Angad Tiwari
India
Mallika Khurana
Japan

William Carlos Williams (1883-1963), regarded as “the most important literary doctor since Chekhov,” was an American Pulitzer prize-winning writer and poet who stands amongst the few full-time practicing physicians to have achieved literary distinction.¹ He regarded art and medicine as “two parts of a whole,” and the intimate doctor-patient interface proved a powerful inspiration for his writing.¹ “The Use of Force” written in twentieth century America is a testimony to his literary prowess and was first published in his short story collection, Life Along the Passaic River (1938). The incident is described in rather simple and literal terms, with no quotations around the dialogue, making it move with urgency and keeping everything straightforward, which also gives the readers a sense of realism.

The narrative opens up with a transaction between the mother of a sick child and the doctor. The conflict begins right away and escalates throughout the plot. The story is suggestive of the 1930s, the era of the Great Depression in the United States. This is perhaps why the narrator remarks that the parents were spending three dollars on his consultation, which suggests that the child must be alarmingly sick. It may also be another reason why the parents refuse to pay heed to the child’s behavior, as they were evidently spending a fortune during the economic depression and are embarrassed by the kid causing a commotion in front of the doctor. We also witness signs of condescension from the doctor where he describes the child’s appearance “as strong as a heifer” which depicts a sense of noblesse oblige. The doctor goes on to show a lot of pathos for the child and goes to examine the child’s mouth, only for it to turn out to be a futile attempt in the end; the child does not cooperate which in turn infuriates the doctor. The narrator goes on to remark, “then the battle began I had to do it,” which suggests the use of force as a necessary evil.² In order to examine the child, the doctor had to force open her mouth to check for diphtheria which could be lethal. The use of force was ironic because the girl’s mother assured her that the doctor would not hurt her. This whole transaction also suggests that when a person in authority is empowered to use force, they may go beyond rational limits and exhibit a nature of sadism.

The young girl in the story does everything to protect herself from the doctor and is portrayed as an extremely headstrong character. The doctor seems to identify with his patient and he goes on to say, “I had already fallen in love with the savage brat, the parents were contemptible to me.”² As they engage in an uncouth battle of wills, the doctor attests to the use of force against Mathilda, the sick child, by convincing himself that it’s for her own good. However, the violence of his examination and the pleasure he takes in her resistance calls the morality of his actions into question and suggests the limitation of consent.

As clinicians, we face this paradox of choice—to respect the autonomy of the patient and also to protect the individual against any physical or psychological harm. This attitude has been well described by Dr. Atul Gawande, “Only a decade ago, doctors made the decisions, patients did what they were told. Doctors did not consult patients about their desires and priorities, they were regarded as children: too fragile and simple minded to handle the truth, let alone make decisions.”³

There is no one-size-fits-all when it comes to medical intervention as the physician-patient relationship is dynamic. To limit any potential for liability, the physician must assess and contextualize each patient-physician relationship individually and identify the level of response in the first few moments of the interaction. This “first-moment” patient response also provides the physician a stencil for his decision-making process, which is co-guided by informed consent. The “informed consent” agreement holds an immensely crucial position in the doctor-patient alliance, which is, however, easily overstepped by a “wrong call” taken in haste by the doctor, who might have good intentions. Thus, doctors have more often than not been painted as the “dreadful heroes” in the health care industry. The dynamics of said relationship are fragile which necessitates keeping in mind the lawfulness of the action being taken. Thus, the decision-making process is a composite motif comprising various factors that have to be considered, including the humanitarian aspect of the situation. The art of medicine requires the manifestation of patience, deliverance, diligence, and experience, in order to create the perfect experience for both the patient and the physician.

References

1. Carter R. William Carlos Williams (1883–1963): physician-writer and “godfather of avant garde poetry”. The Annals of thoracic surgery. 1999;67(5):1512-1517.
2. Williams WC. The use of force. The Social Medicine Reader, Volume I, Third Edition: Duke University Press 2019:32-35.
3. Paterick TJ, Carson GV, Allen MC, et al. Medical informed consent: general considerations for physicians. Mayo Clinic Proceedings: Elsevier 2008:313-319.