Real Man 3.0

Ethical Issues of the Literary Case Study

The literary case study could be seen as a method of introducing medical anomalies to the

general public. The case studies conducted by Oliver Sacks demonstrate an unethical and

demeaning portrayal of his subjects. Sacks’ genre of “romantic neurology” distinguishes the

disorder being studied from the actual patient being evaluated. Supporters of Sacks often credit

him for portraying his subjects in a sensitive and sympathetic way. In “The Cases of Oliver

Sacks: the Ethics of Neuroanthrpology”, Couser writes, “Sacks has a reputation for treating his

subjects scrupulously and sensitively, adopting generous estimates of their capabilities, and

presenting them compassionately” (Couser 1-12). However, there are several instances in “The

Man who mistook his Wife for a Hat” and “the Autist Artist” that challenge this positive review

of Sacks writing.

As I read “The Man who mistook His Wife for a Hat” and “The Autist Artist”, I noticed

that Oliver Sacks was trying to cater to two different audiences simultaneously. “The Man who

mistook his Wife for a Hat” was a recollection of several observations that Sacks made while

observing his patient, Dr. P. In the opening paragraphs of this essay, his discourse was written

for other scientists within his field of neurology. Thomas Couser described Sacks as presenting

strange neurobiological conditions to a “lay audience using nonclinical language” (Couser 1-12).

Psychological conditions such as ataxia and agnosia are not general knowledge terms and the

average reader may not know the definition. Sacks attempts to give the reader a brief overview

on the research done concerning damage to the left hemisphere of the brain and how ablations to

the right hemisphere have often been ignored by neurologists. This overview is insufficient for a

lay audience because the medical terms that Sacks uses are not commonly known to an

individual who is not part of his profession. Medical terms such as aphonia, aphemia, agnosia

and aphasia can be found within Sacks’ story, but are not defined for those who don’t understand

the conditions.

The role of the audience is often ignored when discussing the problems concerning

narrative medicine. It can be argued that doctors such as Sacks are only giving the people what

they demand, which is an inside view of unique and strange case studies. The reader is fascinated

by these stories that they would have otherwise not known about and are given inside knowledge

on the patients and their conditions. In his essay, “Narrative Medicine and Negative Capacity”,

Terence E. Holt states that the reason these stories exist is because people are willing to pay good

money to read them. The lay audience now has access to the “secrets of the examining room and

the operating room- all of these rooms once closed off- now so readily accessible” (Holt 318-

333). However, it’s in this revealing of case studies that causes a disruption in doctor-patient

confidentiality. The patients’ privacy is being violated by the same doctors they thought they put

their trust in when they first revealed their conditions. With the introduction of this new genre,

doctors like Sacks’ are no longer held responsible for respecting the privacy of their patient or

adhering to traditional medical guidelines. However, Sacks’ did receive permission from Dr.P as

well as the legal guardians of Jose before writing his stories.

Rita Charon offered another view of narrative writing in medicine in her essay,

“Narrative Medicine: Form, Function, and Ethics”. Rita herself is a physician that writes stories

about patients that have unique disorders. Her relationship with the patient was altered after she

had begun the narrative writings. She became more confident in her ability to understand what

was wrong with her patients. But unlike Sacks, Rita actively engaged with her patients and asked

for feedback when writing her stories. The patient was allowed to read and review the stories

before they were published, and often times the patient would respond with “you forgot

something” or “we left something out” (Charon 83). Charon avoided the breach in doctor-patient

confidentiality by obtained informed consent from the patient before sharing her stories with the

public.

The initial encounter with Dr. P was told in a comical manner. Examples of this were his

inability to recognize faces within his classroom as well as patting the heads of fire hydrants and

parking meters that he mistook as children. Also, the incidents of him trying to partake in

conversations with inanimate objects in his house could be seen as an embarrassing part of the

story for Dr. P. I understand that Sacks is giving the reader a back story to his patient’s condition

and may be trying to get us familiarized with Dr. P’s antics. However, I think he could have went

about explaining these situations in a more respectable way. Dr. P is described as delusional to

his own medical condition and was the running gag for the people who had come into contact

with him and witnessed his blunders.

When evaluating Dr. P in his office, Oliver Sacks claims to have known there was

something peculiar about him only after talking to him face to face. He noticed how the patient

only fixed his sight on parts of his face, such as the nose or ear lobes. The problem with this is

Sacks can easily look back on that moment in hindsight and say he knew all along that Dr. P had

the inability to view an object as a whole. This part could have been included to further

dramatize the story and makes Sacks inference skills seem better than they actually are.

Even in the scene where Dr. P mistakes his shoe for his foot, Sacks is including dialogue

between the two that may or may not have actually occurred. Whether or not this conversation

actually took place, Dr. P was presented in a foolish manner and the line “Ah! I thought that was

my foot” seems to have been included for comedic purposes. The comedic element can also be

seen when Dr. P nearly shakes hands with his grandfather clock, only to correct himself after he

hears the voice of Sacks.

The moment in which Dr. P mistakes his wife for a hat showcased his wife’s

obliviousness to her husband’s condition, she was described as noticing nothing wrong with her

husbands’ behavior. The audience may depict the wife as uncaring or incompetent because she

wasn’t able to identify her husband’s problem without the help of Sacks. A similar situation had

occurred later on in the story when Sacks was filing through Dr. P’s art collection that was

organized in chronological order. He noticed that throughout the years Dr. P’s paintings were

originally drawn in a naturalistic and very detailed manner, while later they evolved to abstract

cubist art and finally into confusing and nonsensical designs. Mrs. P attributed this change in

style as her husband’s evolving art development. Similar to the previous example mentioned,

some readers might consider Mrs. P foolish for not making a correlation with Dr. P’s abnormal

behavior and the drastic changes in his art work.

Throughout both “The Man who Mistook his Wife for a Hat” and “The Autist Artist”,

Sacks has made a comparison between his patients and children. Dr. P was given a glove and

Sacks asked him to what the object is. Dr. P was unsure of what he was holding and instead

spent time describing what he saw in parts instead of associating the object as a whole with a

glove. At one point he thought it could possibly be a coin holder due to it having five slots. Sacks

mentioned that a child would have been able to look at the glove and identify it as glove without

much trouble. In “The Autist Artist”, 21 year old Jose’s drawing of the fish was referred to as

“primitive” by Sacks’ and similar to the artwork illustrated by a child. Being compared to a child

could be seen as demeaning for grown men such as Dr. P and Jose even if they are unaware of

their conditions and what a “normal” person should be able to do.

At the conclusion of both stories Sacks fails to resolve the problems that his patients are

suffering from and suggested a nontraditional treatment. In “The Man who mistook his wife for a

Hat” Sacks’ advice for Dr. P was to continue being a musician and make music the center of his

life. The reason for this was because Dr. P was only able to associate objects when they were

accompanied by sound. Dr. P almost shook hands with a grandfather clock until Sacks began to

speak. Dr. P’s “inner music” is what drove his perception of the word and if that “inner music”

stopped he would become confused again. He also recognized the movements of his students and

identified them based on that. If a student remained still it would be impossible for him to know

who it was.

However despite “happy” ending, Dr. P will live continue to live the rest of his life in

confusion and disorder because Sacks was unable to keep in touch with him. The conclusion of

“The Autist Artist” is similar in that Sacks documented the life of Jose but failed to improve it in

anyway. He discussed how Jose should use his talent of photographic memory and artistry and

become an illustrator. But Sacks’ made no mention of informing Jose’s relatives or the hospital

attendees of his recommendation to put Jose’s talents to use. It’s as if he obtained his information

of these patients and stopped caring as soon as he got enough material to write his literary case

study.

The issue of ethics was introduced when Oliver Sacks administered several evaluation

tests for Dr. P to take part in, most of which were thought up on the spot. When he asked Dr. P to

watch a television program and describe the facial expressions of the actors. Dr. P was unable to

recognize any emotion on their faces. In response to this strange observance, Sacks refers to Dr.

P’s comments as “positively Martian”. To be Martian means that you’re figuratively from

another planet. This instance of poor word choice ties in with the freak show element of his

works and he tries to maintain a sense of bewilderment with his subjects. There are several

examples of questionable language that can be seen in “The Autist Artist”.

When criticizing Oliver Sacks dialogue throughout both of his stories, it should be noted

that the norms and politically correct terms we follow today did not exist when these works were

created. Also be aware that the morals held by a society are relative to the time frame in which it

existed. However Sacks was in the wrong when he referred to Jose as a “sort of being”, “a

strange species” and “a creature”. He is alienating his subjects and is distinguishing their

behavior from what he considers to be normal.

This issue introduces the problems involving ethics of narrative medicine. Thomas

Couser’s approach to discussing the ethics of Sacks’ literature is to first make a distinction

between the genre of “romantic science” and writing a psychological journal. According to

Couser, there is a difference between retaining ethical ideals and maintaining ethical obligations.

Sacks’ role as a life writer differs from his role as a physician, which means he is not obligated to

uphold ethical guidelines. In response to the critics Couser writes, “In any case, it may be unfair

to criticize him too harshly for failing to reach the very high standards he has developed on his

own , in deviation from the standards of his profession” (Couser 1-12). Perhaps with the

introduction of this newly created genre of narrative medicine, Sacks struggles to walk the line

between portraying his patients’ medical condition for the lay audience, and offending those

within the disabled community that he is representing.

The creation of a new genre should not grant Sacks immunity from following the ethics

of the medical field and failing to uphold patient-doctor confidentiality. Rita Charon agrees that

writers of nonfiction medical writing should be required to obtain informed consent from their

patients before publishing their stories to the public. She writes, “Even though names, dates, and

similar information might be changed, the affiliation of the author points to a given institution,

and the highly singular clinical details of illness make patients recognizable, even if only to

themselves, their families , and those who work in an author’s institution” (Charon 83). Dr. P

and Jose are patients with very unique medical conditions and stories that are unlikely to be

attributed to many other people.

In the conclusion of “The Autist Artist”, Sacks was describing various jobs that Jose

could partake in given his condition, such as being an illustrator for various different

publications. But Sacks goes on to say that Jose will most likely go on to do nothing and “spend

a useless, fruitless life, as so many other autistic people do, overlooked, unconsidered, in the

back ward of a state hospital” (Sacks 1-10). Also within the opening paragraphs of the story, he

recalls a conversation he had with a hospital attendant that calls Jose “an idiot” (Sacks 1-10).

This could be seen as offensive to the workers of the hospital he visited in his story as well as

criticizing Jose’s family for allowing him to spend the rest of his life in the hospital and not

reaching his full potential. It can be considered that Sacks’ critique of hospitals and the

undervaluing of people like Jose may cause them to change the way they treat their patients and

acknowledge the gifts that they possess.

Another problem that needs to be considered when evaluating Sacks’ literature is the way

in which his patients are represented. In “Paradigm’s Cost: Representing Vulnerability”, Thomas

Couser writes, “Such representation poses ethical problems, especially when the conditions in

question render the subjects unable to represent themselves or even to collaborate in an informed

way with others who undertake to represent them” (Couser 19-30). This best represents the case

study of Jose, whose autism rendered him unable to effectively represent his true emotions and

feelings to Sacks.

In “The Autist Artist”, Jose’s only form of self-representation comes from his illustration

abilities. When Sacks asked Jose to sketch the picture of the fish from the photo, Jose was ability

to draw the fish with a distinct personality. Jose’s ability to transform the photograph using his

imagination distinguished him from other autistic children who lacked those abilities. Also,

unlike other autistic children who are diagnosed with the disease before they turned three years

old, Jose lived a normal life until the age of nine. Sacks’ believes Jose knows what it was like to

be social and attend school like a normal child, and that’s something other autistics cannot

understand. Jose’s life changed after being diagnosed with verbal auditory agnosia, a disease

that rendered him unable to understand the speech of others and had caused him to become mute.

The problem with “The Autist Artist” is the way in which Sacks interprets the life Jose

may or may not have lived, and believed he knew what was best for him. The first instance of

this is when Sacks uses Jose’s chart records to create aback story. Constant seizures and

deteriorating mental functioning had caused his parents to move his room into the basement,

where he would be isolated from normal life. Jose’s only true connection with the outside world

was a national geographic magazine that he loved to look at. However, a violent outburst by Jose

made his parents decide that it would be best if he is sent to a mental hospital. The problem here

is not in the back story itself, but the reason Sacks gives to explain Jose’s sudden change in

behavior. Sacks’ believes that Jose’s outburst was a final, desperate call for help. He also thinks

Jose moving out of his parents’ basement was a lifesaving experience, and there is no doubt that

Jose feels the same way.

Obviously the issue with that assumption is that nobody knows what Jose is actually

thinking because he is incapable to representing himself. Couser stresses this point by stating,

“Individuals with disabilities that preclude or interfere with self-representation are thus doubly

vulnerable subjects” (Couser 19-30). Sacks’ also infers that Jose was tempted to make some

form of interaction with others, but felt he restricted himself due to the fact that he lived in a

basement for so many years. Living in solidarity became the norm for Jose. Sacks’ took his

assumptions even further after he asked Jose to redraw the picture of the fish. Unlike last time,

Jose drew a second fish in the picture that was not previously there, along with a tidal wave in

the background. Sacks’ felt the bigger fish in the drawing symbolized him, and Jose drew

himself as the smaller fish. The wave in the background was described by Sacks as angry and

avenging.

Sacks is unable to discover the true meaning behind Jose’s actions because any

conclusion that he reaches will be based on assumption and not on facts. Jose’s attempt at

speaking was also attributed to the progress he made within the hospital. Sacks’ believes Jose

lacked the motivation to speak with others and was hopelessly accepting of his impairments.

This may or not be the truth, but Sacks should not jump to these conclusions without proper

evidence. In the final paragraphs of “The Autist Artist”, Sacks tells the reader that Jose’s

illustrative talents will most likely never be put to use, and he will live the rest of his life in the

hospital. Thomas Couser discusses this exclusion of the abnormal in his writing by stating,

“Representation that deploys the social paradigm tends to be beneficial because it acknowledges

that disability is everybody's business and that disability may be better addressed (more

effectively and universally) by accommodation than by rehabilitation” (Couser 19-30). Placing

Jose in the hospital is essentially separating him from the real world. That comment is not

directed towards Sacks, but to society as a whole that prefer to exclude people like Jose and

place them in mental institutions, rather than accommodating them into their society.

Another problem with the portrayal of subjects is trying to represent not only that person,

but the entire community of people with similar disorders. At the time of writing, “The Man who

mistook his Wife for a Hat”, Dr.P was the only known case involving someone with severe

visual agnosia and prosopagnosia. However, in the stories postscript, Sacks gave several

examples of patients who demonstrated similar characteristics of Dr.P. One patient was unable to

distinguish the faces of his cows, and another patient mistook his reflection for an ape in a

museum diorama. One subject in particular was unable to recognize faces as a whole, which was

similar to what Dr.P was experiencing. The only way this patient was able to distinguish between

people was by the sound of their voice and distinct physical traits. He identified three of his

coworkers with an eye blinking tic, a large mole on their cheek, and the tall stature of the third

employee. Even though the condition shared by these individuals is very rare, narrative writers

must accommodate to all of them even if they are only documenting a single case.

On the other hand, Jose is even trickier to represent because of his unique abilities that

separate him from other autistic children. Thomas Couser identifies the problem of associating

certain individuals with a larger community, he states, “How is membership determined and by

whom? Is mere possession of a particular impairment enough, or does membership involve

conscious affiliation?” (Couser 19-30). Although Jose doesn’t share similar traits to the average

autistic patient due to his imaginative abilities and interpretations, being classified as autistic

would be enough to associate him with the entire group.

The final medical narrative written by Oliver Sacks that will be closely examined is

titled, “Witty Ticcy Ray”. The main subject of the story is named Ray, and the disorder that he is

suffering from is tourettes syndrome. People who are diagnosed with tourettes often experience

uncontrollable tics, strange impulses and outrageous outbursts, the severity of which varies on a

case to case basis. Tourettes was once thought to be a very rare disease that affected one in a

million people. However, Sacks discovered that the disorder was much more prevalent than

anyone had previously thought. Unlike people with conditions similar to that of Dr.P and those

with autism, patients with tourettes syndrome are fully aware of their condition and often play in

active role in spreading awareness of their disorder in an attempt to alter the public’s perception

of them and see them in a more positive light.

Sacks’ describes Ray’s personality as witty and charming, as well as demonstrating a

high intelligence. These characteristics allowed Ray to successfully complete college and get

married. However, his violent tics and constant outburst of profanity had caused him being

stigmatized by his employers. This resulted in Ray being fired from numerous jobs and was

unable to form any meaningful social connections after graduating from college. People started

to judge him on his disorder and not by his character. Ray was even able to diagnose himself

with tourettes after reading an article from the “Washington Post”, this was something Dr.P and

Jose were unable to accomplish themselves. The title of the story, “Witty Ticcy Ray” was a

nickname that Ray had given himself due to him constantly referring to himself in the third

person.

“Witty Ticcy Ray” shares similarities with, “The Man who mistook his Wife for a Hat”,

in that Sacks adds a humorous element to both stories. After Ray was prescribed with a drug

called haldol, his reaction time and coordination were greatly reduced. He ran full speed into a

revolving door and stumbled along the way, resulting in a black eye and a broken nose. Sacks

said the reason he injured himself was due to the fact that patients with tourettes are attracted to

spinning objects. This could be offensive to people with tourettes syndrome because it’s

describing them as injury prone and sporadic in their behavior.

However, the largest ethical concern of this story occurs during Sacks’ weekly

conversations with Ray to convince him to keep taking the haldol. Sacks’ asked Ray to imagine a

life without tourettes syndrome. Compared to the life he has now, this tourettes free life would be

a change for the better, opening new doors for Ray, socially and economically. After the three

month session with Sacks, Ray decides he will take the medicine everyday in an attempt to live a

normal life. After conquering the symptoms of tourettes, Ray stabilized his marriage and his

friends no longer refer to him as a accomplish tourettes clown.

There are several issues regarding the section of this story. Tourettes syndrome is being

perceived as an undesirable trait and Sacks was giving a sense of hope in overcoming the

disorder. The problem is that people within the Tourettes Syndrome Association are trying to

spread awareness and acceptance of their disorder. Sacks’ is essentially portraying the opinion

that a tourettes sufferer is better off getting rid of the disease entirely than to continue living with

it. This can cause the public to lose empathy for those with tourettes, believing it’s a disease that

can be fully managed and making public acceptance for the disorder harder to obtain. Thomas

Couser uses the example of the film “Million Dollar Baby” in which the protagonist a boxer who

becomes a paraplegic after being sabotaged by an opposing boxer. “And it is misleading to

suggest, as the film does, that her decision is ‘for the best’ and a truly free choice. While

presumably no actual paraplegics were harmed in the production of the film, it may be fair to say

that all paraplegics were harmed by it” (Couser 19-30). The main character decides that being

taken off life support and dying was a better fate than living her life as a paraplegic. Putting a

tourettes patient on a drug like haldol is essentially taking away their true personalities and

transforming them into socially acceptable individuals. Ray himself noticed that he no longer

possessed the same characteristics he had throughout the majority of his life. He lost his music

prowess, his fast reaction time, his trademark outbursts, and his killer instinct during sporting

events. He decided to only take haldol during the weekdays where he would need it for his job.

However, on weekends he will not to take the drug and no longer be tied down by social

constructs and being told how he should or should not act. He would rather be his old wild and

frenetic self, even if it’s only for two days.

References

C h a r o n , R i t a . " N a r r a t i v e M e d i c i n e : F o r m , F u n c t i o n , a n d E t h i c s . "   A n n a l s o f I n t e r n a l M e d i c i n e   1 3 4 . 1 ( 2 0 0 1 ) : 8 3 . W e b . 1 4 A p r 2 0 1 1 . < h t t p : / / w e b . e b s c o h o s t . c o m . l i b p r o x y . a l b a n y . e d u / e h o s t / d e t a i l ? s i d = 7 95 9 d 2 b 6 - 1 4 9 2 - 4 3 f 4 - 9 e 2 a - 2 3 0 6 2 8 7 7 1 e d d

% 4 0 s e s s i o n m g r 1 5 & v i d = 1 & h i d = 7 & b d a t a = J n N p d G U 9 Z W h vc 3 Q t b G l 2 Z Q % 3 d % 3 d # d b = a 9 h & A N = 4 6 1 1 0 8 2 > .

C o u s e r , T h o m a s . " " P a r a d i g m ' s C o s t : R e p r e s e n ti n g V u l n e r a b l y S u b j e c t s . " L i t e r a t u r e a n d M e d i c i n e 2 4 . 1 ( 2 0 0 5 ) : 1 9 - 3 0 . W e b . 2 1 A p r 2 0 1 1 . < h tt p : / / m u s e . j h u . e d u . l i b p r o x y . a l b a n y . e d u / j o u r n a l s / l i t e r a t u r e _ a n d _m e d i c i n e / v 0 2 4 / 2 4 . 1 c o u s e r . h t m l > .

C o u s e r , T h o m a s . " T h e C a s e s o f O l i v e r S a c k s : T h e E t h i c s o f N e u r o a n t h r p o l o g y . "   B l o o m i n g t o n , I N ( 2 0 0 1 ) : 1 - 1 2 . W e b . 3 1 M a r 2 0 1 1 . < h t t p : / / p o y n t e r . i n d i a n a . e d u / p u b l i c a t i o n s / m - c o u s e r . p d f > .

H o l t , T e r e n c e . " N a r r a t i v e M e d i c i n e a n d N e g a t i v e C a p a b i l i t y . "   L i t e r a t u r e a n d M e d i c i n e   2 3 . 2 ( 2 0 0 4 ) : 3 1 8 - 3 3 3 . W e b . 3 1 M a r 2 0 1 1 . < h t t p : / / m u s e . j h u . e d u . l i b p r o x y . a l b a n y . e d u / j o u r n a l s / l i t e r a t u r e _ a n d _m e d i c i n e / v 0 2 3 / 2 3 . 2 h o l t . h t m l > .