The Limits of Narrative

A The Limits of Narrative David H. Smith I was pleased when Professor Banks asked me to comment on the essays by David Barnard and Eric Rabkin, for the subject matter is — perhaps I should say subject matters are —of great importance. Professor Rabkin calls our attention to conventions of writing, and I must begin with a doubled conventional demurrer: I am neither a health professional nor a literary critic; I have not even been a patient in recent years. These limitations will not, however, keep me from offering an interpretive commentary on die essays at hand. I write as a moralist. My strategy is simple: I shall begin by singling out a couple of the moral issues raised by the core situation and then make my way to some remarks on die derivative issues of the appropriate roles for participantobservers , literary critics, and moralists. I should say at the outset that I do not mean to imply diat these "derivative" issues are unimportant. By die core situation I mean the diagnosis of and care for Mr. Baker's amyotrophic lateral sclerosis. The disease was frightening to Baker and his doctors; it is also frightening to Barnard, Rabkin, and me. It is folly to diink diat fear can be expunged and perhaps inevitable diat when unrecognized it will be diverted into other, sometimes less attractive, forms of passion. But having raised diis issue I move on, leaving the exorcism of my ghosts to others. The other problem that die core situation must raise is: Exactly what should be said to Mr. and Mrs. Baker and by whom? The issue is not simply : Should he be told he has ALS? To diat all parties concerned agree. The harder issues are: At what stage in developing diagnostic certainty should Mr. Baker be informed? Into what degree of detail should a doctor go in presenting a prognosis? To what extent does die presentation of differing possible scenarios for the end of life empower a patient? Or terrify him? Supposing that I am committed to telling the truth, major questions remain of timing, formulation, and range or scope of my utterance. Let us consider a parallel case. Suppose I have a colleague who is no longer effective because of substance abuse, diversion of energy into nonacademic pursuits, or some other reason. It becomes clear that this man should not write, or should not teach, or should even retire from Literature and Medicine 5 (1986) 54-57 C 1986 by The Johns Hopkins University Press David H. Smith 55 faculty status. But he does not. We can all agree that someone (his chairperson , an old friend) should tell him. But it is hard to say when he should be told, exactly how the message is best conveyed, and what belongs in the bill of particulars. In fact we academics avoid these discussions, usually on the grounds - clearly fallacious to an outside observer — that die sort of academic death I have just tried to describe does not exist "at our place" - or at least not "in this case." A great strength of the Bamard case history is diat it makes the complexities of these issues about truth telling come alive. I do not read the record as a story of either deceit or moral virtuosity. ALS was mentioned to Mr. Baker as soon as it emerged as the likely diagnosis; Dr. Walsh discussed it with him in January 1979, as soon as die diagnosis was clear. She agonized over how to discuss possible use of a respirator with him, and it may be, although it is unclear to me, diat she delayed diis discussion longer than she should have. To describe this behavior as "hiding the truth" or a conspiracy to maintain Baker's ignorance, as Professor Rabkin does, seems to me to be straining for a morally serious posture. Beneath the rhetoric is a very difficult issue: What speech about ultimate matters do we owe each other? Rabkin here inclines to the view diat selves are tough and should take charge of tiiemselves, and that modulations in speech that do anything other than maximize the flow of content are dierefore a moral insult. As soon...