Aequanimitas
Authors: Daniel Sokol
Journal: BMJ (2007)

I have long held the dangerous belief that William Osler's essays, judiciously used, could render teachers of medical ethics redundant. Virtually all the medical student needs for ethical behaviour is contained within them.

One of Osler's most famous essays, Aequanimitas, was first delivered to newly minted doctors in 1889 as a valedictory address at the Pennsylvania School of Medicine. Osler urges his young audience to “consider but two of the score of elements which may make or mar your lives.” The first is imperturbability, which refers to “calmness amid storm, clearness of judgment in moments of grave peril.” This poker faced composure, he claims, is essential to instil confidence in impressionable or frightened patients. Imperturbability is in part acquired through experience and a thorough knowledge of medicine. With these in hand, “no eventuality can disturb the mental equilibrium of the physician.”

The second, related element—equanimity—has been the subject of some debate among Osler scholars. While some have interpreted it as apathy—the absence of emotions—others have read it as “metriopatheia,” measured or moderated emotions. To acquire the virtue of equanimity, Osler recommends a tolerant, somewhat non-judgmental attitude towards our fellow humans. “The more closely we study their little foibles of one sort and another in the inner life which we see,” he remarks, “the more surely is the conviction borne in upon us of the likeness of their weaknesses to our own.” Osler continues: “The similarity would be intolerable, if a happy egotism did not often render us forgetful of it.” Osler also advises us not to seek certainty when it cannot be found but to be satisfied with fragments of the truth and to be ready for the inevitable struggles and disappointments ahead. (Did he foretell MTAS?) When they arrive, “stand up bravely” and “wrestle on” with due persistence; and, should defeat come, cultivating a cheerful equanimity will make the pain easier to bear. When matters of principle or justice are in play, then “cling to your ideal,” Osler urges, even in the face of evident failure.

The final part of the essay is of lesser interest to the modern reader, dealing with eminent alumni of his university and Osler's sadness at leaving.

Osler's essay is a classic for several reasons. Firstly, he tackles head-on a timeless question: what makes a good doctor? The ideals he proposes do not fade with passing years. Like Flaubert before him and Richard Selzer after, his writing is meticulously crafted—each phrase, word, sound, and intonation deftly chosen, at times blurring the line between prose and poetry. Rich in cultural and literary allusions, from Plato to Matthew Arnold, the essay can be enjoyed by the teenage reader and erudite professor alike. What is rare is that Osler's scholarship is not tainted by pretentiousness: “You remember in the Egyptian story, how Typhon with his conspirators dealt with good Osiris”—well, no, I remember no such thing, but this ignorance engenders curiosity rather than shame. Although the essay was written almost 120 years ago, there is a connection between author and reader. Even when discussing sombre matters Osler comes across as a benevolent presence, a calming hand on our shoulder: “It is sad to think, that for some of you, there is in store disappointment, perhaps failure.”

Whatever your position on the value of imperturbability and equanimity in 21st century medicine, Osler's Aequanimitas, with its subtle wit, masterful writing, richness of allusion, unpretentious wisdom, and warmth and charm, is not only a classic of medicine but a classic of the essay genre.