Liam Butchart
Stony Brook, New York

Since the development of medical literature studies in the 1970s, the field has grown and expanded in many fascinating ways.¹ For example, courses in medical schools now encourage students to examine their own biases and emotional responses, and medical literature scholars emphasize the educational and clinical value of learning to work with humanistic data in all of its abstract and plural meanings.^{2, 3} As Hawkins and McEntyre write, literature and medicine “have a long history of cross-pollination.”⁴ Hunter et al suggest that one of the major pedagogical goals of studying literature is to “enhance the student’s ability to understand the experiences, feelings, and values of other persons.”⁵ Medical literature studies’ emphasis on compassionate care then points directly to George Engel’s biopsychosocial model (hereafter, the BPS model). The BPS model is, in the broadest sense, a way of approaching patients that emphasizes the distinctive but interconnected ways that different facets of their phenomenal experiences—the physical world, their inner worlds, and the social worlds that they inhabit—all contribute to illness and disease.⁶

The BPS model often appears in medical humanities courses because of its clinical importance: it requires a different perspective on suffering and disease, and it also directs clinicians to emphasize dialogue with patients, which necessarily entails acquiring and analyzing more abstract detail.⁷ As a result, the BPS model is often invoked in texts that emphasize compassionate care; it comes up extensively in Arthur Kleinman’s The Illness Narratives, for example.^8-10 However, Ghaemi notes that not every thinker has drawn this connection between the BPS model and the medical humanities—some have explicitly rejected it.¹¹ Engel, for example, explicitly spurned medical humanism, writing, “the younger generation is very ready to accept the importance of learning more about the psychosocial dimensions of illness and health care . . . Once exposed to such an approach, most recognize how ephemeral and insubstantial are appeals to humanism and compassion when not based on rational principles.”¹² But a survey of the medical humanities literature indicates that many writers disagree with Engel’s position, and maintain that the BPS model and the humanities can operate synergistically.^{13, 14}

I will not try and mediate whether the BPS model endorses the use of humanism in medical theory and practice; rather, I will argue that the humanities would benefit from the BPS model, a component of what I call the medical lens. To support my position, I will examine Albert Camus’s 1942 novel The Outsider (in French, L’étranger; in other English translations, The Stranger).¹⁵ My analysis will attempt to evaluate the novel through the BPS model in order to elucidate what the theoretical structures derived from the sciences, rather than the humanities, can bring to literary discourse. It is worth noting that this is only a prospective look at how the BPS model may be applied to literature.

The Outsider revolves around the experience of Meursault, a man who, in Camus’s words, “does not play the game.”¹⁶ In situation after situation, Meursault fails to live up to society’s expectations of his feelings and actions: his most grievous offense is when he shoots an Arab man for seemingly inexplicable reasons. The first part of the novel follows his narrative as he experiences all of these events, and the second focuses more on exploring his ruminations during his incarceration and trial. Meursault’s story offers an interesting corollary of the biopsychosocial model: in court, Meursault states that he shot the Arab “because of the sun.”¹⁷ But there is much more to Meursault and his actions than simply the sun; rather, there is a variety of impulses that drive his actions and form his experience. This dynamic parallels that of the BPS model, where the pluralism of experience is baked into the theory, making it a facile paradigm for examining the novel.

The first part of the BPS model concerns physical phenomena—how biological processes impact experience and cause disease. In this reading, we can accede to Meursault’s declaration of the causation of the sun being in his eyes, but with some nuance. Interestingly, Meursault’s statement before the court differs significantly from his internal monologue at the time of the shooting. At the end of Part I, Meursault thinks:

The burning sun struck my cheeks and I could feel drops of sweat gathering above my eyebrows . . . it was my forehead that hurt the most and I could feel every vein throbbing beneath my skin. I was being burned alive; I couldn’t stand it any more so I took a step forward. I knew it was stupid; I knew I couldn’t shake off the sun by simply taking one step . . . the Arab pulled out his knife and raised it towards me in the sun. The light flashed off the steel and it was as if a long gleaming blade was thrust deep into my forehead. At that very moment, the sweat that had gathered on my eyebrows suddenly rushed down into my eyes, blinding me with a warm, heavy veil of salts and tears . . . The sky seemed to split apart from end to end to pour its fire down upon me. My whole body tensed as I gripped the gun more tightly. It set off the trigger.¹⁸

Meursault is describing far more than simply the sun shining in his eyes; he is having what seems like a distinct physiological reaction to his environmental conditions, such that he is not choosing to step forward and shoot the gun, but is rather being forced to by the physical world around him. One possible medical analysis of this passage could try to argue that it is illustrating the experiential impacts of different disorders: for instance, porphyria could manifest as an extreme sensitivity to light, or psychosis brought on by external stimuli could cause Meursault’s perceived lack of agency. But my own assertion is simply that the passage illustrates that the biological world can deeply influence people in their actions and inner experiential states; claiming that Meursault has one of these diseases is not easily defensible with the text of the novel.

The Outsider also reflects the significant ways that psychological health can impact decisions. The novel begins with Meursault stating, “My mother died today. Or maybe yesterday, I don’t know.”¹⁹ His apparent lack of grief at the passing of his mother is a recurring motif in the story: Meursault travels to his mother’s funeral and does not shed a tear,²⁰ he begins an intimate relationship immediately after the funeral with Marie,²¹ and he can only tell his lawyer that he “would have preferred it if Mama hadn’t died.”²² These instances of apparent indifference are tied together by the prosecuting attorney in the trial, who argues that Meursault’s pattern of psychological detachment, combined with his apparent lack of remorse for the shooting, marks him as a deviant who must be put to death.²³ Of course, there are many different psychoanalytic readings of Meursault and his character, but the point that the prosecutor is making is one that fits with this analysis well: that Meursault’s internal psychological state connects to his actions. Meursault is under significant unresolved stress from the death of his mother—he thinks of her through to the last paragraph of the text, where he considers her own mental state at the end of her life.²⁴ Maybe the prosecutor is correct, and Meursault shoots the Arab to clean up a loose end from the earlier confrontation at the beach, and his lack of disquietude is due to an underlying psychopathology. Even if the prosecutor is wrong, however, the import of Meursault’s psychological state on his actions is clear.

Finally, there is the social component of the BPS model. In this case, we can examine how Meursault is influenced by all sorts of social interactions to make the choice to shoot the Arab. However, one that fundamentally defines the story is the fact that Meursault himself is racially distinct from the Arab—he is a pied-noir, a French Algerian.²⁵ Meursault’s status as a pied-noir places him in conflict with the more indigenous people of the region (like the Arab); interestingly, it also seems as though he is also in conflict with the environment during the novel. This is seen most violently in the scene where he shoots the Arab due to the sun, but Meursault has struggled with the outside world during the whole novel: the heat overpowers him and makes him drowsy during the funeral, and its oppressive force appears over and over again.²⁶ Then, when he is in prison, Meursault’s desire to escape into the cooling sea become obsessive.²⁷ The ecological and social conflicts inherent to Meursault’s ethnic status impact how he interacts with the world and makes decisions—like shooting the Arab.²⁸

On face, none of these individual discussions are necessarily novel. However, when put together, they become both summative and illustrative of the utility of the BPS model for literary discourse—for focusing and combining discrete strands of analysis—one that takes as its axiom the multiplicity of meaning. The BPS model illustrates, in the realm of literary theory, a phenomenon that physicians have already identified in their patient interactions: that the same symptoms can be evaluated and treated radically differently based on alternative explanatory paradigms.²⁹ The medical lens, exemplified by the use of the BPS model as a framework for literary analysis, has a great deal to offer to the larger literary discourse by introducing another way to consider the texts before us.

End notes

1. Hunter, Kathryn Montgomery, Rita Charon and John Coulehan, “The Study of Literature in Medical Education,” Academic Medicine 70, no. 9 (1995): 787-788.
2. Shapiro, Johanna, Jack Coulehan, Delese Wear and Martha Montello, “Medical Humanities and Their Discontents: Definitions, Critiques, and Implications,” Academic Medicine 84, no. 2 (2009):194-195.
3. Skelton, JR, Macleod, JAA, and CP Thomas, “Teaching literature and medicine to medical students, part II: why literature and medicine?” The Lancet 356 (2000): 2001.
4. Hawkins, Anne Hunsaker and Marilyn Chandler McEntyre, “Introduction: Teaching Literature and Medicine: A Retrospective and a Rationale,” in Teaching Literature and Medicine, ed. Anne Hunsaker Hawkins and Marilyn Chandler McEntyre (New York: Modern Language Association, 2000), 1-3.
5. Hunter et al, “Study of Literature,” 789.
6. Engel, George, “The Clinical Application of the Biopsychosocial Model,” The American Journal of Psychiatry 137, no. 5 (1980): 536-538.
7. Puustinen R, Leiman M, and AM Viljanen, “Medicine and the humanities – theoretical and methodological issues,” Medical Humanities 29 (2003): 78.
8. See Kleinman, Arthur, The Illness Narratives: Suffering, Healing & the Human Condition (New York: Basic Books, 1988).
9. See Epstein RM, “Realizing Engel’s biopsychosocial vision: resilience, compassion, and quality of care,” The International Journal of Psychiatry in Medicine 47, no. 4 (2014): 275-287.
10. See Kusnato H, Agustian D, and D Hilmanto, “Biopsychosocial model of illnesses in primary care: A hermeneutic literature review,” The Journal of Medicine and Primary Care 7, no. 3 (2018): 497-500.
11. Ghaemi, S Nassir, “The rise and fall of the biopsychosocial model,” The British Journal of Psychiatry 195 (2009): 4.
12. Engel George, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196, no. 4286 (1977): 135.
13. See Bhugra, Dinesh and Antonio Ventriglio, “Social sciences and medical humanities: the new focus of psychiatry,” BJPsych International 12, no. 4 (2015): 79-80.
14. See Puustinen R, Leiman M, and AM Viljanen, “Medicine and the humanities – theoretical and methodological issues,” Medical Humanities 29 (2003): 77-80.
15. Camus, Albert, The Outsider, trans. Sandra Smith (London: Penguin Books, 2013).
16. Qtd. in Carroll, David, Albert Camus the Algerian: Colonialism, Terrorism, Justice (New York: Columbia University Press, 2007), 27.
17. Camus, The Outsider, 93.
18. Camus, The Outsider, 53-54.
19. Camus, The Outsider, 3.
20. Camus, The Outsider, 9-10.
21. Camus, The Outsider, 17.
22. Camus, The Outsider, 58-59.
23. Camus, The Outsider, 90-93.
24. Camus, The Outsider, 110-111.
25. Kulkarni, Mangesh, “The Ambiguous Fate of a Pied-Noir: Albert Camus and Colonialism,” Economic and Political Weekly 32, no. 26 (1997): 1528.
26. Camus, The Outsider, 8-10, 15-16.
27. Camus, The Outsider, 69.
28. See DeLoughrey, Elizabeth and George Handley, Postcolonial Ecologies: Literatures of the Environment (Oxford: Oxford University Press, 2011).
29. Jaber, Raja, Steinhardt, Susan, and Jeffrey Trilling, “Explanatory Models of Illness: A Pilot Study,” Family Systems Medicine 9, no. 1 (1991): 40.

References

1. Bhugra, Dinesh and Antonio Ventriglio. “Social sciences and medical humanities: the new focus of psychiatry.” BJPsych International 12, no. 4 (2015): 79-80.
2. Camus, Albert. The Outsider. Translated by Sandra Smith. London: Penguin Books, 2013.
3. Carroll, David. Albert Camus the Algerian: Colonialism, Terrorism, Justice. New York: Columbia University Press, 2007.
4. DeLoughrey, Elizabeth and George Handley. Postcolonial Ecologies: Literatures of the Environment. Oxford: Oxford University Press, 2011.
5. Engel, George. “The Clinical Application of the Biopsychosocial Model.” The American Journal of Psychiatry 137, no. 5 (1980): 535-544.
6. —. “The Need for a New Medical Model: A Challenge for Biomedicine.” Science 196, no. 4286 (1977): 129-136.
7. Epstein RM. “Realizing Engel’s biopsychosocial vision: resilience, compassion, and quality of care.” The International Journal of Psychiatry in Medicine 47, no. 4 (2014): 275-287.
8. Ghaemi, S Nassir. “The rise and fall of the biopsychosocial model.” The British Journal of Psychiatry 195 (2009): 3-4.
9. Hawkins, Anne Hunsaker and Marilyn Chandler McEntyre. “Introduction: Teaching Literature and Medicine: A Retrospective and a Rationale.” In Teaching Literature and Medicine, edited by Anne Hunsaker Hawkins and Marilyn Chandler McEntyre. Modern Language Association (2000): 1-25.
10. Hunter, Kathryn Montgomery, Rita Charon and John Coulehan. “The Study of Literature in Medical Education.” Academic Medicine 70, no. 9 (1995): 787-794.
11. Jaber, Raja, Steinhardt, Susan, and Jeffrey Trilling. “Explanatory Models of Illness: A Pilot Study.” Family Systems Medicine 9, no. 1 (1991): 39-51.
12. Kleinman, Arthur. The Illness Narratives: Suffering, Healing & the Human Condition. New York: Basic Books, 1988.
13. Kulkarni, Mangesh. “The Ambiguous Fate of a Pied-Noir: Albert Camus and Colonialism.” Economic and Political Weekly 32, no. 26 (1997): 1528-1530.
14. Kusnato H, Agustian D, and D Hilmanto. “Biopsychosocial model of illnesses in primary care: A hermeneutic literature review.” The Journal of Medicine and Primary Care 7, no. 3 (2018): 497-500.
15. Puustinen R, Leiman M, and AM Viljanen. “Medicine and the humanities – theoretical and methodological issues.” Medical Humanities 29 (2003): 77-80.
16. Shapiro, Johanna, Jack Coulehan, Delese Wear and Martha Montello. “Medical Humanities and Their Discontents: Definitions, Critiques, and Implications.” Academic Medicine 84, no. 2 (2009):192-198.
17. Skelton JR, Macleod JAA and CP Thomas. “Teaching literature and medicine to medical students, part II: why literature and medicine?” The Lancet 356 (2000): 2001-2003.