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Abstract

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

Medical commentators on the play W;t by Margaret Edson, have tended to highlight the play's medical themes in the hope that this will help to improve the care of the dying. In this essay, the author argues that a close reading of the play suggests an alternative approach. This approach would require physicians to become personally engaged with the play's broad underlying themes, in particular the themes of dignity, relationship, and forgiveness. Physicians who do this might be able to undergo the sort of personal transformation that could allow them to relate to dying patients more fully as fellow human beings. Such a reaction to the play by physicians might truly and radically improve the care of the dying.

The play W;t by Margaret Edson won the Pulitzer Prize for drama in 1999.1 The plot concerns a woman dying of ovarian cancer in an academic medical center. It has attracted not only enormous critical acclaim but widespread interest among physicians.2 It has been reviewed in medical journals, a rare event for a work of literature.3,4 It is even being used for purposes of medical education aimed at improving the care of the dying.5 Yet, both in informal discussions with physicians and in these reviews, major themes of the play seem to be receiving little attention. Certainly, some of these reviews have addressed certain broader themes such as care and abandonment and the intricacies of the physician–patient relationship. But the tendency has been to focus on this play as a satire about the care of the dying. While, as a multilayered, intricately woven work of art, this is certainly part of its truth, such an emphasis does not give the play its due. In a way, saying that W;t is a satire about the care of the dying is like saying that Hamlet is a play about royal succession in Denmark. True enough, but something is rotten if we say no more.

The focal point of the play is its protagonist: Vivian Bearing, PhD, Professor of English literature, expert on the Holy Sonnets of John Donne, and her coming to grips with her ovarian cancer, her life, and her death. In the play, we follow her from diagnosis, through her treatment, aplasia, and sepsis, to her death in the throes of an aborted attempt at cardiopulmonary resuscitation despite an order that she not be resuscitated. The play is peppered with flashbacks to her childhood and career in academia. Most of the dialogue takes place between her and several health care professionals in the all-too-familiar setting of the “University Comprehensive Cancer Center.” But the plot is only a vehicle for a much richer drama. The story of someone dying under the care of doctors is not necessarily a story that is primarily about doctors.

The message of this play is intended for all audiences. And it is only when doctors learn this message that they will learn anything really useful from this play. The doctors portrayed in W;t do not seem to appreciate this message, and doctors who see or read the play may also fail to appreciate it. And this, in the graphic words of the play, would be another “doctor fuckup” (p 85). Just as the play ends in a mistake, there is a danger that our professional reaction to the play will be a mistake. We may find ourselves, like the house officers at the end of the play, “coding a No-Code.” And the only way the play can teach us how not to make such a mistake is if we realize that the point of the play has both nothing and everything to do with learning how not to make mistakes. “Herein lies the paradox. John Donne would revel in it.” (p 47)

Among W;t's many themes, intended for all who see or read it, forgiveness, relationship, and dignity are central. Physicians wishing to learn from the play would do well to understand these themes. In this brief article, I will address each of these themes in turn, illustrating each with text from the play. I will then suggest some lessons that clinicians can draw from the play, once they have appreciated that its thematic scope is far wider than medicine.

FORGIVENESS

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

Forgiveness is a complex concept. In the context of the play, it implies a recognition of one's failings. But it also implies the human need to be assured that one is accepted and loved despite one's failings. And morally, of course, it entails a resolution to improve. The theme of forgiveness emerges subtly, but forcefully, as the play unfolds. Simply put, Professor Bearing spends much of her time on stage asking the audience to forgive her. As the play begins, Professor Bearing states that she's “sorry [she] won't be around” when the doctors ask her corpse, “How are you today?” (p 5) She later apologizes that her request for a “palliative treatment modality” disrupts “the dramatic coherence of [her] play's last scene.” (p 70) And her “last coherent words” are “I'm sorry.” (p 73)

In the middle of the play, at its very heart, stands the text of Donne's Holy Sonnet IX, (Gardner edition V) “If poysonous mineralls…” Bearing recites it and delivers a lecture on its meaning. Its last 5 lines are:

O God Oh! of thine onely worthy blood,

And my teares, make a heavenly Lethean flood,

And drowne in it my sinnes blacke memorie.

That thou remember them, some claime as debt,

I thinke it mercy if thou wilt forget.

This poem is a complex plea for God's mercy and forgiveness, spoken by one whose intellect cannot fully accept the possibility of such forgiveness. In the play's wonderful irony (p 6), the audience grasps that in her third person analysis of the poem, Bearing is really talking about herself. (To drive this point home, the stage directions state, “VIVIAN moves in front of the screen and the projection of the poem is cast directly upon her,” [p 50]). From this position she addresses her “class,”

Doctrine assures us that no sinner is denied forgiveness, not even one whose sins are an overweening intellect or overwrought dramatics. The speaker does not need to hide from God's judgment, only to accept God's forgiveness. It is very simple. Suspiciously simple. (p 50)

She teeters on the brink of forthrightly understanding her own need for reconciliation with God, death, and other human beings, but the play leaves open to interpretation the question of whether she ever fully resolves these issues. She speaks for the audience as much as for herself when she says:

But it is too late. The poetic encounter is over. We are left to our own consciences. Have we outwitted Donne? Or have we been outwitted? (p 50)

Bearing really needs forgiveness. She is one whose “sins are an overweening intellect and overwrought dramatics.” But the conception that it might even be possible to be forgiven lies just beyond the grasp of her own keen intellect. She has no idea how to ask for it, and considers it easier just to disappear.

RELATIONSHIP

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

Dignity and forgiveness only happen in a context — the context of relationship. The postdoctoral fellow in the play, Dr. Jason Posner, quite unwittingly describes the way human relationships form the glue that binds both dignity and forgiveness together when he describes the cellular biology of cancer to Vivian Bearing. In this richly layered dialogue, conducted simultaneously at 2 levels of interpretation, one discovers even more of the play's wonderful irony. Both characters describe an intellectual interest in what they do not possess, and profess an intellectual affinity for what they are both studiously avoiding even as they speak about it. What Jason and Vivian both say they find “awesome” about cancer cells is the loss of “contact inhibition.” Yet both are obviously inhibited by contact with human beings. Jason goes on to state, suggestively, that this loss of contact inhibition is what it means for cells to become immortal (pp 56–7). And when Vivian is placed in clinical isolation, she states explicitly that it is not cancer (i.e., not the loss of contact inhibition) that has driven her into isolation. It is the treatment she has received at the hands of her doctors (p 47). She and her oncologist, Dr. Harvey Kelekian, are really co-conspirators in this treatment. Her treatment plan is about knowledge and toughness, a way of avoiding both life and death (pp 11–2). In short, her treatment, like her life, involves the maintenance and restoration of contact inhibition.

In their own personal isolated alienation and overintellectualization, the physicians in the play really mirror Vivian Bearing, even as she mirrors us, the audience. Her real struggle is not against the cancer, but against what the postdoctoral fellow, Jason, correctly calls the theme of “salvation anxiety” in the poetry of John Donne (pp 75–6). Bearing's anxiety concerns precisely the nexus of relationships that might ultimately carry her past death. That is to say, her struggle “is ultimately about overcoming the seemingly insuperable barriers separating life, death, and eternal life,” as Donne describes it in Holy Sonnet X, (Gardner edition VI) “Death, be not proud.” (p 14) Her graduate school mentor, Professor E.M. Ashford tells her in a flashback, “It is not wit, Ms. Bearing. It is truth. The paper's not the point… Don't go back to the library. Go out. Enjoy yourself with your friends.” (p 15)

Like Professor Bearing, Jason understands this only intellectually. We learn that in living his life, he has shunned the “fellowship” part of his postdoctoral fellowship (“the part with the human beings,” p 57) in favor of a research career. He is in need of constant reminders to be “clinical” (i.e., human) in his dealings with patients. And Dr. Kelekian, Professor of Oncology, treats Vivian exactly the way she treats the students in her classes. Both his patients and her students become pretexts in which to display personal prowess and control — an exercise in wit. Like her doctors, Vivian Bearing fears both love and death. Like her doctors, she overintellectualizes all relationships and thereby avoids any need for reconciliation. She never shows any mercy to her students, not even allowing extensions for late term papers, even when the excuse is a death in the family, which she dismisses sarcastically. “Don't tell me. Your grandmother died.” (p 63)

We also learn, slowly, how isolated her life really is. There are hints of a tough childhood. There is no mention of her mother other than death. We learn that she preferred the library to the company of her fellow students in graduate school. She is childless and unmarried. Her parents are now dead. Her colleagues fear her. No one visits her in the hospital.

Her relationship with Kelekian is also purely intellectual. We learn that they both decry the dullness of their students (p 10). To her delight, after a student answers one of his questions incorrectly during rounds, Dr. Kelekian remarks, “Why do we waste our time, Dr. Bearing?” (p 39) They exchange knowing winks. Wit keeps people at bay.

At one point in the play, she tries to reach out to the fellow, Jason Posner, at a human level, asking him if he ever misses any of his patients. He almost opens up, but then quickly turns the conversation into a mental status exam (pp 57–9). She also tries to reach out to the nurse, Susie. And Susie offers her the only meaningful interaction she has with the medical staff anywhere in the play — they share a popsicle together (pp 65–6). But Susie also quickly escapes from any deeper interpersonal engagement and turns the conversation into an abstract discussion of the risks and benefits of a do-not-resuscitate order (pp 67–9).

Only in the haze of morphine does Vivian manage any interpersonal reconciliation. The painful flashback of her interaction with her father at age 5 becomes redeemed in her dying days. As the morphine is injected, she shares a joke with Susie the nurse about its “soporific” qualities, using the same word that she claims, in her flashback, launched her career. And in place of her father, in place of her mother, comes a visit from her old mentor. Professor Ashford crawls into bed with her and reads for her — not Donne — but a children's bunny story like the one in which Vivian, at age 5, first read the word “soporific.” The scene is quite tender and compassionate. Both the bunny story and Ashford's own actions are filled with the hope of an unconditional, reconciling love. This is the love and forgiveness that Vivian has always wanted, but has never allowed herself to accept.

DIGNITY

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

Dignity means value or worth. In a deeper philosophical sense, it means the value that each human being has simply because each is human. Although she does not set out consciously in this direction, Professor Vivian Bearing's journey through the play is towards this deeper sense of dignity in the face of the “countless indignities” she suffers (p 41). She might have thought that her dignity came with the pomp of her title, but her title subtly migrates through the drama from “Doctor” to “Ms.” to “Vivian.” She might have thought that her dignity was based on her appearance, but she quickly loses her beauty with her publicly vanishing hair (p 40). She might have thought that her dignity consisted in freedom from pain and the enjoyment of life's pleasures, but she loses it in the pain that “hurts like hell” (p 70) and in the ugly vomitus at the bottom of her plastic washbasin (p 32). Finally, she learns that her dignity cannot be associated with power and control (p 48), because it is absent from the play's first moment, tethered to the intravenous pole that she drags with her throughout the play like a ball and chain. In the end, Vivian Bearing has to learn that she has no worth or value except herself. The one who sees her dignity is her true mentor, E.M. Ashford, whose reconciling love is expressed in a kiss. “May flights of angels sing thee to thy rest.” (p 80)

How much of this Vivian understands through the haze of morphine is initially unclear. But as the stage directions state, just as the play ends, in the throes of her final indignity, in the calamity of the “code on the no-code,” in the playing out of an egregious medical mistake, she is described as “naked and beautiful, reaching towards the light.” (p 85)

LESSONS FOR CLINICIANS

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

These themes, then, are among the central messages of the play. At its deepest level, it is not about health care professionals or the care of the dying. It is about “salvation anxiety”— the question of whether we, as human beings, finally have any worth or value independent of how we appear to others or what we even think of ourselves; whether we can recognize this in each other; whether we can reconcile ourselves to each other for our individual and collective failures to treat each other with such dignity; whether we can allow ourselves, finally, to be loved and forgiven; and whether this, ultimately, in any way saves us. Like Vivian, we all, one day, will take our final exam. But like Vivian, we do not understand the question and time is running out. (p 70)

To be forgiven, we must first understand that we have done wrong. And this is where physicians and other health care professionals can benefit most from this play. We need to learn, at least as professionals, what it is that is broken in our relationships and what it is for which we must say (coherently) that we are sorry. We do not learn from W;t any useful lines that we can use with patients, nor should we be led to believe that we can even learn which turns of phrase are especially unhelpful. It is not W;t. It is truth. The plot is not the point. What we need to learn is that we must be persons of reconciling love before we will ever be equipped to meet the needs of the dying. And that is a tall order.

BEYOND W;T'S END

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES

For what do we need forgiveness? The play does not tell us everything, but invites us, as persons, to ask this question. Collectively, as a profession of persons, we can begin to ask this question of ourselves. Grappling with this question may help make us better healers.

We need forgiveness, first of all, for our failure to recognize the dignity of our patients as persons.6 For the times we have treated them merely as objects of science or profit.7 For the times we have failed to learn from them as persons, learning only, as Vivian Bearing accuses Dr. Kelekian, enough to write papers about their ovaries (p 53). For our insensitivity, when we have acted like Jason, who does a pelvic examination, notes a problem, is unable to conceal his surprise at the findings, and never mentions it again to his terrified patient (p 31). For the times we have kept our patients at bay, have over-intellectualized our clinical world, and have created an atmosphere of isolation for them and for ourselves.8 For the times we have lied to our patients —“You're doing swell. Isolation is no problem. Couple of days. Think of it as a vacation.” (p 46)

We need forgiveness, secondly, from each other. For our petty jealousies, backbiting and detracting (“…subservience, hierarchy, gratuitous displays, sublimated rivalries…” p 37). For our cutthroat competitiveness as students, and in our practice and academic settings.9–11 For our overly harsh educational system that teaches by humiliation and sleep deprivation.12–14“Wake me up when the counts come back from the lab.” (p 45) For our collective denial of death and our failure to realize the limitations of our craft.15,16

Finally, we need to forgive ourselves — or to allow ourselves to be forgiven.17 For our individual limitations as practitioners. For the patients we have harmed through our ignorance, our rashness, or our indecisiveness, whether culpable or not.18–20 For our failure to embrace our own humanity, with its dignity and its limitations, casting ourselves in the roles of the superheroes we are not.21 Our most profound dignity comes not from our roles as health care professionals, but from the fact that we are persons.22,23

Unless we are prepared to deal with these issues of dignity and forgiveness in our own lives, we will not be able to deal with issues of dignity and forgiveness in the lives of those we serve. We share Vivian Bearing's predicament. “I thought being extremely smart would take care of it. But I see that I have been found out.” (p 70)

Is what comes between life and death a mere comma's worth of breath, or is the gap as wide as a semicolon (p 15)? Like John Donne, like Vivian Bearing, like Harvey Kelekian, we all face this question, each in our own way. And we answer, each in our own way. Like our patients, we have heard of “this promise of salvation,” and like them, we “just can't deal with it.” (p 76)

This promise has been written in the sometimes disappearing ink of dignity and forgiveness. And so, with fierce doubts, we face the play's starkly contradictory conclusion. “It [the promise of salvation] just doesn't stand up to scrutiny. But you can't face life without it either.” (p 76) The dying, especially, are painfully aware of this paradox. But until we realize that this is our paradox as well, Margaret Edson's brilliant play will be lost on us. And we will go on playing our usual roles as just the sorts of persons about whom satires will be written. If so, let us hope that our patients will forgive us anyway.

REFERENCES

  1. Top of page
  2. Abstract
  3. FORGIVENESS
  4. RELATIONSHIP
  5. DIGNITY
  6. LESSONS FOR CLINICIANS
  7. BEYOND W;T'S END
  8. REFERENCES