What makes a young man or woman want to become a doctor? Ego? Intellectual challenge? The prospect of financial success? Scientific fascination?

The answer for most of us—none of the above—can be found in the 2009 debut novel Cutting for Stone, by fellow physician Abraham Verghese.

It is a novel that is widely loved by readers, if not all critics. The New York Times Sunday Book Review, for instance, concluded its critique of Cutting for Stone on a decided downer: “In Verghese’s second profession, a great surgeon is called an editor. Here’s hoping that in the future the author finds stronger medicine in that line.”http://www.nytimes.com/2009/02/08/books/review/Wagner-t.html?_r=1And the Boston Globe’s traducing review was no kinder: “…not a great work of fiction but an interesting one…Despite its somewhat labored plot and alternately flat and overwrought characterizations, Cutting for Stone is worth  reading…”

http://www.boston.com/ae/books/articles/2009/03/19/a_familys_odyssey_of_love_and_healing/

Most other reviews, however, were glowing, and readers have decisively overruled the above outliers. Many reasons for the book’s appeal have been suggested: Verghese’s engrossing description of Ethiopia, where much of the action occurs; the detailed descriptions of all things medical and of the taxing life of a surgeon (which Verghese is not, by the way—he is an infectious disease expert and professor of medicine at Stanford); the obvious love the author has for medicine; the compassion he holds for his characters.

There is no denying, though, that Verghese qua author found it difficult to detach from being a doctor, and consequently let the physician in him rule the novelist. The price paid is that the book is laden with long, jargon-filled passages that bring its narrative flow to a screeching halt. Yet despite this, it is clear that both Abraham Verghese and his physician-characters in Cutting for Stone became doctors to help people. Which is why the public continues to hold physicians in such high esteem, repeatedly naming “doctor” as the most respected career choice, reserving their deepest contumely for lawyers and politicians. In my opinion, it is on account of its manifestation of human altruism that Cutting for Stone has enjoyed such stunning commercial, if not always critical, success.

Altruism has fascinated mankind for centuries. Altruistic behavior is at first blush inconsistent with Darwinian natural selection, in that it is behavior by an organism that benefits another at its own expense. The great religions of the world use the fact of human altruism as evidence of God’s existence, by equating love of others with love of God: “…thou shalt love thy neighbor as thyself: I am the LORD.” (Leviticus 19:18.)

For unbelievers, the existence of altruistic behavior is a glaring contradiction, an inconvenient conundrum that challenges the very foundation of secular rationalism: evolution. For how could behavior benefitting another to one’s own detriment possibly be explained by evolution theory? But recently, the scientific community—mostly, though not exclusively, atheist—has produced a multitude of studies purporting to show that altruism is purely a neurobiological phenomenon. One of the earliest came out of Duke, and showed that sophisticated MRI scans of the brain revealed relatively greater activation of the brain’s posterior superior temporal sulcus when experimental subjects were watching as compared to playing a computer game. This heightened activity strongly predicted a given subject’s propensity for altruistic behavior. (Nat Neurosci. 2007 Feb;10(2):150-1. Epub 2007 Jan 21.Altruism is associated with an increased neural response to agency. Tankersley D, Stowe CJ, Huettel SA.
Brain Imaging and Analysis Center, Box 3918, Duke University Medical Center, Durham, North Carolina 27710, USA.)

Other researchers found that areas of the brain stimulated by food or sex—fronto-mesolimbic networks—became relatively more active when subjects were asked to think about donating a large sum of money as compared to keeping it for their own use. That is, it made them feel good to be altruistic, thereby explaining Saint Francis of Assisi’s famous observation: “For it is in giving that we receive.”

http://www.pnas.org/content/103/42/15623.full

Predictably, it was only a matter of time before a study appeared to advance the notion that altruism was selected out over the course of human evolution in order to confer a survival advantage. Last October, Dr. Tim Phillips and colleagues studied the responses of identical and non-identical female twin pairs to questions about their own altruism and how desirable they found altruism to be in potential husbands. Results showed a link between human altruism and sexual selection, supporting the theory that altruistic behavior evolved as it became necessary for the earliest human beings to choose mates who would be willing to make the sacrifices required for successful child-rearing. (Tim Phillips, Eamonn Ferguson and Fruhling Rijsdijk. A link between altruism and sexual selection: Genetic influence on altruistic behaviour and mate preference towards it. British Journal of Psychology, 2010; DOI: 10.1348/000712610X493494)

So, is altruism a conscious, moral act of free will, or is it a complex neuronal circuit? I have covered this ground before in a discussion on Cartesian dualism and the mind-body problem: Does human consciousness—the mind—exist separately from the human body? This is the larger issue under which any debate about the origins of altruism must be subsumed.

http://richardbarager.com/near-death-experiences/watching-yourself-die/

Whatever the answer, the attraction of medicine as a calling is born in large part from the altruistic urge to help other human beings. What the proximate cause of this desire is depends on where one believes consciousness resides: in the soul or in the neurochemistry of the brain. It is my personal belief that the mind and soul are not discoverable by scientific method, as they are infinitely intangible and not part of the observable, accessible universe. Serious works of fiction like Cutting for Stone, however—with complex meanings embedded in narrative in a manner beyond the capacity of ratiocination to convey—are capable of accessing the infinitely intangible.

And of revealing why doctors become doctors.

The title of Everyman, the mordant yet immensely moving 2006 novel by Philip Roth, comes from a medieval play of the same name, and is intended to remind us that aging and death await us all, every man and every woman. In 2009, Roth became the third living American writer to have his work published by the Library of Congress. As I have said before in these pages, Philip Roth is the greatest living writer never to have won the Nobel Prize in Literature.

Roth sets the tone for this 192-page novella with an epigraph quoting Keats.

Here where men sit and hear each other groan; / Where palsy shakes a few, sad, last gray hairs, / Where youth grows pale, and spectre-thin, and dies; / Where but to think is to be full of sorrow.

The novel begins with Everyman’s funeral, then skips backward in time to an unvarnished accounting of his life. The protagonist, who remains unnamed throughout, is a 71-year-old retired—and materially successful—advertising executive who has walked away from two marriages, three children, and his once-revered older brother, leaving him ill-equipped to cope later in life with his decaying body and a series of medical events—appendicitis, two heart surgeries, and various other procedures—that force him to confront his own mortality. His death-and-dying tocsin, though, rings well before his body fails him, at his father’s funeral.

All at once he saw his father’s mouth as if there were no coffin, as if the dirt they were throwing into the grave was being deposited straight down onto him, filling up his mouth, blinding his eyes, clogging his nostrils and closing off his ears. He could taste the dirt coating the inside of his mouth well after they had left the cemetery and returned to New York.

Everyman reaches old age and Starfish Beach, the retirement community his infirmities consign him to, cynical and resentful, unshriven (by two adult sons) for cheating on his first wife, unforgiving of the body that betrays him and robs him of his prodigious sexual vigor. Only his daughter from his second marriage remains loyal—as only daughters can. She sees to it that he is buried in a Jewish cemetery alongside his parents, even though he is an atheist, because she …didn’t want him to be somewhere alone.

The last to pay respects at his funeral is Maureen, a home health nurse who cared for him after his first heart surgery.

…a battler from the look of her and no stranger to either life or death. When, with a smile, she let the dirt slip slowly across her curled palm and out the side of her hand onto the coffin, the gesture looked like a prelude to a carnal act. Clearly this was a man to whom she’d once given much thought.

And that was that.

…In a matter of minutes, everybody had walked away—wearily and tearfully walked away from our species’ least favorite activity—and he was left behind. Of course, as when anyone dies, though many were grief-stricken, others remained unperturbed, or found themselves relieved, or, for reasons good or bad, were genuinely pleased.

I once recommended—prescribed—this book to a patient, now deceased, who in addition to being on dialysis with kidney failure, had heart disease so severe it was clear to all, my patient included, that he would not survive another year. A fiercely intelligent man, he understood his predicament intellectually, but refused emotionally to accept it. When he grew angry and then despondent, I suggested Everyman, which he agreed to read. He found the protagonist’s cynicism and bitterness and lack of grace so contemptible he vowed to die a better way. For the remainder of his life, a few months only, he was notably happier and at peace. Sometimes, only great fiction can tell the truth in a way that is transformative; we humble doctors lack the words.

Everyman is a profound adumbration that settles nothing, but fearlessly illuminates everything, leading the reader to a place where confronting death is at least possible.

Why do we fear death so? Do the atheists among us fear they are right? And the faithful that they are wrong? And this notion of bodily decay, how to deal with that, our unwanted senescence? Is there no limit to what we are willing to do to forestall it?

Perhaps it is the loss of those we love that we most fear. A different way of saying we fear losing our humanity. But what I have learned from my patients, I think, is that it is the sweetness of life, the intensity, the vividness we fear losing. And that the balm for this fear is to have savored fully all the heavenly ambrosia this mortal world holds.

Before youth grows pale.

Middlemarch is the magnum opus of George Eliot, the masculine nom de plume of Mary Ann Evans, one of the foremost English novelists of all time. She was born in 1819 at Arbury Farm, England, to an Evangelical Protestant father whose religious beliefs she soundly rejected. Like Tolstoy and Flaubert, George Eliot was part of the nineteenth century realist movement in literature, taking great pains to create life-like characters representing ordinary people in stories of remarkable verisimilitude. Eliot believed female novelists were held in low regard by the English literati, thus the pen name.

At 838 pages and 86 chapters, Middlemarch is no light read; entire semesters have been consumed by it. Suffice it to say that a broad cast of characters—none dominant, all astonishingly real—drive three wide-ranging but interwoven story lines revolving around a number of themes: love and marriage; the station of women in Victorian society; class and social mobility; and the clash between idealism and self-interest, all set in the (fictitious) rural English town of Middlemarch. The book’s complete title— Middlemarch: A Study of Provincial Life—suggests as much.

Among the principal characters is Tertius Lydgate, an ambitious young doctor who comes to Middlemarch intent on starting a new fever hospital for the poor. Lydgate vows to establish new ways of practicing medicine, based on observation and the recording of data and scientific method, in place of the rampant charlatanism of the day.

“A fine fever hospital in addition to the old infirmary might be the nucleus of a medical school here, when once we get our medical reforms; and what would do more for medical education than the spread of such schools over the country?”

…there was a general impression that Lydgate was something rather more uncommon than any general practitioner in Middlemarch.

But Lydgate, like many visionaries, is arrogant, to colleagues and patients alike.

“I have not yet been pained by finding any excessive talent in Middlemarch,” said Lydgate bluntly.

Lydgate’s conceit was…never simpering, never impertinent, but massive in its claims and benevolently contemptuous.

He winds up marrying the town beauty, Rosamond Vincy, but it is an unhappy match. Rosamond is shallow and materialistic, and her pretentious spending quickly plunges Lydgate into severe indebtedness. His financial desperation leads him to accept a loan under dubious circumstances, and the ensuing public humiliation he suffers causes him to surrender his dream of revolutionizing the way medicine is practiced. To appease his wife, he becomes the kind of doctor he once held in contempt, catering to the wealthy until he becomes wealthy himself. Lydgate dies at fifty, disillusioned and unfulfilled, arrogant no more.

But arrogance is not the brilliant and perceptive Lydgate’s worst flaw; a lack of empathy is. He seeks to understand human behavior in a cold, dispassionate way, without emotionally connecting to the human beings he studies. Both his métier and marriage suffer for it.

“I was early bitten with an interest in structure, and it is what lies most directly in my profession. I have no hobby besides.”

The tragedy of Lydgate is the tragedy of any doctor who fails to become proficient in the art of medicine as well as the science. The science of medicine involves knowing what treatment to apply; the art of medicine requires the persuasion of other human beings to suffer it.

All medical schools produce their share of Lydgates, brilliant classroom students who excel at mastering the basic sciences, but founder at the bedside. It just isn’t there, that natural camaraderie that causes a patient to turn to his wife and say, within minutes of meeting a surgeon, “I like her. I’m going to let her do whatever she needs to.”

Consent to undergo the often invasive and sometimes hazardous treatments we ask patients to endure depends upon an irrational trust—irrational in that an emotional connection forged between doctor and patient gives rise to it. Such trust is the coin of the medical realm, and the path to gaining it begins with authentic recognition of—and genuine sympathy for—the plight of the afflicted. These skills are not acquired in cellular biology class, but rather are developed with the aid of paintings and plays and poems and novels.

Like Middlemarch.

Every so often there are cases that challenge our understanding of what constitutes futile medical care. Cases that remind us of the tremendous ability human beings have to adjust their capacities to the reality of their impairments. Sometimes majestically so.

There is no more inspiring example of this than the story of Jean-Dominique Bauby, the editor-in-chief of Elle magazine who in 1995 suffered a stroke that resulted in what is known as “locked-in syndrome”—a brainstem vascular occlusion of the pons resulting in quadriplegia and speechlessness, but with the retention of normal consciousness and cognitive ability. In other words, complete awareness and comprehension of being unable to move or talk. Pure terror.

Most patients die soon after the occurrence of this devastating event. But not always. Some live for months or even years in this immured state, at great financial cost to society. One cannot help but wonder in such cases if the cost justifies the benefit? Surely locked-in syndrome meets the definition of futile care: cases with so little hope of improving that continued measures of life-sustaining support are deemed futile and therefore abandoned in favor of palliation. Modern hospice care, with the proper use of analgesia and sedation, can make the embrace of death for victims of locked-in syndrome no more traumatic than slipping off into a drugged slumber from which they never awaken.

Interestingly enough, the literary world gave voice to this pitiful syndrome long before the medical world did. Plum and Posner didn’t coin its name (Posner, J.B., Saper, C.B., Schiff, N.D., and Plum, F., The diagnosis of stupor and coma. 4th ed. 2007: Oxford University Press.) until 1966; Alexander Dumas wrote of it in 1820, in The Count of Monte Cristo. A character in the story, Monsieur Noirtier de Villefort, suffered from this precise condition, and was described by Dumas as “a corpse with living eyes”—as apt and succinct a description of a patient with locked-in syndrome as any modern day neurologist could ever hope to articulate.

But what of Jean-Dominique Bauby? What became of his locked-in syndrome? It turns out that Bauby, due to the peculiarities of his particular stroke, was left with movement in one part of his body, and one part only: his left eyelid, a slightly incomplete variant of locked-in syndrome. And what did Monsieur Bauby choose to do with this pathophysiologic oddity? Unbelievably, he “dictated” his memoir—by blinking.

“It is a simple enough system. You read off the alphabet . . . until, with a blink of my eye, I stop you at the letter to be noted. The maneuver is repeated for the letters that follow, so that fairly soon you have a whole word.”

In this way, he laboriously blinked out his memoir, working hours a day for nearly a year in response to a scribe who meticulously called out letters ordered by their frequency of use. It took him on average two minutes per word to produce a book that fearlessly chronicled his every indignity.

“One day . . . I can find it amusing, in my 45th year, to be cleaned up and turned over, to have my bottom wiped and swaddled like a newborn’s. I even derive a guilty pleasure from this total lapse into infancy. But the next day, the same procedure seems to me unbearably sad, and a tear rolls down through the lather a nurse’s aide spreads over my cheeks.”

One of the more astounding revelations of this excruciating account was that shortly before his stroke, Bauby had reread The Count of Monte Cristo.

Jean-Dominique Bauby died two days after The Diving Bell and the Butterfly was published. The diving bell was meant to represent the prison of his body, and the butterfly his trapped mind fluttering inside it. His story is testimony of the majestic agony of the afflicted—and of the penumbra of medical futility, which even for a corpse with living eyes swirls beyond the palings of our certitude.

One of the true narrative medicine gems of contemporary literature is The Echo Maker, by Richard Powers. This lavishly written story won a 2006 National Book Award and was a finalist for the 2007 Pulitzer Prize for Fiction. Powers is a fiercely intelligent writer who turns out superbly crafted fiction leavened with heavy doses of medical science and technology.

Though The Echo Maker’s chief concern is with the elusive concept of self-identity, it is one of its subordinate themes that attracted my attention: the munificent but not limitless capacity of human beings to care for loved ones. A capacity in no small part determined by the nature of the relationship between caregiver and afflicted: consider the intensity of a woman’s devotion to her stricken child compared to what she may muster for an ill third cousin.

But what of a woman’s devotion to her brain-injured, delusional brother? Somewhere in between, perhaps.

The novel begins with an accident suffered by Mark Schluter, a 27-year-old meat-processor whose truck spins out of control and rolls over on a deserted stretch of highway outside Kearney, Nebraska. He suffers massive closed-head trauma and lapses into a coma, from which he later awakens with a rare neurological condition: Capgras syndrome, an identification disorder characterized by the patient’s belief that his closest friends and relatives are actually imposters of his closest friends and relatives, perfect doubles posing as loved ones in an elaborate plot to deceive him. The disorder, of which there are fewer than 500 reported cases, is thought to occur from a failure to integrate the emotional recognition of someone with the intellectual recognition of that same person’s face.

“His amygdala can’t talk with his cortex,” is how Mark’s sister, Karin Schluter, comes to understand his doctors’ explanation of the disorder.

“…Pushed to a choice, cortex has to defer to amygdala,” they say. “So it’s not what you think you feel that wins out, it’s what you feel you think.”

Karin, four years older than Mark and his sole remaining family, abandons her job at a computer company in Sioux City—and a subsistence romance with a techie co-worker—to care for her brother, who rewards her by steadfastly refusing to believe she is his sister, insisting instead that she is a diabolical body double sent to confound him. The plot is advanced by a cryptic note alluding to the cause—and meaning—of Mark’s accident. And by the appearance on the scene of a nationally renowned neurologist, whose fame as a diagnostician rests on his ability to coax painfully intimate life stories from his patients.

“Consciousness works by telling a story…” he has written, in one of his numerous best-selling books.

Mark’s recovery, the unmasking of a mysterious nurse’s aide as an accessory to the accident, and the intersecting character arcs of Karin and the neurologist are all tied together in a satisfying ending with lasting resonance about the way we view ourselves. But overshadowed by the story’s strong primary theme of self-identity is the no less compelling one of human fealty.

How long would you, if you were a thirty-one-year-old woman with nothing but false starts in life, be willing to put everything on hold for your brother? A brother who even when his amygdala was talking to his cortex, never amounted to more than a gamer with a taste for cheap beer and lowbrow goofiness. A brother who rabidly, obstinately, tragically insists you are not his sister—calling you instead “the actress Karin” and “the pretend sister”—until you secretly wish it were so. How long would you keep trying to reach him, keep waiting for his emotions to reconnect with his intellect? A month? A year? The rest of your life? How long a postponement of your own wants and needs before you begin to wonder if he’s worth it?

During a quarter-century of caring for chronically ill patients, I have seen acts of devotion and loyalty so loving and unwavering it made me feel unworthy to witness them. So, too, have I seen heart-cracking abandonments that made me doubt the future of our cruel, unblinking species. And patients who destroyed the lives of those around them with their insatiable needs, leaving me pleading with co-dependent loved ones to distance themselves before it was too late.

Perhaps some of you have experienced the tension between altruistic impulse and the need to live your own lives, the joy and sorrow of being your brother’s keeper. Perhaps some of you even know what it is like to be the brother.

Tell us your thoughts on human devotion, brothers and keepers alike.

Pity me as I wish to be pitied. That is the plea of the tortured protagonist in Leo Tolstoy’s brilliant 1886 novella, The Death of Ivan Ilyich.

Tolstoy was born in 1828 into Czarist Russia’s landed gentry. Though orphaned at a young age, he enjoyed the typical privileges wealth and title afforded—passive income, summers in the country, and enrollment at Kazan University. But it was later, after dropping out of school and joining the army, that Count Tolstoy would launch his career as a writer from the Crimean front.

There is perhaps no other literary character who gives voice to the agony of the afflicted more profoundly than Ivan Ilyich, a forty-five-year-old parvenu who assiduously wends his way through Czarist Russia’s bureaucracy to become a respected judge, only to develop an insidious illness that announces its presence while he is hanging curtains in a stylish home beyond his means to afford.

…he made a false step and slipped…but only knocked his side against the knob of the window frame. The bruised place was painful but the pain soon passed…

But not for long.

…Ivan Ilyich…had a queer taste in his mouth and felt some discomfort in his left side.

His symptoms begin to disrupt his carefully ordered and superficially fulfilling life. He grows irritable from discomfort and more quarrelsome with his wife, with whom his relationship is abysmal to begin with, a thing to be endured to keep up appearances. Her patience with him is soon exhausted.

She began to wish he would die; yet she did not want him to die because then his salary would cease.

Tolstoy passes judgment on the spiritual emptiness of social striving with one of the most famous and devastating sentences in Russian literature.

Ivan Ilyich’s life had been most simple and most ordinary and therefore most terrible.

Ivan’s symptoms intensify, mystifying a bevy of doctors who attribute it one day to a “floating kidney,” and the next to appendicitis.

The pain in his side oppressed him and seemed to grow worse and more incessant, while the taste in his mouth grew stranger and stranger…It seemed to him that his breath had a disgusting smell, and he was conscious of a loss of appetite and strength.

The nephrologist in me cannot resist pointing out that with the exception of his pain, all of Ivan Ilyich’s symptoms can be explained by uremia, an advanced stage of kidney failure. But whatever the cause, he becomes angry and bitter over his doctors’ failure to cure him. He realizes he is dying.

And he had to live thus all alone on the brink of an abyss, with no one who understood or pitied him…

He becomes resentful, especially of his still-healthy wife.

While she was kissing him he hated her from the bottom of his soul and with difficulty refrained from pushing her away.

Why is he so resentful? Because no one gives him what he wants. We come, now, to the heart of things, to what patients want and need and crave with all their being.

…what most tormented Ivan Ilyich was that no one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (though he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted.

He finally gets the succor he seeks from the peasant Gerasim, who holds him the way he wants to be held—and talks to him about death openly and honestly. The authenticity of Gerasim, in contrast to the hypocrisy of the aristocrats Ivan Ilyich has lived his life to please, has a powerful effect on him.

“Maybe I did not live as I ought to have done,” it suddenly occurred to him…“What if my whole life has been wrong?”

He softens and allows a priest to hear his confession, then endures an agonizing three days, during which…he struggled in that black sack into which he was being thrust by an invisible, resistless force.

In the end, Ivan Ilyich rejects the lie of his life and embraces the truth of his death; in so doing, he is at peace.

He sought his former accustomed fear of death and did not find it. “Where is it? What death?” There was no fear because there was no death.

In place of death there was light.

“So that’s what it is!” he suddenly exclaimed aloud. “What joy!”

Ivan Ilyich wanted nothing more than to be stroked like a child. Tolstoy’s insight into the enormous frustration patients feel at the end of life, the agony they endure, at not being touched in a compassionate way is a call to physicians—to all caregivers—to lay hands on our patients not only in a clinical way, as part of an examination, but also in an emotionally meaningful, loving way. Embrace them. Pity them. And patients: express your need. No pathos, no pity. Let people know you want to be held like a baby.

For from this will come a relief no surgery or medication can bring.

Doctors are often asked to treat disagreeable patients. Sometimes really disagreeable patients: loathsome, repugnant, nasty, hateful human beings. But it is not often that a doctor is asked to treat a patient who has invaded his home, threatened his life, and forced his daughter to strip naked in front of him. Such are the circumstances confronting London neurosurgeon Henry Perowne in the hugely successful novel Saturday, by Ian McEwan.

Ian McEwan is one of the most acclaimed and popular British novelists of our time. He has won the Somerset Maugham Award for his collection of short stories, First Love, Last Rites, and the Booker Prize for Fiction—England’s National Book Award—for his 1998 novel Amsterdam. He is perhaps best known to American readers for the lush period piece Atonement, made into an Oscar-nominated film starring Keira Knightley.

Saturday is written in present tense, with the entire story occurring on a single day: February 15, 2003, the date of the largest anti-war demonstration—against the war in Iraq—in English history. It is a day in which the forty-eight-year-old Perowne awakens and makes love to his still-fetching attorney wife; has a trivial car accident on the way to his weekly squash game that leads to a discomfiting scrape with a thug named Baxter (whom Perowne perceptively realizes is suffering from Huntington’s Disease, a degenerative neurological condition with no known cure); visits his demented, nursing home-bound mother; attends his talented, blues guitarist son’s jam session; and then makes his way back home to cook dinner for a family gathering that includes his poet daughter and literary lion father-in-law.

In the middle of dinner, this affluent, refined, accomplished—if rather self-conscious and guilt-ridden—English family is surprised by knife-wielding lowlifes, led by the impoverished, unaccomplished, uncouth Baxter, who has stalked Perowne to his home out of anger at all he represents—and out of a sense of desperation that Perowne might somehow conjure a cure for his incurable disease.

At the darkest moment of the intrusion, Perowne’s daugter Daisy—stripped naked and quivering, her gravid belly swollen with child— recites the poem Dover Beach, temporarily calming Baxter.

Perowne sees a glimmer of hope.

It’s of the essence of a degenerating mind, periodically to lose all sense of a continuous self, and therefore any regard for what others think of your lack of continuity. Baxter has forgotten that he forced Daisy to undress, or threatened Rosalind. Powerful feelings have obliterated the memory. In the sudden emotional rush of his mood swing, he inhabits the confining bright spotlight of the present. This is the moment to rush him.

He seduces Baxter into fantasizing about a cure for his Huntington’s long enough for Perowne and his musician son Theo to tackle him and knock him down a staircase onto a stone landing below, where he lies unconscious, a threat no more. Police and paramedics are called. The traumatized family begins to recover, leaning on one another for comfort.

Until Perowne receives a call from the hospital informing him of a case of head trauma in need of surgery. Intracranial hemorrhage of a life-threatening nature, it seems. Baxter.

Is Perowne obligated to treat Baxter? Or, given the circumstances of what Baxter has just put him through, is it acceptable for Perowne to tell the hospital to find another neurosurgeon—even though Perowne is the one on call that night? And if he does refuse, what if no other neurosurgeon can be located in time to operate on Baxter? What is Perowne’s duty—if any—to Baxter then? And what about Baxter’s terminal illness of Huntington’s? Even if Perowne were inclined to save him, wouldn’t it be more compassionate to refuse to operate on Baxter in order to spare him the undignified death of relentless neurological degeneration? Or perhaps Perowne should save Baxter to guarantee that he suffers a grinding, debilitating decline, poetic justice meted out by Perowne’s own scalpel.

So what does Henry Perowne do? He responds with hardly a bump in pulse rate and leaves for the hospital, where he saves the hapless Baxter—for what, he wonders: prison and an excruciating death from Huntington’s?—with his considerable surgical skill.

I suspect the overwhelming majority of physicians, myself included, would have reacted in exactly the same manner. There would be no more doubt about how a well-trained physician would respond in a situation like this than there would be over how an Alaskan sled dog would respond to being asked to race on a very cold day: it’s what we do. The average physician will treat anyone, anywhere, anytime, under the most trying of circumstances. Like sled dogs bred to run, we are bred to deliver care to patients. There was no agonizing by Perowne over whether or not to treat Baxter, because his sense of professional duty overwhelmed all other considerations—hate, fear, and revenge included.

But Perowne’s dilemma does raise an important medical ethics issue. When is a physician justified in refusing to treat a patient who has threatened him or her in some way, either explicitly or implicitly? At what point on the continuum does a physician’s safety become more important than a physician’s duty? Where—and when—to draw the line with dangerous patients?

Much is required of physicians: an unstinting devotion to others, a mountain of psychic energy. The punishing effect of these demands on doctors’ personal lives has long been recognized. Medicine is indeed a jealous mistress.

But what of the women and men who are married to doctors? What of the impact this grueling profession has on them, the non-physician spouses of doctors? (Two-physician marriages are another matter; doctors who are married to other doctors enjoy a considerably lower divorce rate than marriages where one spouse is a physician and the other not.) The phone rings all night long, emergencies constantly disrupt family functions, and their physician-mates, immersed from dawn to dusk in the drama of human illness, are often emotionally unavailable. Yet how to compete with matters of life and death?

One of the unhappiest medical marriages of all time is the subject of Gustave Flaubert’s Madame Bovary, a literary masterpiece about the dreamy wife of a kind, but inferior small-town doctor. Flaubert’s father was the resident physician of a hospital in Rouen, France, but Flaubert the younger chose to study law in Paris before turning to writing. He published Madame Bovary in 1857, following the acquittal of charges of immorality brought against him because of the book’s frank treatment of adultery.

The doctor in the story is Charles Bovary, an amiable dullard smitten by young Emma Rouault, the beautiful and—compared to Charles—refined daughter of a patient of his. After the death of his first wife, Charles pursues Emma and convinces her to marry him. But their torpid, ordinary marriage leaves Emma yearning for the excitement, opulence, and romance she has read about in certain novels of the day.

…it was at meal-times that life seemed especially unbearable, down there in that little ground-floor dining-room with its smoking stove, its creaking door, its sweating walls, and its damp floors. It seemed as though all the bitterness of life was served up to her on her plate…

Was this hopeless existence going to last forever? Was there to be no escape?

…She would lean her head against the wall and weep, longing for a life of excitement, masked balls and tumultuous pleasures…

She enters into a lengthy affair—which her adoring husband Charles remains oblivious to—with a local rake, who seduces her and then casts her aside, plunging her into a state of depression made worse by the financial burden of her many impulsive purchases.

Emma’s opinion of Charles during this time suffers even more on account of his disastrous attempt to repair the clubfoot of a villager named Hippolyte. An under-qualified, second-rate doctor with an appealing bedside manner and gentle disposition, Charles’s motivation for trying such (then) experimental surgery is professional vanity. Unfortunately, he is nowhere near skilled enough to perform the procedure, which he bungles horribly, resulting in the amputation of poor Hippolyte’s leg.

…Bovary kept indoors, not daring to stir from the house…If Hippolyte were to die, everyone would say he had killed him. And then what was he to answer when he went his rounds and people asked him about it? Perhaps he had made a mistake somewhere…Of course the best surgeons make mistakes. But that’s just what people will never understand. They would laugh at him. Everyone would be talking…There would be controversy in the papers and he would have to reply. Hippolyte might bring an action against him. He saw dishonor, ruin, irretrievable disaster staring him in the face…

Emma emerges from her grief no more satisfied with Charles than before; she takes another lover, and is even more indiscreet than the first time.

It little mattered that she felt herself humiliated by such degrading pleasures. Habit, or vice, demoralization, compelled her to cling to them; and every day saw her calling ‘for madder music and for stronger wine’, drying up pleasure at the source by asking too much of it.

Her contempt for Charles and her ruinous spending intensify, even as she grows tired of her new lover. When a creditor calls in her debt, which has been secured by her husband’s modest estate, she turns in desperation to her first lover, offering herself in prostitution to secure the money she needs. His refusal drives her to suicide; she poisons herself with arsenic, a torturous, anguished death.

A minute or two later she was bringing up blood. Her lips were drawn, her limbs contracted, her body covered all over with brown patches, and her pulse flickered away beneath the fingers like a taut wire, or like a harp-string, stretched to breaking point. Then she began to scream.

Only after Emma’s death, upon finding her love letters, does the loyal but fatuous Charles learn of his wife’s adulteries. He dies penniless and alone, leaving their daughter Berthe an orphan who is forced to work in a cotton mill.

This remarkable piece of writing is best known for its explicit treatment of adultery and for Flaubert’s complex rendering of Emma Bovary. His brilliant characterization of her is so vivid and original it even gave name to a new kind of psychological malady: bovarism, from the French bovaryisme, romantic fantasy run amok, until the dreamer becomes detached from reality and pursues her dreams with wanton self-destruction.

So, the question is, was this new malady of bovarism cause or effect? That is, did Emma Bovary destroy herself? Or did the peculiar oppression of being a doctor’s wife drive her crazy?

Tell us your thoughts about medicine, marriage, and Madame Bovary.

Welcome to The Literary Doctor’s inaugural “prescription,” a moving short story by T. C. Boyle called Sin Dolor –Without Pain.

I can think of no finer writer to begin a narrative medicine blog with than T. C. Boyle, a luminary of American literature. He is a graduate of the University of Iowa Writers’ Workshop and a Distinguished Professor of English at USC. In 2009 he was inducted into The American Academy of Arts and Letters, considered the highest formal recognition of artistic merit in the United States. He is the author of twenty-one—and counting—works of fiction. Sin Dolor comes from a collection of short stories entitled Wild Child and Other Stories, published in 2009. If you are unfamiliar with this author, do yourself a favor and read one of his thirteen novels.

What would it be like to never experience pain? Sin Dolor is T.C. Boyle’s discomfiting exploration of this very question.

Mercedes Fumes brings her four-year-old son Dámaso to the town doctor—who is the first person narrator of the story—for burns on his hands. But these aren’t just any burns; these are black, oozing eschars on his palms that came, his mother insists, from snatching hot coals off the brazier she uses to cook the indigestible tacos she and her husband Francisco hawk on the street. The doctor doubts her story and wonders about child abuse.

No one, not even the fakirs of India (and they are fakers), could hold onto a burning coal long enough to suffer third-degree burns.

She answers his skepticism with the unlikeliest of explanations. “He’s not normal, Doctor. He doesn’t feel pain the way others do.”

She urges him to prick her son with a needle. The doctor doesn’t hesitate. He swabs Dámaso’s arm and takes a syringe from the cabinet.

The boy never flinched. Never gave any indication that anything was happening at all…

“We call him Sin Dolor, Doctor…The Painless One.”

The next time the doctor sees the boy, now eight, he is with his father, Francisco. Dámaso comes in limping, favoring his right leg, which the doctor discovers is broken, a fractured tibia. That he walked in on. Without the slightest whimper. The doctor again suspects child abuse, but Francisco Fumes tells him Dámaso did it by jumping off the roof of a shed. The doctor realizes he has stumbled onto an unprecedented medical marvel.

I felt the boy’s gaze on me. He was absolutely calm, his eyes like the motionless pools of the rill that brought water down out of the mountains…For the first time it occurred to me that something extraordinary was going on here, a kind of medical miracle…

He is seized by ambition, an intense desire to claim credit for discovering what must be…a mutation in his genes, a positive mutation, superior, progressive…He befriends Dámaso in hopes of spectacular medical fame.

If that mutation could be isolated—if the genetic sequence could be discovered—then the boon for our poor suffering species would be immeasurable. Imagine a pain-free old age. Painless childbirth, surgery, dentistry…What an insuperable coup over the afflictions that twist and maim us and haunt us to the grave!

He encourages Dámaso to spend time at his clinic and to come to his home for dinner. At the same time, he contacts a geneticist he knows from medical school in Guadalajara, who implores him to send scrapings from the inside of Dámaso’s mouth for analysis. But Francisco Fumes becomes jealous of the attention lavished on his son—and of Dámaso’s response to the attention. He forbids all contact between Dámaso and the doctor, destroying the doctor’s ambitions and his son’s only chance to escape his circumstances…the stew of misinformation and illiteracy into which he’d been born…

Five or six years pass before the doctor sees Dámaso again…Though I heard the rumors—we all did—that his father was forcing him to travel from town to town like a freak in a sideshow, shamelessly exploiting his gift for the benefit of every gaping rube with a peso in his pocket.

Finally they meet again, Dámaso now thirteen or so, no longer in school and supporting his family by performing cheap carnival tricks that weren’t tricks, burning and slicing and maiming himself for the crowd without a hint of pain. After witnessing one such performance, the doctor observes that Dámaso has changed.

He seemed to walk more deliberately than he had in the past, as if the years had weighed on him in some unfathomable way…

Later, he learns the price Dámaso has paid for being a medical freak.

“I have no friends, Doctor, not a single one. Even my brothers and sisters look at me like I’m a stranger. And the boys all over the district, in the smallest towns, they try to imitate me.”

He tells the doctor that he does what his family asks of him—exploiting his painlessness, profiting from his miracle in the most vulgar of ways—out of a sense of duty to them.

“But what they’ll never understand, what you don’t understand, is that I do hurt, I do feel it, I do.” And then he taps himself over his heart. “Here,” he says. “Here’s where I hurt.”

He dies a week later, after leaping off a three-story building to satisfy the little sycophants who idolize him. “Jump!” they shout. “Sin Dolor! Sin Dolor!” He dies without a twinge of pain.

The story concludes with the doctor treating a small girl who has stepped on a sea urchin.

As delicately as I could, I held her miniature heel in my hand, took hold of the slick black fragment with the grip of my forceps and pulled it cleanly from the flesh, and I have to tell you, that little girl shrieked till the very glass in the windows rattled, shrieked as if there were no other pain in the world.

The last twenty years have seen the rise of an entirely new medical field: the specialty of Pain Medicine, or Algiatry, a discipline devoted to the prevention of pain. At first blush a noble endeavor, relief from the myriad cancers, fractures, nerve impingements, torsions, and infarctions we human beings suffer long overdue. But having practiced medicine during this time, I have witnessed firsthand a troubling and proportional surge in prescription drug addiction, patient after patient hooked on Vicodin, Norco, Percocet, Xanax, Oxycontin and countless other “mother’s little helpers,” as the eponymous song by the Rolling Stones goes. Perhaps, as T.C. Boyle so poignantly suggests, a certain amount of pain—I know, not childbirth and Oh God, please not kidney stones—is necessary to the human condition. Perhaps the complete elimination of pain is not without consequences.

Tell us what you think about the quest to eliminate pain, both from the perspective of a doctor seeking to relieve it, and from the perspective of a patient—of a human being—who suffers from it.