery of the profession”.1 At the Peninsula Medical School in the UK, Bleakey et al describe a more far-reaching shift of the kind I am suggesting, where the medical humanities have been adopted as “an explicit theme in the core undergraduate curriculum” as well as being represented in elective study units. As they report them, these changes represent a significant expansion of the underlying conceptions of medicine.27 My sense is that, for the arts and humanities to play an effective role within medical (or other health professional) curricula, there needs to be a similar broadening of understanding. From my experience of teaching ethics in medicine, I am aware that a change, toward recognising ethics as underpinning medical practice, was required before it became accepted and integrated within medical education. For years, even after being adopted as a required course in many schools of medicine, ethics struggled as an add-on, an adornment in the school brochure, but not taken seriously by faculty.

Short of re-conceiving foundational metaphors in medical education, it still remains open to individual teachers to introduce elements of the humanities or arts in their teaching in any course within medicine, or for a medical school to introduce a substantial strand that has integrated the humanities (such as the personal and professional development modules in some medical schools). In skilful hands I believe this can work. However, teaching the humanities is a challenge within a medical course founded on the traditional biomedical model.