Introduction

While the oldest programs in medical humanities within US medical schools date back to the 1960s and 1970s, defining “medical humanities” remains a challenge. The absence of a widely-agreed-upon definition may be of little practical importance if the medical humanities is the sort of thing that “we know when we see.” A good deal of the pedagogical literature on medical humanities, however, is based on the belief that the field is currently marginalized within the academic health professions, and ideally deserves a greater role. That belief hints that a clear definition is essential to further progress.

During most of my own career in medical humanities, I held an unreflective “list of disciplines” conception of the field. I found it sufficient to view medical humanities as some combination of its relevant disciplines—ethics and philosophy, religious studies, history, literature, and so forth. My gaze was expanded upon joining the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston. The Institute was established in 1973 and its graduate program, offering interdisciplinary MA and Ph.D. degrees in medical humanities, was begun in 1988. I then became aware of two other conceptions, the “program of moral development” and the “supportive friend.” I suggest that all three conceptions must be taken into account if we are to evolve an adequate definition. I will also suggest that the best way to address the three conceptions is to put each in the context of a historical narrative.

Each of the three conceptions could just as well be a conception of the humanities as well as the medical humanities. I will, however, restrict my discussion to the latter as my main interest is teaching and research within medicine and the other health professions.

Other efforts at definition

One might expect that a good place to look for a definition of “medical humanities” is in the first number of a journal of that title. However, when Medical Humanities was spun off from the Journal of Medical Ethics, no formal definition was offered. Greaves and Evans instead offered two “formulations,” an “additive view” and an “integrated view.” The former entailed sprinkling a bit of humanities over the top of an essentially unchanged biomedical enterprise, while the latter contemplated a more fundamental and critical role.Footnote 1

Writing in Academic Medicine in 2009, Shapiro et al. posited an “ongoing lack of clarity on what exactly the medical humanities comprise, and how they should be integrated into medical education.” They proceeded to offer a narrowly “pedagogical” definition: the medical humanities use the methods and concepts of one or more of the humanities disciplines, teach students critical reflection aimed toward a more humane practice, and are by nature interdisciplinary and collaborative.Footnote 2

Another approach was suggested in 2008, when Evans identified three “manifestations” of medical humanities: as an academic field of intellectual inquiry, as a dimension of medical education, and as “…a source of moral and aesthetic influence upon the daily praxis of organized clinical health care”.Footnote 3

The American internist and poet Raphael Campo was less deferential when he titled an essay, “‘The Medical Humanities,’ for Lack of a Better Term.” Campo concluded, “Despite some public exposure…no conception of ‘the medical humanities’ compels, caught somewhere between manifesto, mushiness, and marketing lingo”.Footnote 4

In short, there appears to be sufficient evidence for definitional ambiguity, to justify further attempts at clarification.

Three conceptions

I will present my three proposed conceptions of medical humanities—as a list of disciplines, as a program of moral development, and as a supportive friend—indirectly through three narratives. The first conception, I would claim, is the implicit conception operating in most discussions of academic programs in medical humanities, at least in the US. I was therefore intrigued to find the second conception entrenched at the University of Texas Medical Branch in the description of the goals of its graduate studies program.Footnote 5

First narrative: the history of the modern liberal arts college

Once upon a time the Anglo-American culture had an image of what it meant to be a liberally educated person. Such a person had read certain books, had heard certain pieces of music, and had seen representations of certain works of art. The person was able to discuss intelligently and thoughtfully all of these works, that represented the great moments in the history of Western culture. Indeed it sometimes seemed as if the very idea of “Western culture” was as a sort of grand conversation. The conversation had begun long before the individual was born, and would continue long after the individual died. One aspired, during one’s lifetime, to be a meaningful participant in the conversation.Footnote 6 The greatest of each generation actually changed the conversation, introducing original and novel ideas; most were content merely to participate and to keep the conversation going.

The role of a college education became clear against the backdrop of this idea of culture-as-conversation. The goal of a liberal arts education was to prepare one for full, active participation in the conversation. The education was designed, first, to expose one to all the correct books and ideas, and second, to train one in the intelligent way to discuss them.

The view of the grand conversation began to fray as life and the university both became more and more specialized. Increasingly one found oneself participating not in a grand conversation across the entire culture, but in narrow conversations intelligible only to specialists within certain disciplines. Attending to the narrow conversations seemed the best route both to technological progress and to individual career advancement. As time went on, other problems with the old idea of the culture-as-conversation also arose. People became much more aware whose ideas, whose books, art, and music, had been excluded from the canon that defined the “liberal” education.

As narrow disciplinary conversation replaced broad cultural conversation, the role of the liberal arts in a college education gradually lost its meaning and significance. Things had arrived at such a pass by the 1990s that the presidents of 15 of the most prominent liberal arts colleges in the northeastern US had to admit that they did not know the meaning of the term “liberal arts education.” They were forced to hire a public relations firm to remedy their deficiency. Not surprisingly, given that the presidents of the colleges could not define the idea, the public relations firm couldn’t either.Footnote 7

Second narrative: Petrarch and the “Studia Humanitatis”

Once upon a time there was a poet now commonly known as Petrarch (Francesco Petrarca, 1304–1374). Petrarch surveyed the world around him in fourteenth-century Italy and observed a society in considerable ferment. The reign of the landed aristocracy with their agrarian way of life was quickly being supplanted by a mercantile, urban society. The ships that landed at the wharves of the Italian cities brought more than goods from foreign ports; they brought accounts of strange countries and peoples previously unknown to Europeans.

Petrarch took a special interest in educating the youth, and he assumed that the university ought to prepare students with the wisdom needed to live successfully and to provide civic leadership in changing and challenging times. But when he surveyed the university curriculum of his day, a product of late medieval times, he saw technical cleverness but no wisdom. The subjects emphasized—mathematics, law, logic, and metaphysics—seemed designed to show off technical reasoning skills rather than to address the demands of a changing society.

Petrarch’s own wide reading had, he thought, made clear where the youth could find the role models they needed for wisdom and civic virtue. The heroes of ancient Greece and Rome, he believed, had led those sorts of inspiring lives. Moreover, as a poet, he believed that classical Latin was the purest and most elegant language with which to express profound moral truths and to tell the stories of heroes. Compared to the debased medieval Latin then used in the universities, classical Latin seemed a world apart.

Rather than the disciplines stressed in the traditional medieval curriculum, Petrarch recommended that students study poetry and literature, languages, history, ethics, and rhetoric. Rhetoric would assure that the curriculum had a strong interdisciplinary tilt. Classical rhetoric had two goals—first, to apply reason to determine the right course of action; and second, to then arouse the passions of the listeners to motivate them strongly to perform the right action. Rhetoricians would employ any discipline that could help toward either goal—law, logic, moral philosophy, knowledge of empirical facts—without being tied down by the methods of any single discipline.

Petrarch had personal as well as pedagogical reasons for stressing the heroes of the ancient world and the classical Latin that some spoke and wrote. Living as he did at the time of the Black Death and of major social unrest, Petrarch had suffered many tragedies and losses in his own life. Of all authors, he found that the writings of Cicero, the Roman orator and philosopher, seemed to speak to him most directly. Cicero wrote of his own losses and sufferings and of how the stoic philosophy seemed to provide succor and relief in grief. Petrarch took very much to heart both Cicero’s stoicism and the latter’s personal example of steadfastness in the face of grief and suffering.

In the near term, Petrarch and his followers were amazingly successful. Across Europe the university curriculum was slowly transformed in keeping with Petrarch’s “humanism”—or the studia humanitatis, a term he adopted from one of Cicero’s orations. In many ways this new curriculum saw the end of medieval times and the beginning of the Renaissance in Europe.

Sadly, as more decades passed, the new Renaissance humanism came to resemble more and more the curriculum it had sought to displace. From seeing classical Latin as the ideal language to convey poetic messages of wisdom and virtue, scholars turned to seeing classical Latin as the goal of study in itself, and engaged in endless debates about grammar and declension. Having turned outward toward engagement with society and the social issues of the day, the university curriculum gradually turned inward as technical cleverness again took over and as academics addressed each other in terms quite apart from the interests of anyone but their fellow scholars.Footnote 8

Third narrative: the life of sir William Osler

Once upon a time William Osler (1849–1919) was born in the Canadian backwoods and gradually ascended to medical school professorships in Canada, the US, and England. He was a key designer of the medical curriculum at Johns Hopkins that ultimately became the model for all US twentieth century medical teaching. He became the best known and most widely respected English-speaking physician of his day. He was the last person to attempt (by all accounts, successfully) to write a single-authored textbook of internal medicine.

Osler as respected not only for his medical and scientific knowledge but also for his wide knowledge of the classic works of our culture. He liberally sprinkled quotations from the great books of the past throughout his essays and orations.

Osler spent each day in a busy round of activities including caring for patients, autopsy investigations, teaching, and writing. Evenings were frequently spent socializing with his colleagues and students. The time set aside for reading classic literature approached with night. Osler devoted his bedtime reading to this pursuit and recommended strongly that his students follow suit, often loaning them works from his own extensive library.

Insofar as we can read Osler’s inner thoughts, he appears to have been similar to Cicero and Petrarch in finding a stoic philosophy most congenial as a way to deal with life’s challenges and vicissitudes. Both the losses he personally suffered, and the anguish he faced daily in the lives and deaths of his patients, could be rendered more tolerable by the wisdom of classical literature.Footnote 9

Today, Osler’s memory is still celebrated within American medical institutions, as demonstrated by the activities of the American Osler Society and its branches.Footnote 10

The three narratives and the three conceptions

The first narrative relates in two ways to the conception of medical humanities as a list of disciplines. First, it shows why the bureaucratic demands of an American university setting would tend toward this conception. Imagine that you were dean of a medical school, that the medical school was located on a university campus that contained a liberal arts college, and that you wanted to build a medical humanities program from scratch. The most natural way to go about it would be to visit in turn each of the departments in the liberal arts college to ask what it might contribute, which of its faculty had special interests in medicine and health issues, and so on. Second, it also shows why the “list of disciplines” approach is bound eventually to be unsatisfactory. Ultimately it can give no account of the shared mission of the medical humanities, of why these disciplines and not some others were chosen.

The second narrative is, of course, a prequel to the first, as movie critics might put it. The second narrative leaves off the story of the role of the humanities in education around 1550–1600, and the first narrative picks up the story again around 1850. The fact that the second narrative traces the concept of “humanities” back to its historical roots offers one possible justification for adopting its related conception, medical humanities as a program of moral development. A second justification is found in tracing analogies between the challenges facing the medical educator today, and those that Petrarch faced in his fourteenth-century world. These analogies include the need to teach some presumably unchanging principles of wisdom in the face of rapid expansion of the empirical knowledge base, incorporating training in the moral virtues within the curriculum, and the goal of making education responsive to the challenges of the real world.

Today William Osler might seem a dated figure. In some of his essays, quotations from and allusions to literary classics are liberally sprinkled as decoration, in much the same way that gingerbread adorns the exterior of Victorian houses. This would seem to be an example of the unsatisfactory “additive” formulation of the medical humanities. Yet, as we have noted, the Oslerian model of the liberally educated physician appears to have had remarkable staying power.

To better understand the attractions of a stoic philosophy for such diverse figures as Cicero, Petrarch, and Osler, we might return to the original formulation of studia humanitatis in Cicero’s oration Pro Archia (In Defense of the Poet Archias, 62 BCE). This oration was a pleading in court in defense of the Greek poet who had been one of Cicero’s own teachers. A relevant passage reads:

And these studies [studia humanitatis] nourish youth, delight old age, adorn prosperity, offer refuge and a solace in adversity; they delight at home, nor do they embarrass one abroad; they accompany us overnight, as we travel, and into the countryside.

Here, it seems, the orator is painting a portrait of the humanities as a boon companion or supportive friend. The books that have spoken so meaningfully to one throughout one’s formative years remain there to offer wisdom, comfort, and solace, even when one may have been abandoned by one’s human companions. The reason why Osler found these works his ideal bedtime reading (“they accompany us overnight”) becomes clearer.

Three complementary conceptions

The three conceptions of the medical humanities are each individually incomplete and require the others to fill critical gaps.

As noted within the first narrative, it is hard to avoid some recourse to the “list of disciplines” conception in describing the scope of the medical humanities. Yet the narrative itself also shows why the conception is ultimately uninformative. It cannot explain where these disciplines came from or what they have in common.

The second narrative completes the first by taking the story back to the historical origins of the humanities in the Renaissance. The conception of the medical humanities as a program of moral development reminds us that the ultimate goal is to make a difference in the world of practice, and to do so guided by wisdom and virtue. Yet the second narrative also sounds its own note of warning. It reminds us how strong is the tendency of academics (in their commendable pursuit of rigor and method) to divert a field of study away from its original goals of engagement in the wider world, and to reduce it to the refinement of academic methods for their own sake.

If the second narrative corrects the first by reminding us of the humanities’ historical origins, why do we then need the third narrative as well? Perhaps a part of the reason that the Oslerian ideal has had such remarkable staying power in today’s world is the way that it recaptures the pure joy and love we feel for our favorite books, how opening one of them after a period of absence is like revisiting an old friend. The third narrative, in turn, fails on its own to explain the critical and reflective function we believe that the medical humanities can serve. As a rule, we seek comfort and solace in our bedtime reading, not acute intellectual challenge. Yet intellectual challenge is essential if the humanities are truly to contribute to health professions education and practice.

Conclusion: does it matter?

I have proposed three complementary conceptions of the medical humanities, each tied to a narrative. I believe that the narratives matter; they are not mere seductions to get a distracted reader to pay attention. The narratives remind us that the conceptions of the humanities are linked to ways of living our lives and of addressing problems in the real world.

In a similar vein, I propose an answer to the question with which I began. Defining “medical humanities” more clearly and precisely may be difficult and multifaceted, but it does matter that we continue the exercise. As part of the pedagogical “manifestation” of the humanities, we seek to educate future health professionals who adopt a more critical and reflective stance toward their work and toward the knowledge that informs it. We must, ourselves, model that critical and reflective attitude toward our own field if we wish this educational endeavor to be successful.