Perspectives
The art of medicine
The value of medical uncertainty?
See Editorial page 1666 In medicine—a field where the physical body registers
palpable outcomes—certainty about diagnosis, therapy,
and prognosis is a logically desirable goal. In the arts, by
contrast, uncertainty or ambiguity are often embraced
because they create opportunities, moving the perceiver
beyond the obvious into a realm where values, meanings,
and priorities are weighed and adjudicated. I would like to
suggest that this exploratory potential applies to medical
practice. While clearly, clinical medicine seeks assurances,
it is also an “art”, whose practitioners acknowledge, and
even thrive upon, the messiness and complexity it targets.
There is, then, a positive role for medical uncertainty that
can serve as a counterforce to our unexamined quest for
definitive answers.
Bruno Perillo courtesy of the artist and Irvine Contemporary
Bruno Perillo, Secretly Hoping for Plan C (2004)
1686
This notion of medical certainty as an intrinsic good is
thoughtfully challenged in David Gewanter’s poem, “My
Father’s Autopsy”. The poem’s opening brings into play a
dynamic element of interpretation, since the father is a
pathologist, not a corpse.
The one he did, that is, and took me to
when I was 13. I turned as white as
the old woman lying naked there;
Yet this poem challenges the reader to wonder who is really
being dissected, because there seem to be two concurrent
actions, both of which are true. While the father works
on the body, the son proceeds with his own autopsy: he
dissects his father’s character. The autopsy of the title turns
out to be that of the father, after all, only not in the way the
reader might first have assumed—not as a corpse, but as
a difficult human being. The poem creates and dismantles
assumptions, and that, in fact, is its theme.
The father’s agenda in taking his 13-year-old son to the
morgue is to introduce him to his scientific work.
Dad took stock
of her length, weight, muscle tone, telling me
or the microphone how she lived,
what made her sick. “Like being a detective,”
he said, “except I answer my own questions.”
The boy, however, attends in this inaugural visit to
forces of sexuality and death. While the father produces
a pebble—presumably the cause of death, reduced to a
single piece of condensed matter—the son is wondering
about the dead woman’s breasts and pubis, and meditates
on human transience. While the father snips and saws,
searching for revelations, the son reassembles the corpse as
a whole person, one whose opacity he wishes to preserve.
He wishes that she would not be so opened: “I wanted
her body to resist interrogation, prayed weirdly she never
said ‘aah’ for a doctor.” As the poem develops, the father
and the son represent two juxtaposed forces: the force of
science seeking answers at the expense of what humanly
matters, and the force of the poet, whose insights concern
the unknowable. The previously mentioned play on our
assumptions is an active demonstration that we blind
ourselves to the whole when we focus on a single point of
measurable fact.
In a powerful image that captures the limitations of
science as a means of gaining access to another human
being, the father is likened to a microscope.
at night he sat over journals and drinks,
compact, severe, inward as a microscope.
www.thelancet.com Vol 375 May 15, 2010

The very instrument that represents the father’s scientific
enterprise to the son becomes an image of his mystery.
Ultimately, the poet’s autopsy has to fail, because that is
what happens when dealing with living human beings:
Once I thought my pen would open him here
like the corpse on its single pan of judgment;
but as I cover this pan with pages
he is alive on another one
The lesson of this poem for practitioners is that
uncertainty is not a necessary evil. On the contrary, for
the prepared subject, uncertainty is an opportunity for
growth. Its acceptance shows respect for the opacity
and integrity of other subjectivities. At the very least, it
shows that medical uncertainty means different things
to different people, and that the response uncertainty
provokes depends on the values of the participants.
Helping to define the role of subjectivity in its
confrontations with medical uncertainty is one of the
potential contributions of the arts. This reframing
of uncertainty is the subject of another poem,
Veneta Masson’s “Reference Range”. It is not an accident
that the numerical references of the title (d)evolve into
poetic images.
Your tests show
the numbers 73, 90, 119 and 2·5,
the letter A,
the color yellow,
a straight line interrupted by a repeating pattern
of steeples and languid waves…
The nonsense of the numbers—laboratory values without
any context other than a reference range—transforms
itself into a different kind of sense. This sense becomes
clear at the end of the poem, when the clinician speaks of
laughter and death. These human experiences become the
essential realities of the poem, in which the uncertainty of
the numbers dissolve.
Art does not invariably dismantle its objects, it can
also be an unexpected ally of science. Take, for example,
Bruno Perillo’s painting Secretly Hoping for Plan C. The
portrayed subject could easily be a patient we see for
the first time. We proceed to mobilise our interpretive
gear. We look at the body language—the forward-
leaning stance, the wide-eyed, slightly frightened facial
expression. What is this person worried about? The face is
square, mannish, but the hair is long, the shirt flowery. Is
this a man or a woman? As with a patient, this painting
demands closer observation. Perillo, the artist, has
discovered that most viewers don’t even notice what
the figure holds in his/her hand. It is a contraceptive
packet, clearly marked “Plan B”, a morning after pill.
Thus reproductive issues layer themselves over gender
ambiguity, but the idea of “Plan B” may simply be a witty
www.thelancet.com Vol 375 May 15, 2010
Perspectives
metaphor for a generic alternative. When confronted
with such a patient and ambiguous information, an
obvious place to start resolving these uncertainties is
the reason for the visit. In the painting, the equivalent
of the chief complaint is the title: Secretly Hoping for
Plan C. Have Plan A and Plan B failed this individual?
Is the subject looking for a synthesis? Or perhaps an
escape? I had the opportunity to ask the artist about his
intentions in the painting. He told me that he had based
it on the story of a contraceptive accident, resulting in a
relationship conflict. The woman in the scenario refused
to take the morning-after pill, while the man felt unready
for fatherhood. In the painting, Perillo melds the male and
female perspectives, the woman’s right to exert control
over her own body and the man’s wish to postpone
paternal responsibility. Thus the title refers to the desire
for another, transcending option.
Working through this painting’s ambiguity is a revealing
exercise. Physicians go through much the same process
in our dealings with patients, reading facial expressions
and body language, adducing intrinsic and extrinsic
evidence. This is a process that occurs over time. It also
challenges our own values and beliefs. Whether we like it Further reading
or not, our feelings about transgender and contraceptive Carey J. What good are the arts?
issues come into play as we contemplate the work, and Oxford: Oxford University
Press, 2006.
even shape our interpretation of it. As the poems by
Gewanter D. In the belly. Chicago:
David Gewanter and Veneta Masson show, grappling with
University of Chicago Press, 1997.
uncertainty can paradoxically allow for a clarification of
Ghosh AK. Understanding
values. Art, I would suggest, makes all of these elements medical uncertainty: a primer for
visible in a way that the scientific approach to uncertainty physicians JAPI 2004: 52: 739–42.
doesn’t allow. It reveals a temporal process that involves Hewson MG, Kindy PJ, Van Kirk J,
the subjects of the consultation as well as its object. Gennis VA, Day RP. Strategies for
managing uncertainty and
Art cannot provide help with diagnosis or treatment complexity. J Gen Intern Med
in resolving uncertainty, but perhaps it can increase 1996; 11: 481–85.
physicians’ comfort with uncertainty through self- Masson V. Voices from the heart
reflection. “Literature does not indoctrinate, because of medicine. Pulse Magazine.
June 21, 2008. http://www.
diversity, counter-argument, reappraisal and qualification pulsemagazine.org/Archive_
are its essence”, suggests John Carey in his polemical Index.cfm?content_id=13
treatise What Good Are the Arts? Art can demonstrate (accessed April 27, 2010).
the interpretive process that leads to resolution of Masson V. Full text of Reference
range is available at http://www8.
uncertainty: first, by defining its precise nature; second, georgetown.edu/departments/
by identifying which information is lacking; third, by familymedicine/imh/unit8/
recognising that interpretation is a process that occurs Unit8Sec5b.html (accessed
April 27, 2010).
over time; and finally, by knowing the contributions of
Slouka M. Dehumanized: when
various aspects of the context. All of these are reflective math and science rule the school.
processes that can take place in the context of a framed Harper’s Magazine. Sept, 2009.
discussion that applies the arts to a medical context. Such http://harpers.org/
archive/2009/09/0082640
discussions are just as useful to practising physicians as
(accessed April 27, 2010).
they are to trainees.
For more on Georgetown
University’s Interacting with the
Caroline Wellbery medical humanities programme
see http://www8.georgetown.
Department of Family Medicine, Georgetown University,
edu/departments/
Washington DC 20007, USA familymedicine/imh/main.htm
wellberc@georgetown.edu (accessed April 27, 2010).
1687