Introduction: Illness and hospital as unfamiliar territory
Sontag’s characterization of the illness experience as an entry into the
“kingdom of the sick” aptly captures the displacement that people may
experience when they, or their loved ones, become patients. Both the
illness itself and the unfamiliarity of what is happening with one’s own
or a loved one’s body, and the new territories associated with the
illness—physicians’ offices, waiting rooms, hospital wards, et
cetera—can lead to a profound disorientation and need for guidance.
Just as when one enters a new geographic territory and encounters new
languages, customs, people, spaces, sounds, and smells, the kingdom of
the sick comes with its own language, customs, people, spaces, sounds,
and smells.
This disorientation has been recognized in the medical humanities. Frank
opens his book with these words of a patient with a chronic illness:
“The destination and map I had used to navigate before were no longer
useful.”2 Biro similarly describes the alienation and
estrangement that patients experience from their bodies and the rest of
the world. With reference to Sontag’s geographical metaphor, he writes:
“Entering the land of the ill, personally or vicariously (caring for
loved ones or listening to and reading the stories of patients), we
quickly realize how consuming the experience is.”3
Attending to all aspects of the experience of illness, including this
disorientation, are part of a physician’s professional purview. The
needs of patients newly arrived in the “kingdom of the sick” are often
myriad, however, and may place significant requests upon physicians
already busy with the demands of clinical practice. In part to ensure
that physicians account for these needs, professional organizations have
invoked the core value of altruism, “the capacity to put the needs and
interests of another before your own.”4 Yet
reconciling altruism, a concept that is not only “intangible and
opaque”5 but also limitless, with the realities of
contemporary healthcare may lead to “burnout, work–life imbalance and
overall career dissatisfaction.”6 As such, governing
and accrediting bodies7,8,9 have put some limits on
altruism by recognizing, to varying degree, the need for physicians to
also care for themselves. In the interest of self-preservation, some
physicians may simply not acknowledge the disorientation and alienation
that accompany illness, or consider them beyond their biomedical
responsibility.
How might we re-interpret the laudable value of altruism in such a way
that it supports physicians in charting a course away from the dangers
of over-commitment and burnout, while also recognizing the core need for
patient guidance and support in the unfamiliar terrain of the “kingdom
of the sick”? We might examine this issue in more depth through
exploring one part of this kingdom with which many physicians are
intimately familiar: the acute care hospital environment.
It is easy to forget that the hospital’s landscapes and the movements,
sounds, and medical discourse that flow through them – so natural to
physicians after years of training and practice such that the hospital
has become a second home to them – is often jarringly unfamiliar and
unhomelike10 for patients and their families. As one
way, then, to attend to the lofty desires of altruism yet ground them in
the complex realities of providing health care, this paper proposeshospitality as an ethical framework that is particularly
well-tailored to the hospital context in which a significant proportion
of medical education and health care continue to unfold. Hospitality, in
the way in we will discuss it – namely based on the work of the French
philosopher Jacques Derrida – is altruistic in the sense that it is
other-centred, but it also takes into account the context in which some
people come to function as hosts, whereas others find themselves in the
position of guests, visitors, or strangers. Moreover, an ethic of
hospitality pushes back against more behaviouristic and
assessment-driven conceptions of altruism,5 clearly
insisting that it is an ethic that cannot be perfected and evading the
“moral calculus” and certainty of knowing one has done the right
thing.
The paper will first explore the hospital as a place in which people
seek relief from the unhomelike state of illness. It will outline a
Derridean ethic of hospitality, exploring it in the context of other
literature on altruism, while arguing for its ability to provide a
sharper focus upon medical practice and education than the concept of
altruism currently does. It will then present and analyze the
(composite) case of parents bringing their four-month-old infant with
breathing difficulties to medical attention in order to demonstrate how
this ethical framework situates an individual health care provider into
a specific type of response to the demands of patient care. Finally, it
will offer some considerations for how an ethic of hospitality might be
optimally integrated into medical education curricula.