Saturday, April 28, 2012

"By Blood" by Ellen Ullman

I've just finished reading a remarkable novel: By Blood by Ellen Ullman.

I'd read in a review that the story is told by a disgraced professor who eavesdrops on a psychotherapy occurring in the adjacent office. How could I, after years of psychiatric practice, resist a story like that!

The professor/narrator, whose name we never learn, and whose sordid doings at the university he's been forced to leave we only get hints about, is immediately obsessed with the young lesbian, adopted patient and her German born therapist. To the narrator, being adopted means being free from blood ties to one's past. Since his ancestry is replete with suicides, the image of escape is appealing. But once the person he refers to as his "dear patient" begins to search for her birth mother, he becomes a detective, and ferrets out clues that he passes on to her, in the guise of the agency that handled her adoption. The complex story leads from San Francisco to Bergen-Belsen and Israel. I won't spoil the reading experience by giving too many details.

For me Ullman's novel created an experience that was common in clinical practice and, more broadly, life: a feeling that behind a surface that initially seems bland there's a fascinating, illuminating story to be found.

When Elvin Semrad, the training director in my residency was asked whether he didn't sometimes get bored with his patients, he said something like this:
No human being is boring. If we feel bored, one of two things is happening - either the patient is avoiding what's really bothering him, and the words are a cover, or the patient is talking about an issue that we haven't resolved for our self, and boredom is our defense.
Whenever I felt bored in clinical practice I applied Dr. Semrad's teaching - it always gave good guidance.

By Blood is about curiosity, and I'll bet that if you start it you'll find that it evokes such strong curiosity you won't be able to put it down. "Curiosity" is title of a 1999 essay in the Annals of Internal Medicine by Dr. Faith Fitzgerald that I admire and have often used in teaching. Dr. Fitzgerald was offended when patients were described as "uninteresting," and challenged the resident leading the team she was making rounds with to choose the least interesting patient on the ward:
He chose an old woman admitted out of compassion because she had been evicted from her apartment and had nowhere else to go. She had no real medical history but was simply suffering from the depredations of antiquity and abandonment. I led the protesting group of house staff to her bedside. She was monosyllabic in her responses and gave a history of no substantive content. Nothing, it seemed, had ever really happened to her. She had lived a singularly unexciting life as a hotel maid. She could not even (or would not) tell stories of famous people caught in her hotel in awkward situations. I was getting desperate; it did seem that this woman was truly uninteresting. Finally, I asked her how long she had lived in San Francisco.

“Years and years,” she said.

Was she here for the earthquake?

No, she came after.

Where did she come from?


When did she come?


Had she ever been to a hospital before?


How did that happen?

Well, she had broken her arm.

How had she broken her arm?

A trunk fell on it.

A trunk?


What kind of trunk?

A steamer trunk.

How did that happen?

The boat lurched.

The boat?

The boat that was carrying her to America.

Why did the boat lurch?

It hit the iceberg.

Oh! What was the name of the boat?

The Titanic.

She had been a steerage passenger on the Titanic when it hit the iceberg. She was injured, made it to the lifeboats, and was taken to a clinic on landing, where her broken arm was set. She now was no longer boring and immediately became an object of immense interest to the local newspapers and television stations—and the house staff.
I'm writing about By Blood in an ethics blog because I believe the right kind of curiosity about our fellow human beings is the royal road to good ethics. Fancy words used in ethics teaching - "autonomy," "informed consent," "beneficence" and more - provide useful frameworks, but they don't provide the vivid human truth that empathic curiosity points us to.

(An excellent interview with the author can be found here. And an excellent review from the New Republic is here.)

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