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BRIEFINGS
A strange deceit
David Stafford-Clark
"In cottage gardens sweet flowers drink
Last dregs of colour from the fading light.
Their scent floats on the dusk, to link
With the now distant thunder of the engines
In a strange deceit;
As if the world went well ..."
Two questions arise from this quotation: What
is the nature of this strange deceit? and
why is it still with us? (as it still is). The poem
was written during 1943, and the author was a
doctor whose duties included flying with
bomber command of the Royal Air Force. It
was in fact part of my increasing awareness
of the inseparability of psychiatry from
general medicine and of the understanding of
morale and fear and guilt in the context of
both.
But now, over 50 years later, 25 of them
spent as a teacher and senior consultant in
psychiatry at Guy's Hospital, I am left with a
conviction that doctors are still uneasy in the
way that they deal with death, common
enough in their experience, but often
shunned in their communication to the next
of kin to whom they owe honest and lucid
explanation and compassion as well as
concern. I could give many examples of this
but one will have to suffice.
The patient was a boy of eight, who had
developed bone cancer in his left shin: a
Ewing's sarcoma. Following confirmation of
the clinical diagnosis by biopsy, he had his left
leg amputated up to the lower third of his
thigh. Even so the outlook was virtually
hopeless but the correct procedure was to
plan for his survival, including the fitting of an
artificial limb. Meanwhile he was encouraged
to regain mobility, first by crutches, and then
after discarding them with a child's
combination of impatience, natural poise
and adaptability, to hop about the ward on
one leg like a lively little bird. He did all this
with tireless and supremely optimistic
enthusiasm.
Iwas at that time engaged in researching the
attitude of children to their disability, and to
those responsible for their care, including their
parents as well as doctors and nurses. A
routine question concerned the child's plans
for the future. "What do you plan to be when
you grow up, Billy?" "1 want to be a
professional cricketer. I want to be one of the
best." "A cricketer Billy, what about running?"
"I'd aim to be a batsman. You see if I can hit
enough boundaries running isn't going to
bother me; I could always have someone else
to run singles or twos or threes ..." This
encounter arose out of a research fellowship. It
was no part of my job to demur at anything the
children said but the doctors and nurses on
Billy's ward were already firmly enrolled in his
supporters' club for this impossible fantasy. It
not only settled his attitude, but theirs too, for
the remaining six months of his life. His
parents were grateful for the sustenance
which this fictional magical promise, and
denial of inevitability of his death, gave them
during his brief post-operative survival. But
their gratitude did not survive the realisation,
once he had died, that at no point during his
post-operative course had anyone tackled,
humbly but honestly, the admittedly terrible
but inescapable duty of telling them the truth.
Deprived of this essentially professional
service, they had not only gone along with
the merciful deception of their child, they too
had allowed themselves to be deceived. For
them, this deception had to be seen for what it
was: a betrayal. At no stage had they been
given the chance to come to terms with the
heartbreaking reality - until it was too late.
There is nothing exceptional about this. The
first simple and obvious answer to this in our
profession is that we have a duty to be honest,
lucid and compassionate in dealing with the
hardest facts we may encounter, but it is also
reasonable to ask what can be our motivation,
apart from professional integrity. I submit that
it has to be love of a dedicated and
dispassionate kind for those for whom we
care and particularly their next of kin. Both
the Qur'an and the Bible stress the supremacy
of love over fear and guilt.
504 Psychiatric Bulletin( 1995), 19. 504-505
BRIEFINGS
"There is no fear in love; but perfect
love casteth out fear."
(First Epistle General of St John)
". . . For love is strong as death; jealousy
is cruel as the grave."
(Song of Solomon)
Apart from love, is anything stronger than
fear or guilt in the human range of emotion?
Certainly not hatred, jealousy or envy; all have
firm roots in fear. The denial of fear, guilt or
responsibility, without acknowledgement of
the necessity of love, is the nature of the
'strange deceit'. If doctors, as responsible
educated men and women, and particularly
psychiatrists, who do understand something
about fear, guilt and responsibility, are to be
listened to they must first set their own house
in order. Physicians as a whole can be
complacently ignorant even about things
which are within their total and immediate
concern.
A leading article in the British Medical
Journal (13 November 1982), dealt with the
prolongation of dying when it is impossible to
preserve life with any quality of awareness or
participation. It was subtitled "Thou shalt not
strive officiously". Its opening sentence read,
"Most medical students encounter the dictum
Thou shalt not strive officiously to keep alive'
early in their clinical years."
I took the trouble to look it up in the Oxford
Dictionary of Quotations. It is part of a poem by
Arthur Hugh Clough (1819-1861) entitled The
Latest Decalogue' and its first five couplets are
as follows
"Thou shalt have one God only, who
Would be at the expense of two?
Thou shalt not kill; but needs't not strive
Officiously to keep alive.
Do not adultery commit;
Advantage rarely comes of it.
Thou shalt not steal; an empty feat.
When it's so lucrative to cheat.
Thou shalt not covet; but tradition
Approves all forms of competition ..."
So not only is the article headed by a
misinterpretation of the poem which heads it,
but that poem has nothing to do with medical
ethics or responsibility and proves to be a
diatribe against current public and political
hypocrisy on moral issues in the 19th century.
To use the quotation in its incorrect context is
evidence of a carelessness which doctors must
avoid. But it would not be so well-enshrined in
the tradition of medical teaching if the people
who so readily use it had checked on its origin
and meaning. This is simply an example of the
responsibility which doctors must accept, to
act and write and think and talk as educated
people. Their even greater responsibility is to
speak out clearly and unambiguously on all
issues of humanity when they are asked.
So what is my final message? It is simply
this: it may not be possible to develop or
acknowledge perfect love in our hearts for
every one of our fellow men and women but it
is vital that we acknowledge that love and
compassion must be part of medicine and that
fear, ignorance, sloth, complacency or
indifference are its worst enemies.
Confronted by a sick, frightened, disturbed,
unhappy or even paranoid and threatening
person, the doctor can remember this simple
precept: "attention must finally be paid to
such a person ..." The phrase comes from
Arthur Miller's play Death oja Salesman. Once
patients realise that you care about how they
feel, then you have given them a bridge to link
their need to your capacity to help them. A
bridge which they can cross to meet you and
which you can cross to meet them. Good
doctors have always recognised the necessity
for such a bridge. And attention in the special
context of the phrase I have quoted means not
simply interest, not even simply compassion
but the active, dedicated, detached, yet
uncompromising love for other human beings
which alone can inspire and ultimately crown
the highest endeavours of medicine and of
mankind.
David Stafford-Clark, retired; Consultant
Emeritus. Guy's Hospital. London SEI
A strange deceit 505
