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.