Narayan, R. K. (Rasipuram Krishnaswami)
|Keywords||Art of Medicine, Doctor-Patient Relationship, Medical Ethics, Professionalism|
Dr. Raman, a fictitious physician in the imaginary South Indian city of Malgudi that is the microcosm for many of Narayan's stories, is renowned for his diagnostic acumen and "certain curt truthfulness; for that very reason his opinion was valued; he was not a mere doctor expressing an opinion but a judge pronouncing a verdict." When Dr. Raman is called upon to make a house call and subsequent operation on his dearest friend, Gopal, he faces a very difficult professional ethical dilemma.
For Gopal is very sick (dying in Dr. Raman's judgment) and requests a truthful prognosis in order to settle his will and avoid the "endless misery for his wife and children" that an unsettled will would entail, a realistic eventuality with which Dr. Raman concurs. Yet, if Dr. Raman reveals his pessimistic opinion, which he does to his assistant, i.e., that Gopal will not survive the night, then it would "virtually mean a death sentence and destroy the thousandth part of a chance that the patient had of survival."
Dr. Raman does "a piece of acting" and assures his friend and patient that he will live. Gopal replies, "If it comes from your lips it must be true . . . . " Gopal lives and Dr. Raman remarks to his assistant, "How he has survived this attack will be a puzzle to me all my life."
This story adroitly tackles truthfulness in the physician-patient relationship as well as the intricate associations between truth-telling, prognosis and hope. Additionally it raises, in a minor way, the tricky problem of a professional relationship with a good friend. It often happens that one becomes friends with a patient. But to initiate a professional relationship with a long-standing friend (they have been friends for 40 years) may not always be wise. It is clear in this story that Gopal's original physician was not his friend Dr. Raman but a "doctor in the next street," a physician Raman does not know.
In other words, this story's concern is not only with professional ethics but also with the tension that often arrives when personal ethics and professional ethics intersect and conflict (see B. Freedman's "A meta-ethics for professional morality" in the journal Ethics, 1978; 89:1-19) since it is clear that Dr. Raman violates his usual practice of truth-telling in the interest of his friendship. It is also a commentary on paternalism; Dr. Raman tells the patient's wife and patient only what he wants them to hear since the truth as he perceives it would be damaging to the patient's outcome, a much censured notion known as "therapeutic privilege."
This story demonstrates the economy and grace with which expertly wrought fiction can capture and present for discussion important issues in (medical) ethics. I have used it with success in a student seminar on the medical ethics of truth-telling, prognosis and conflict of interest. In this seminar, I paired it with Twain's Was It Heaven? Or Hell? (see this database), a magnificent short story dealing with many of the same issues of truth-telling and paternalism versus hope.
|Place Published||New York|
|Annotated by||Ratzan, Richard M.|
|Date of Entry||01/17/95|