“Oh, Daddy, can’t you give her something to make her stop screaming?” asked Nick.
“No. I haven’t any anæsthetic,” his father said. “But her screams are not important. I don’t hear them because they are not important.” 1
In Ernest Hemingway’s “Indian Camp,” Nick’s father has just explained to Nick that the woman is screaming in pain because “all her muscles are trying to get the baby born” (p. 92). He cannot, however, focus his attention on her pain because, in order to help her, he must concentrate on delivering the baby. “Hearing” the screams would not help and might actually compromise the task at hand. This quotation illustrates in a dramatic way the tension between emotion and reason in medical practice. Nick’s father appears to be a kindly and courageous physician—he has, after all, just left his fishing campsite, rowed across the lake at night, and walked to the Indian camp to perform an emergency Caesarian section with only a “jack-knife and . . . nine-foot, tapered gut leaders” (p. 94)—yet he believes that emotional vulnerability in this situation will impair his professional performance. He decides to remain detached from the woman’s screams. He delivers the baby successfully, but the woman’s husband, lying wounded from a cut foot and unable to leave his bunk, kills himself. By shutting himself off from the woman’s pain, the doctor fails to recognize its power and danger.
Such detachment has long been considered a necessary condition for medical practice. The appropriate stance of physicians vis-à-vis their patients has variously been termed “clinical distance,” “detached concern,” and “compassionate detachment.” 2 Sir William Osler, for example, wrote that physicians should adopt a “judicious measure of obtuseness” by which they become relatively “insensible” to the slings [End Page 222] and arrows of involvement with patients. 3 Medical educators have traditionally given two reasons why patient care demands substantial emotional and psychological distance between physician and patient. First, detachment protects the physician from being personally overwhelmed and paralyzed by a patient’s pain and suffering. Unlike the boy Nick in Hemingway’s story, the physician cannot turn away from the task at hand. The medical student who faints at the sight of blood becomes an accomplished surgeon, at least in part by learning to disconnect from the emotional side of the experience. Perhaps in this context the word barrier offers a better metaphor. Although physicians are physically close to their patients, they (metaphorically) wear protective clothing—gowns and masks—to shield themselves from emotion. This process of building barriers begins in gross anatomy laboratory and develops over many years of socialization in the culture of medicine.
The second reason for detachment is to protect the patient. In this view, medical decisions ought to be objective, uninfluenced by feelings and biases. Herman L. Blumgart, for example, writes that detachment is necessary to prevent loss of objectivity and perspective. 4 An emotional response may bias clinical judgment, compromising patient care. Hence the tradition that physicians ought not treat their loved ones. Emotional vulnerability, strong attachment, or repulsion—all greatly impair doctoring. The ordinary emotional responses of day-to-day practice interfere less, but are still undesirable insofar as they compromise the ideal of objectivity.
Despite the perceived need for detachment, physicians almost universally agree that they should nevertheless connect in some way with their patients. Physicians think they ought to be compassionate, develop good rapport, cultivate bedside manner, and demonstrate the art of medicine. 5 An abstract motivation for “doing good” is not sufficient: doctors should be concerned about their patients as individuals. In order to connect with patients, doctors must somehow transcend the barrier and bridge the distance, while still maintaining the ability to detach when necessary.
I have long been interested in the tension between connection and detachment, subjectivity and objectivity, in medical practice. Early in my own experience, the traditional formulation of detached concern seemed plausible, a kind of attenuated relationship in which some mild or abstract feeling was permitted but rigorously monitored. I seized upon the concept of empathy as a bridge...