The last decade of my career as a medical ethicist was consumed by the issue of physician complicity with torture. I wrote several books, many articles, served on commissions, and assisted in several hearings. During the pandemic, I wrote a novel, The Leopard’s Furies, about Col. Foday Anyoto MD, a physician facing trial for abetting torture. A junior human rights attorney and a West African law student attempt to convince a corrupt grand jury to send the doctor to trial. The Leopard’s Furies narrates the legal process and the evolution of these three major characters. I wrote this book for three reasons: to synthesize what I had learned, to speak to a different audience than my academic works, and to assuage my trauma from working on this topic and its horrifying details for so long.
There is a peculiar asymmetry between those who write novels and those who work in medical ethics. Many novels address medical ethics: Brave New World, 1984, The Little Red Chairs, I Robot, Never Let Me Go, Frankenstein, The Manchurian Candidate, Anil’s Ghost, and The Sea and Poison are but a few. Medical ethics humanists, such as Joanne Trautmann, Katherine Montgomery, and Rita Charon, sensitively analyzed this genre of fiction. But very few medical ethicists have written novels.
There are two main reasons why few medical ethicists have explored moral dilemmas by writing a novel. Novel writing is so time-consuming that it is essentially incompatible with holding or pursuing advancement in an academic or clinical career. More importantly, I was profoundly struck by how differently novels and ethics case analyses handle moral problems.
Medical ethicists, by and large, gather facts and lay a matrix of principles over a case. The story below the principles is scrutinized for details where principles can be attached in order to drive a best course. Students are taught to look for the values of the best decisionmaker so as to respect the principle of respect for autonomy. They are taught to look for evidence of coercion or constraints that might obstruct the exercise of autonomy. They also examine benefits and harms as they compare the various alternative solutions. Hypothetical cases are salted with details to teach how to apply the matrix of principles. an analytic point or to drive the case in a certain direction. For example,
A niece and a daughter show up at the bedside of an elderly man with dementia. They differ on whether to use life-prolonging antibiotics and an amputation. The daughter lives in another state and has not seen her father in five years. The niece shops for his groceries, pays the housekeeper, and brings him to clinic. Who is probably the best person to speak as to the patient’s interests and preferences regarding these treatments?
A solution is then rationally derived by a friendly, fair, and ideally omniscient, observer—an ethics consultant.
By contrast novels present characters as embedded in their personal moral lives. They have values, traits, and habits. They are in relationships with relational duties. Their virtues and impulses are at times true and flawed. They are shaped by past experiences and affected by luck, opportunity, and power. This character-rich, embedded moral life, rather than an overlaid matrix of principles, is the moral landscape of a novels. This is much closer to how people really live and experience choices. Principle-forward fiction are called ‘allegories.’ Consider Pilgrim’s Progress or Marvel comics. Pedantic. Predictable. Boring.
In novels, healing (if the author allows it to occur), entails some kind of moral catharsis in which the character is transformed. Meanwhile, in a good novel, a harmonic of empathy connects the reader to the moral movement of a character. In non-allegorical novels, the reader sees a new kind of meaning or grows a new form of empathy.
“Most of all, writing a novel reminded me again that principle-foreground ethics analysis impoverishes how we read patients and others touched by a clinical decision.“
– Steven H. Miles
Medical ethicists, whether by performing a case consultation, studying a hypothetical vignette, or by reading a novel is truer to life when it works on the character and relational moral plane of a novel. Principles belong in the background, not the foreground. As an example of a character-forward, rather than principle-forward moral reframing, consider these brief words by the pastor of an old man as we removed a respirator a day after a prolonged cardiac arrest:
The family had gathered. I had turned off the monitors in the room, lowered the bed rails, freed his hands for his family to hold and placed a box of tissues on his chest. “Lord, we are gathered here at the bedside of Earl, husband, father, uncle, grandfather, deacon. As he passes, we are reminded that each breath he took was your inspiration. We commend his soul to you.”
In novels, moral reasoning and case development is more akin to Frankl’s logotherapy, by which meaning is sought and affirmed. It is also the ethics of MacIntyre’s After Virtue about virtues as defined by relationships; of Jonsen and Toulmin’s The Abuse of Casuistry in which cases are understood by comparison to norms and cultural mores; or Nussbaum’s The Fragility of Goodness, which reviews how luck, context, and opportunity all help determine the possibilities and shape of a moral life.
As for my original aims, I was able to synthesize what I have learned about physician complicity with torture. All of the torture events were drawn from diverse records. The defendant physician was a composite of numerous factual accounts. The novel joins my two non-fiction works on physicians who torture (Oath Betrayed: America’s Torture Doctors and The Torture Doctors: Human Rights Crimes and the Road to Justice) as a trilogy.
Writing this novel eased some of my secondary trauma from studying medicalized torture for so long. It did so by allowing me to reset such evil in a moral narrative about justice. Although the hearing does not end in a simple allegorical victory, the story tells of the moral transformation of the three major characters and some survivors and onlookers. The book illustrates MLK’s wise and tragic observation that “the arc of the moral universe is long, but it bends toward justice.”
Most of all, writing a novel reminded me again that principle-foreground ethics analysis impoverishes how we read patients and others touched by a clinical decision. Medical ethicists must reflect as people do, in terms of how human experiences, relationships, values, power, luck and empathy affect the situation that they find themselves in.
Steven H. Miles, M.D. is Professor Emeritus of Medicine and Bioethics at the University of Minnesota.