Well written, informative essays on the state of contemporary medicine by thoughtful physicians are not unknown, but Pauline Chen's wise, eloquent reflections on mortality raise the bar. Addressed to medical professionals, her meditations are of equal, even more, value to those of us who know that we are likely to be among the 90% who will die from a prolonged illness.  It is very much in our interest that physicians learn how to care for the dying when hope of cure does not exist. To do so they, and we, must confront our own mortality.  "Preparing for death may be the most difficult exam of all, but it is the one that will, finally, free us to live." (P. xv)

Chen's vivid, detailed accounts of her long years of training to become a surgeon specializing in liver transplants demonstrate that medical training is an indoctrination in keeping the patient alive. Even before they start the process of becoming professionals, medical students may be attracted to medicine as a means of dealing with the fear of death .Professional training, with its emphasis on algorithms, procedures, and protocols, demands depersonalization of patients to focus on the rituals of cure. Dying patients are evidence of failure even when no errors occur, and physicians take it personally.   Her descriptions of the rituals of medical training, from the first year gross anatomy lab, through the procedure of declaring the time of death to the frantic efforts at resuscitation when a code is called to the formal accounting of patient deaths at M and M (Morbidity and Mortality) conferences illustrate the depersonalization and denial of death which are central to the professionalization of physicians.  The SUPPORT study in the mid 1990's provided evidence of just how poorly dying patients were being treated.  Most physicians did not know what the wishes of their patients were, and half of all patients who were conscious complained of moderate to severe pain at least half the time.  The intensive efforts of the researchers to correct the sorry treatment of the dying led to no improvements even after two years!  "Dying patients continued to be a profound source of unease that physicians avoided or ignored." (P.72)   To counter the strength of denial as a coping mechanism, research and education on palliative care and hospice services have become widely available.  Dr. Chen is cautiously optimistic that physicians are beginning to acknowledge their own mortality and to throw off the protective cover of denial.

Although the above summary is accurate, it is fundamentally deceptive.  Final Exam is much more than an impersonal discussion of the causes and possible solutions to the problem of the wretched treatment of patients at the end of life. What remains with the reader is the vivid descriptions of her dead patients, which bring them alive as a novelist brings a character alive.  The pale pink nail polish on the cadaver she dissects, Joseph walking out into the Chicago winter after his wife had just died, and most hauntingly, the brain- dead young oriental woman in whom she recognizes the face of her own mortality:  all these, and many more, are what makes this book extraordinary.  These patients do not fade from the readers' memory any more than from Dr. Chen's.

The vivid depictions of individual patients, the conclusions drawn about the need for better care at the end of life plus the fascinating excursions into her medical training and career are sufficient grounds for an enthusiastic recommendation of Pauline Chen's Final Exam to even the casual reader.

However, repeated readings provide evidence of a deeper achievement and gives hope of a better approach to bioethics. Many bioethicists find the conventional use of case studies, modeled on medical case histories, defective.  Cases are typically used to illustrate dilemmas presented by conflicts between general principles, most commonly between autonomy and beneficence.  Narrative ethics is an alternative to the standard use of cases in bioethics. In-depth, detailed accounts of the patient's personal experience of illness are supposed to be a remedy for the depersonalized focus on organs and organ systems in medical practice.  Occasionally such narratives are illuminating; memoirs of the experience of depression, especially when the authors are gifted writers, come to mind. Such narratives are limited in what they accomplish.  The way in which Pauline Chen combines descriptions of patients, her responses to them and to research about end of life care provides a third approach, one which weaves the personal and the emotional with the abstract and scientific. The most impressive achievement of Final Exam is Pauline Chen's success in uniting the expressive and the intellectual so that each balances and reinforces the other. She shows that the science of medicine and the compassion of caring need not be at odds. To appreciate the achievement of Final Exam, it should be not only read but reread.              

© 2007 Hannah M. Hardgrave

Hannah M. Hardgrave, Ph.D., Department of Philosophy, Wake Forest University, Winston- Salem NC.

Categories: General, Ethics