KATHRYN HUNTER

W H A T W E D O : T H E H U M A N I T I E S A N D

T H E I N T E R P R E T A T I O N O F M E D I C I N E

"What is it, exactly, that you do over there?" All of us in the medical humanities have grown accustomed to explaining ourselves. Whether PhDs or MDs, we are doing something out of the academically or medically ordinary, and whether we regard the question with an inward groan or welcome it as an opportunity to gain support, there it is again: "What do you actually do at the medical school?"

My nightmare as a professor of humanities in medicine is that when my chairman, in one of the periodic reviews that we as academics undergo, makes the routine inquiries into my standing in my profession, the reply will come back: What profession? Are the medical humanities - - or their constituent parts -- a discipline? In what ways are the faculty in the medical humanities important, even essential to medicine? These are vital questions not only for our own sense of worth but for our institutional presence, for we are judged by senior colleagues who have a very strong sense of their own disciplines and firm criteria for the usefulness and value of the young and unpromoted. How are we to describe what we do?

First of all, we are teachers. Some of us are also scholars; others take care of patients as well. We teach the the humanities: philosophy, literature, history, religious studies, jurisprudence, and values-oriented social sciences such as social anthropology, political philosophy, historical sociology. We teach in health care institutions: we teach medical students, nursing students, residents, fellows, and our colleagues on the faculty. A few of us have begun teaching those in our own disciplines who would like someday to do what we do.

There is still a great deal to be done. We cite often the number of medical schools in the United States which have humanities programs, the ones reported in Tom McElhinney's 1981 study, Human Values Programs for Health Care Professionals, 1 and we know that there are new ones. But

what are our criteria for programs? Are all those programs genuine ones? The report of the DeCamp Conference, published in the New England Journal of Medicine, 2 describes the standard for a minimum competence in medical ethics for medical students, a standard developed by ten of our most experienced philosophers. How many schools have achieved this?

Janet Bickel at the Association of American Medical Colleges has undertaken a study funded by the Picker Foundation which will soon tell us. Her project in and of itself will help. I believe that there is a kind of

Theoretical Medicine $ (1987) 367--378. © 1987 by D. Reidel Publishing Company.

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moral "Hawthorne effect": studying the phenomena leads to alteration. The recent survey by the American Medical Students Association will also nudge the matter into the consciousnesses of deans. In addition, the Society's consultation with the Liaison Committee on Medical Education, a project led by Jim Knight, has added questions about human values education to the new Guidelines for Accreditation. We are influential in residency education: Albert Jonsen has worked with the American Board of Internal Medicine, Howard Brody with the Association of Teachers of Family Medicine, Alan Cross with the American Academy of Pediatrics, and Loretta Kopelman with the American College of Surgeons to begin to include ethics in the training programs and on the specialty certifying examinations. Perhaps even the Association of American Medical College's report on the General Professional Education of the Physician (GPEP), Physicians for the Twenty-First Century, 3 ultimately will encourage the acceptance of the medical humanities. But its failure to mention the contribution of humanities in medicine is an important omission. A concern for ethical issues and for addressing them during medical school is to be found there, but, other than the invocation of good role models, there is no suggestion for how this is to be accomplished. The subsequent commentary on the GPEP report by the Executive Council of the AAMC 4 reaffirms that body's commitment to scientific medical education with even less in the way of curricular or ideological balance.

In preparing for the GPEP report, the AAMC made no special effort to include members of the Society for Health and Human Values in the working groups that reported to the panel: Jo Ivey Boufford participated as president of the Health and Hospitals Corporation of the City of New York rather than as a former president of the Society; my own participa- tion was the accident of sharing a discipline (a mainstream one) with the university administrator who chaired the group on values and attitudes. No member of the Kennedy Institute, the Institute for the Medical Humanities, or the Hastings Center participated -- although, when they learned of the committee's work, someone at all three institutions con- tributed letters of advice. The recommendation on humanities in medicine - - that every school have a human values program with at least one full time faculty member -- with much else that came from the Working Group on Personal Qualities, Values and Attitudes 5 _ did not survive to the final report.

Nevertheless, it is still possible that the GPEP study will bring about change. Johns Hopkins, whose president, Steven Muller, chaired the study, has joined the University of Rochester in not requiring the Medical College Admissions Test of its applicants. Work on curricular revisions is

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in evidence in a number of institutions. Harvard's "new pathway" funded

by the Kaiser Family Foundation, the Oliver Wendell Hol l ies Society, offers independent and enriched study to 12% of its students each year: Rochester's "new curriculum" is a wholesale revision of the first two years that coordinates each week's greatly compressed classwork with a Friday afternoon presentation of a patient in all his or her social and psycho- logical complexity. Both these changes were underway before the GPEP study began, but the study itself, even while it was being conducted, aided both of them. Both plans include attention to the medical humanities in somewhat greater proport ion than the curricula they replace or to which they provide an alternative.

These new programs suggest that if the GPEP report does succeed in encouraging curricular change, there will be benefits for us as well as for medical students. As a profession we have a strong interest in its success. A reduction in class hours means time for electives and, potentially, more attention to the nature of medicine. But the meat axe David Rogers called for in The Pharos after spending a term as a visiting professor - - advising deans to "cut the curriculum, with a meat axe if necessary ''6 - - cuts two ways. Less memorizing, more actual thinking by medical students will shift our role from the current one of intellectual resuscitation to an examina- tion of such matters as scientific thought, epistemology, the nature of the clinical encounter, the self-awareness of the healer, the place of medicine in society. Are we ready for such a shift? Our readiness, I believe, is bound up with our status as a profession. Both depend in large part on the sort of research and the sort of thinking we are doing.

We teach well now. Good teaching is almost uniformly the rule in the medical humanities, primarily because poor teaching would not long be tolerated in what is still not universally regarded as an essential field. But we need lively, significant research as well. Those of us who have no responsibility for the care of patients, after all, are judged as scholars. What is the nature of our research?

Those members of the Association for Faculty in the Medical Human- ities who have MDs and are teaching philosophy, history, religion, or literature differ from MDs whose intellectual interests are in social science, clinical epidemiology, decision analysis, science itself. (Not, of course, that these interests are mutally exclusive.) Do those of us who have degrees in the humanities differ from our disciplinary colleagues? More particularly, do we differ in our research from our teachers in the main- stream, parent disciplinary departments? How are those differences to be regarded? To what extent should our work differ and in what respects? The answer is mixed -- much of the teaching we do is very like main-

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stream disciplinary teaching to undergraduate non-majors. No matter how valuable this may be, it may not be sufficient either for some golden age that will dawn with GPEP reforms or for our independent status as a profession.

I believe we can go on teaching and writing about Job and The Death of Ivan Illych, about whether Richard Cabot did or did not invent the clinical-pathological case conference, and about the ethics of confiden- tiality and informed consent. I certainly intend to do my share. The plenary session of the Association of Faculty in the Medical Humanities on the question of core texts in the medical humanities - - whether there are works that all well educated medical students should read -- suggests that there is a certain preliminary solidity to our profession. Yet we should not shut our minds to new ways of bringing our disciplines to medicine or to discovering what it is from our store of knowledge that we may offer to the understanding of medicine as a human enterprise.

What is called for is a reciprocal relationship between medicine and the humanities. In the particular debate over the authenticity of literature and medicine as a discipline, George S. Rousseau has specified "interactivity" as a criterion for independent status. 7 Medicine has always supplied literature with many of its stories; the question is, what has literature contributed to medicine? Rousseau's argues that until literature has made that contribution, there can be no discipline called literature and medicine. Many of us can agree with him thus far and would be willing to generalize this requirement to the medical humanities as a whole, but still would not be willing to agree with him - - or with William Bennett 8 - - that the "applied" humanities are to be avoided. 9

One could argue that our contribution to medicine lies in our teaching. It is a major contribution to a discipline that labors under a severe pedagogical handicap: few of its courses and even fewer of its books are devoted to what doctors do. To remedy this defect, we teach in ways that differ from the teaching that college professors in our parent disciplines do. We seek resources from those disciplines to bring to medical students. In my own field, these resources are poems and plays and short stories about doctors and illness and aging and death, readings that offer students (and faculty) a chance to consider the physician's attendance in the moral crises, great and small, of human life. In doing this we are most like undergraduate teachers of non-majors, and we do not stray too far from our disciplinary folds. This, nevertheless, is the beginning of interactivity.

Is our research even so far advanced? Certainly many of us during much of the working day are studying and writing about religious studies or history or jurisprudence in much the same way our mainstream

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colleagues are, still using mainstream, or what might from a broader viewpoint might be called insular, methods of doing intellectual work. Some of us, however, are not. We have succumbed to the impurity of interdisciplinafity -- and on doing this and doing it well, I believe, the success of humanities in medicine depends. The answer to my nightmare question -- What profession? -- lies in immersing ourselves (but not our disciplines) in clinical reality.

The philosophers were the first to do this, and they altered the very questions and methodology of ethical inquiry thereby. They do not do philosophy like their colleagues anymore. Increasingly, their colleagues are coming to respect the difference. Stephen Toulmin has made a strong argument for the wider benefits of this in an essay called "How Medicine Saved the Life of Philosophy. ''1° Medical philosophers' immersion has begun to alter the kinds of question they consider. No longer are they exclusively occupied with personal ethics or with the large "neon" ques- tions. We can see the effect of their clinical immersion in the recent pragmatic retreat from the politically relevant insistence of the 1970s on patient autonomy and in the attention now being given -- under the salutary pressure of the clinically experienced -- to the ethical issues of clinical assumptions and of everyday practice.

Philosophers have observed and recorded and responded to the ethical problems so well that it is possible now for younger philosophers just coming along to take the existence and importance of these "problems" and the methods of addressing them almost for granted and go looking for them -- "working within the paradigm." What comes next may be a flesh look not at ethical issues but at medicine itself, using an education in philosophy as a way of seeing. Richard Baron's phenomenotogy of medicine in the Annals of Internal Medicine is an example of this: H the interest in epistemology is another. The growing number of philosophers who are interested in literature and medicine is a third.

We see always through the lens of the discipline in which we have been educated, and this is never an unbiased vision. Far from being a dis- advantage, that is good thing. Our training is, just as they told us it would be, our tools. We should not abandon the traditional ways of working in our disciplines even though they may not be sufficient for our present needs. It is ourselves we are immersing in the life of medicine; the disciplines are our anchors in this venture, and we should be holding tightly to them. In literature, for example, the close reading of a text is fundamental, habitual, and although it may not now be enough to execute brilliant readings of the core texts, careful attention to works to literature remains the foundation of the discipline. More may be done. I do not

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believe we are taking advantage of the possibilities in medicine which humanists' very different assumptions about the nature of human knowl- edge open to us. Our understanding of historicity, of the fundamental character of interpretation in human knowledge, of the relation between epistemology and ethics are only a few of humanists' ordinary working assumptions that, explicated and applied, can be useful to medicine. Certainly our understanding of the nature and importance of "soft knowl- edge" is valuable in moderating medicine's idealist physicalism. Making these assumptions available to medicine is, I believe, essential to the reciprocity that the intellectual standing of the medical humanities requires of us.

Examples of reciprocity of medicine and the humanities abound. I will choose several close to home. My colleague, Ted Brown, who in his regular work is an externalist intellectual historian of science writing a history of psychosomatic medicine, when asked about white coats, pro- duces a history that is itself an account of the scientification of western medicine that prompts reflection on the physician's role. Women's studies also offers a model of scholarly engagement with the "real" world. Another of my history-of-medicine colleagues, Ellen More, is writing a collective autobiography of women physicians in Western New York from 1870 to 1930. There were a great number of them: my adopted territory is not only the home of the Women's Rights Convention but the place Elizabeth Blackwell and other women came for their medical education, however unwillingly granted. No one who learns of their prevalence, their flourishing, and their difficulty and decline can doubt that such a study illuminates the character of medicine in this century.

Law has its own opportunities to contribute to medicine. In New York state, where there seems no hope of passing a Right to Die statute and where it can take eight months and $12,000 to have a guardian ad litam appointed, there is a need for those learned in jurisprudence to create a judicially acceptable method of establishing disinterested people as surro- gates for the incompetent. This may not seem to be the traditional work of lawyers, but for the scholars among them, it is the work that validates the degree they have recently assumed: Doctor of Jurisprudence. Such reci- procity enriches not only the studies we call the humanities but the practice of medicine and the society it serves.

There are also joint ventures to be undertaken which combine scholarly methods and clinical realities. In one of the Society's recent Works in Progress session, Julia Connelly, who teaches internal medicine at the University of Virginia, with Stephen DalleMura, a doctoral student in philosophy there, reported on the results of an "epidemiology" of ethical

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issues in a small town primary care practice. 12 At the 1985 meeting there were even more striking examples of clinical immersion. Ed Waldron has described a survey of the perception of ethical issues by doctors, nurses, and hospital administrators in North Dakota. 13 Many of us were reminded of David Hilfiker's recent Healing the Wounds, TM a book that describes his experience in primary care in northern Minnesota. These projects testify to the interest in ethics away from transplantation centers, continuing this decade's valuable extension of ethical inquiry to ordinary practice. But there is an irony in the comparison: interactivity, if that is what it is, has proceeded so far that, in the case of Waldron and Hilfiker, it is the PhD who has done the social-science study, complete with questionnaires, and the MD who has written the essays. The former will be useful in persuad- ing the powers that be of the pervasiveness of the issues -- a practical task that, in an effort to demonstrate our worth in a time of tight budgets, increasingly falls to the humanists. The latter, Hilfiker's essays on ethical quandaries in rural practice, performs the humanist's traditional task in helping us understand the nature of the problems.

I believe in the value of this "immersion". Clinical experience is the first thing we who are able should offer those who are beginning to work in the medical humanities. I remain grateful to AI Vastyan and Chester Burns, who urged me to become involved clinically long before anyone but the ethicists and the ministers in medical education were doing so, and to John Stone, who first made it possible. All of us should be involved in clinical medicine, not just the ethicists. Nor is ethics the only work to be done there. Nevertheless, having declared my belief both in clinical immersion and in the reciprocity of the humanities and medicine, I want to point to a danger in our engagement as humanists with the "real world."

We are falling in love with data. We are beginning to sound like social scientists. The pressures and temptations are all around us in medicine. When I began work on clinical story-telling, my departmental colleagues in preventive and family medicine assumed that I would first establish a nosology of stories and then conduct my work by taking a census. Far from it. Counting can be important, but it is not the work of the humanities. This is particularly important because social scientists them- selves for some time now have been in considerable conflict over their proper methodology and over the status of their knowledge. 15 We need to be at least equally thoughtful about the methods we borrow from them.

Moreover, if humanists are to use sociological methods, we need to observe carefully the rules of rational investigation in social science. We humanists are beginning to show signs of having acquired our medical colleagues' habit of studying everything we do. A tittle of this is salutary.

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Blind trust in the effect of our efforts in the world and in the world's need for our services may be appropriate for our parent disciplines, but it is ill advised for us. Nevertheless, we cannot legitimately or usefully study phenomena that it is our job to shape. And can the double-blind ethical trial, described at a recent Association meeting, itself be ethical?

Questionnaires and surveys need not kill the spirit. In Habits of the Heart, 16 Robert Bellah and his colleagues, all sociologists, have based their examination of American character on several traditionally sociological studies. But the project did not stop with those studies, which were published separately in the journals of their discipline. For the book, Bellah drew these investigations together in an extended essay that addresses the meaning of the questions they asked as well as the answers they elicited. This study reminds us that the best work in the sociology of medicine uses our methods rather than the more traditional statistical methods of social science. Charles Bosk's account of the transmission of culture in surgical residency, Forgive and Remember, 17 is an ethnography. Paul Starr's Social Transformation of American Medicine, 18 as his former department at Harvard reminded him, is a historical study.

The "historical approach" is a familiar method, long shared by the humanities; about it I need not speak. Ethnography offers what may be a less familiar but equally useful way of understanding the "real world." Anthropologists and social-science theorists, like Barney Glazer, Anselm Strauss 19 and Joan Cassell, 2° describing the methodology of ethnograph- ical research, have established it as an enterprise far closer to research in the humanities than to research in the natural sciences. They are engaged in something very like reading: hypothesizing and correcting as the research proceeds, moving readily from the general to the particular and back again. They are not concerned with measurement or even mensura- tion. They are concerned with the existence and meaning of a bit of human behavior, however rare. It is not replicability or statistical likeli- hood that is important but interpretation, how that bit of behavior is to be understood in its cultural context. The parallel with reading may not be immediately apparent simply because ethnographers' texts are not written ones. But interpretative anthropology such as Clifford Geertz's "Thick Description ''21 seems to a literary scholar very like the work of literary criticism. As he describes it, culture is a construct to be understood by much the same method as a poem is understood. The book in which this essay appears is called not The Analysis of but The Interpretation of Cultures.

A generation of philosophers and literary critics concerned with under- standing continental philosophy have made this hermeneutic approach

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clearer and more accessible. A conference on Philosophy of Science and Literary Theory organized by Richard Rorty and E. D. Hirsch, Jr., at the University of Virginia in the spring of 1984 went so far in this epistemo- logical rapproachment that by its conclusion the word "metastory" was being used in place of "metaphysics". 22 Yet this understanding of science is almost unknown in medical centers, the home of the last of the positivists. We work in proximity to these positivists, who believe that physical laws (even the ones we have on hand at present) can account for all phe- nomena, and we struggle not only to meet the demand that we demon- strate our effectiveness but for intellectual respectability in that milieu. Thus, it is not surprising that humanists are likely to be sidetracked into the pursuit of "hard facts" about ethics or attitudes and values. Neverthe- less, our need for strong research in the medical humanities and for clinical interactivity should not be misconstrued as a recommendation that humanists suddenly begin to measure and count. Instead we can immerse ourselves in the clinical reality as humanists no less than an ethnographer would, qualifying ourselves not simply to explain our disciplinary perspec- tive there but also to see by its light the puzzles that surround us.

Certainly our job as humanists in medicine is not simply to bring a knowledge of medical matters to the exercise of our disciplinary skills. We could have stayed in departments of history or philosophy or religion for that. It is no doubt useful to know, for example, that the doctor in William

Carlos Williams's "The Use of Force," a short story set in the early 1930s, would have had a serum that was fairly effective against diphtheria. This knowledge surely influences our understanding of the story, but the close acquaintance with clinical reality that is our privilege in health care institu- tions is not necessary for that. Our colleagues in the colleges of arts and sciences can do this equally well. They can learn enough from books or from their acquaintance with medicine as occasional patients to make rich sense of The Magic Mountain or rewrite a chapter in the history of medicine. We who live our professional lives in health care institutions may do more.

We bring our disciplines to medicine and we see what is to be seen there. When Jo Banks goes along with her surgical colleague to the operating room, she discovers there an allusion to classical legend: the procedure is a mastectomy and suddenly she sees that everyone in the room - - the surgeon, the resident, the patient, the nurses, even the narrator - - is a woman. They become Amazons to her, women who are fitting one of their number for fife. You may read this story in two places: in her Healing Arts in Dialogue z3 where she tells it and gives it to Richard Seizer as a gift, and subsequently in his Confessions of a Knife. 24

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William May's book, The Physician's Covenant, 25 recasts the current discussion of the nature of the doctor-patient relationship in terms of the traditional imagery of the physician. Turning from the recent abstract and theoretical discussion adout patient's rights, he finds that good medical practice is being conducted now as always on the basis of trust, and he describes that trust as grounded in the sacred. His discussion of the covenantal character of that relationship has reframed the impoverished debate between mutually exclusive camps of medical authoritarianism and libertarian patient autonomy.

Scholars like these direct our way. In order to consolidate our status as a profession, we must not only understand how medicine fits into the scheme of things studied and made sense of by the humanities, but more important (and newer) we must see medicine so clearly through the inevitable lens of the disciplines we profess -- literature, philosophy, history, religious studies, jurisprudence -- that we will be able to frame its predicaments as ours. This is our job in medicine.

One way of looking at medicine is as a practice influenced by an increasing number of intellectual disciplines, bodies of knowledge brought to bear on the care of human maladies. The application of a succession of physical and biological sciences to clinical practice that began in the nineteenth century has reaped great rewards in understanding and in improvement of the human lot. In the twentieth century social science methods have yielded useful knowledge in medical sociology, in health care services research, in health care economics, and, most recently, in clinical epidemiology. These medical social sciences represent the "do science" pole of the debate over method that medical humanists should be taking part in. Alvan Feinstein has given clinical epidemiology the label "clinimetrics," describing it as "a new basic science for medicine." 26 This is surely a strategy of intellectual politics, for never in all his writings does he mention that statistics is also what sociologists and political scientists do. He would have clinicians regard this field simply as the application of mathematics to medicine. What purity! Clinimetrics is thereby made to seem quintessentially scientific. This may persuade deans of research and promotion who hold fixed views on the hard and the soft sciences. Mean- while, the strong argument on behalf of interpretation in medicine is still to be made, and the status of clinical knowledge remains obscured in a haze where "scientific" is confused with "rational." As odd as it may seem, clinical epidemiology may need our help.

The humanities, too, are in this succession of disciplines brought to bear on medicine. They are not last in one sense, since there have always been a history and a philosophy of medicine, and since medicine has

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always provided themes for literature and for religious study -- probably even for law. But we are last to arrive as professors in the health care establishment. We are not simply practicing our humanistic trades across town or on the other side the tracks. We apply our knowledge to the knowledge of medicine. We teach medicine. In order for our profession to flourish, our research -- without abandoning our disciplinary methods and habits -- must be research in medicine as well.

Here is what the humanities offer medicine: a model of non-scientific rationality that may point to the rational validity of much that is not scientific in the practice of medicine; an understanding of texts and of how to read them; our own interpretation of medicine's ordinary medical activity as itself interpretative; and above all, the understanding that medicine is not a science, not only a science. It is the genius of the physicians among us to have known this in varying degrees from the beginning. That is why they invited humanists to teach with them and why they have joined the humanists in this enterprise. Because illness and health care have become the arena of modern moral choice, the interpre- tation of medicine is a somewhat larger task than can be undertaken along with its everyday practice. Moreover, medicine itself has no special duty of self-examination and reflection. That is where we come in. All of us are engaged in the philosophy of medicine: We explain medicine to itself. To ourselves, to the world. The imperiled place of medical education in the university, 27 and, indeed, medicine's survival as one of the intellectual disciplines depend in some part upon what we do.

K A T H R Y N H U N T E R The University of Rochester Medical Center, 601 Elmwood A venue, Rochester, New York 14642, U.S.A.

N O T E S

1 Thomas K. McElhinney, ed. Human Values Teaching Programs for Health Professionals. Institute on Human Values in Medicine, Report 14 (Ardrnore, PA.: Whitmore Publishing Co., 1981). 2 Charles M. Culver, K. Danner Clouser, et al. "Basic Curricular Goals in Medical Ethics," New England Journal of Medicine 312 ( 1985), 253--6. 3 Physicians for the Twenty-First Century: The GPEP Report (Washington, D.C.: Associa- tion of American Medical Colleges, 1984). 4 Executive Council of the Association of American Medical Colleges, Physicians for the Twenty-First Century: Commentary on the GPEP Report (Washington, D.C., AAMC, 1985).

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5 Working Group on Personal Qualities, Values, and Attitudes, "Final Report to the [GPEP] Panel," Association of American Medical Colleges, June 1983. 6 David E. Rogers, "Some Musings on Medical Education: Is It Going Astray?," The Pharos, Spring 1982, pp. 11--4. 7 George S. Rousseau, "Literature and Medicine: The State of the Field," Isis 72 (1981), 406--24. s William J. Bennett, "The Role of the Humanities in Medical Education," Keynote address at the Association for Faculty in the Medical Humanities meeting, Washington, D.C. November 6, 1983. 9 Kathryn Montgomery Hunter, "Literature and Medicine," in Daniel Callahan, Arthur Caplan, and Bruce Jennings, edd. Applying the Humanities, Hastings Series in Ethics (New York: Plenum Press, 1985), pp. 289--304. 10 Stephen Toulmin, "How Medicine Saved the Life of Philosophy," Perspectives in Biology and Medicine 24 (1982), 736--50. 11 Richard Baron, "An Introduction to Medical Phenomenology: I Can't Hear You While I'm Listening," Annals oflnternal Medicine 103 (1985), 606--11. lz Julia E. Connelly and Stephen DaUeMura, "The Characteristics of Ethical Problems in Primary Care," Society for Health and Human Values meeting, Chicago, October 27, 1984. 13 Edward E. Waldron, "Ethics in Rural Health Care," Society for Health and Human Values meeting, Washington, D.C., October 26, 1985. 14 David Hilfiker, Healing the Wounds: A Physician Looks at Hist Work (New York: Pantheon, 1985). is See, for example, Richard J. Bernstein, The Restructuring of Social and Political Theory (Philadelphia: University of Pennsylvania Press, 1978). 16 Robert N. Bellah, Richard Madsen, William M. Sullivan, Ann Swidler, and Steven M. Tipton, Habits of the Heart: Individualism and Commitment in American Life (Berkeley: University of California Press, 1985). 17 Charles L. Bosk, Forgive and Remember: Managing Medical Failure (Chicago: Univer- sity of Chicago Press, 1979). 18 Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982). 19 Barney G. Glazer and Anselm L. Strauss, The Discovery of Grounded Theory: Strategies for Qualitative Research (Chicago: Aldine, 1967). 20 Joan Cassell, A Fieldwork Manual for Studying Desegregated Schools (Washington, D.C.: Department of Health, Education, and Welfare, 1978). 21 Clifford Geertz, The Interpretation of Cultures (New York: Basic Books, 1973). 22 Papers from this conference have been printed as Philosophy of Science and Literary Theory, volume 17, number 1 of New Literary History (1985), 1-- 171. 23 Joanne Trautmann, ed. Medicine and Literature: The Healing Arts in Dialogue (Carbondale: Southern Illinois University Press, 1982), pp. 104--5. 24 Richard Seizer, "Amazons," Confessions of a Knife (New York: Simon and Schuster, 1979), pp. 35--40. 25 William F. May, The Physician's Covenant: Images of the Healer in Medical Ethics (Philadelphia: Westminster, 1983). 26 Alvan R. Feinstein, "An Additional Basic Science for Clinical Medicine, I--IV," Annals oflnternalMedicine, 99 (1983), 393--7, 544--50, 705--12, 843--8. 27 Steven Muller, "The Medical School in the University," Journal of the American MedicalAssociation 252 (1984), 1455--7.