The Renewal of Generosity

The Renewal of Generosity is a normative and ethical approach to how doctors should treat patients. It is not a social scientific study. There is no data on how many people report experiences of various types, of physicians’ attitudes, of the institutional history of doctor-patient relationships, or of problems in diagnosis or treatment stemming from flawed doctor-patient interchange. The book appears in a world waiting for advice on how doctors could treat patients better; it offers a detailed account of the good doctor-patient relationship grounded in the book’s philosophical precepts, and presents a specific model of doctor-patient interaction as the right way to do things. These admonitions are developed from philosophical approaches, presented as stories depicting examples of the right way and wrong ways for doctors to deal with patients. The roots of the admonitions are in the Meditations of Marcus Aurelius, a document of the Stoic framework for the right way to live. But this framework is not a sufficient basis for Arthur Frank’s ideas on the right way for doctors to treat patients. Additional elements are extractions from works by contemporary writers, most significantly Mikhail Bakhtin, Emmanuel Levinas, and Michael Berube. Frank’s ideas are based on an idea of dialogue. Without using the intricate phraseology developed in the book (and thereby conceding a fundamental inadequacy in faithfully summarizing the book’s points), the basic point is to suspend the authority medical professionals bring to their meetings with patients and to allow the patient to participate as an equal and whole person in the diagnosis and determination of treatment. The patient’s cultural models and personal values should be as much a part of the encounter as the doctor’s scientific medical knowledge. The quality of dialogue that takes place as an attribute of the structure of the relationship, as well as of the interactive give and take in each encounter, is the heart of the book. The idea of generosity is that doctors are not generous if they are unwilling or unable to participate in dialogue with patients as equals, a form of relationship that is markedly different from the common models of doctor-patient relationships. Frank establishes a basic image of what is wrong in the modern pattern of treatment, a model of good (right) relationships, and a series of applications of that model to the situations of doctors, nurses, patient roles, and considerations of palliative care, that is, treatment of patients with intractable pain. The author advocates use of his model of dialogue and acceptance of the patient’s understandings of illness and treatment in a case in which the patient’s cultural commitments to the spiritual importance of body integrity will not accept lifesaving surgery. The patient is a child whose relatives hold to a traditional ethnic belief system. The doctor can do the surgery by seeking, and almost certainly getting, a court order to do the surgery. But the case study fails to deliver on the key issue of whether the doctor, according to the author’s model, is to let the patient die. This patient’s relatives, at the last moment, accept the medical definition of her illness and agree to the surgery. What should the doctor have done had the relatives stood firm? The final chapter applies Frank’s expansive model of care to the realities of modern institutional medicine. This model for treatment requires near-infinite time, patience, understanding, and fortitude. The author takes a realistic look at modern medical care and discusses what to do when we cannot fully go his way with such large caseloads. (The answer: Use more conventional models of doctor-patient relationships, but understand you are doing so and feel guilty about it.) The book is a worthy effort. There is much to be learned from it about this form of dialogue and about how it applies to all professional-client relationships, including that between social workers and their clients. But, is this book a unique source of such insight? What surprised me were the specifics of the approach in this book. Do we need to consult a source on Marcus Aurelius to