by John Berger
Yet however he argues, the disquieting questions return. And the harder he works, the more insistently they are posed. Whenever he makes an effort to recognize a patient, he is forced to recognize his or her undeveloped potentiality. Indeed in the case of the young or early-middle-aged it is often this which prompts the appeal for help – like the cry of a passenger who suddenly realizes that the vehicle in which he is travelling is not even going near the destination he believed he was making for. If as a doctor he is concerned with the total personality of his patients and if he realizes, as he must, that a personality is never an entirely fixed entity, then he is bound to take note of what inhibits, deprives or diminishes it. It is the inwritten consequence of his approach.
He can argue that the foresters are in some respects fortunate compared to the majority of people in the world. But what is far more relevant to his own preoccupations is that he knows that the foresters are in almost all respects unfortunate compared to what they could be – given better education, better social services, better employment, better cultural opportunities, etc.
Talk of the ‘bad old days’ before the war can encourage a certain superficial belief in progress. But faced with the young – and the prospects before them – it is hard to maintain any such belief. Sassall is forced to acknowledge that, by his own standards, they are having to settle for a fifth best.
The situation by no means leaves him helpless. He can safeguard their health. Through the Parish Council he can urge improvements in the village. He can explain children to parents and vice versa. His word about a boy or a girl can carry some weight in the local schools. He can try to extend the meaning of sex for them. But the more he thinks of educating them – according to the demands of their very own minds and bodies before they have become resigned, before they accept life as they find it – the more he has to ask himself: by what right do I do this? It is not certain that it will make them socially happier. It is not what is expected or wanted of me. In the end he compromises – as the limitations of his energy would anyway force him to do; he helps in an individual problem, he suggests an answer here and an answer there, he tries to remove a fear without destroying the whole edifice of the morality of which it is part, he introduces the possibility of a hitherto unseen pleasure or satisfaction without extrapolating to the idea of a fundamentally different way of life.
I do not want to exaggerate Sassall’s dilemma. It is one that many doctors and psychotherapists have to face: how far should one help a patient to accept conditions which are at least as unjust and wrong as the patient is sick? What makes it more acute for Sassall is his isolation, his closeness to his patients and a bitter paradox which we have not yet defined.
I believe that Sassall’s disquiet is provoked, not by individual issues or cases because then all his attention is absorbed in ‘feeling his way’ and in reckoning how far he can go, but by the constant contrast between the general expectations of his patients and his own.
The average forester of over twenty-five expects, when healthy, little of life. (His extravagant expectation of fraternal recognition when ill is understandable precisely because the illness returns him to childhood, to a period before he had learned to abandon his hopes, and when these hopes could still be reasonably satisfied within the family.) He expects to maintain what he has – job, family, home. He expects to continue to enjoy his pleasures – a cup of tea in bed, Sunday newspapers, the pub at week-ends, an occasional trip to the nearest city or to London, some form of game, his jokes. His wife has her equivalent pleasures. Both of them have fantasies which are infinitely more resourceful and rich – perhaps particularly the wife, who ages far faster. They also have their opinions and their stories to tell, and these may cover much wider ground. But what they expect in their own situation in any foreseeable future is very little: they may want more, they may believe they have a right to more: but they have learned and they have been brought up to settle for a minimum. Life is like that, they say.
Their foreseen minimum is not purely economic: it is not even principally economic: today the minimum might include a car. It is above all an intellectual, emotional and spiritual minimum. It almost empties of content such concepts (expressed in no matter what words) as Renewal, Sudden Change, Passion, Delight, Tragedy, Understanding. It reduces sex to a passing urge, effort to what is necessary in order to maintain a status quo, love to kindness, comfort to familiarity. It dismisses the efficacity of thought, the power of unrecognized needs, the relevance of history. It substitutes the notion of endurance for that of experience, of relief for that of benefit.
This makes them, as Sassall is always observing, tough, uncomplaining, modest, stoical. His respect for them is genuine and deep. But it does not alter the fact that his own expectations of life are diametrically opposed to theirs.
It is necessary to emphasize here that we are talking of generalized expectations rather than specific personal ones. The question is philosophical rather than immediately practical. Life is like that, the foresters say. A man may be lucky and have everything he wants, but the nature of life is such that this is bound to be an exception.
Unlike the foresters, Sassall expects the maximum from life. His aim is the Universal Man. He would subscribe to Goethe’s dictum that
Man knows himself only inasmuch as he knows the world. He knows the world only within himself, and he is aware of himself only within the world. Each new object, truly recognized, opens up a new organ within ourselves.
His appetite for knowledge is insatiable. He believes that the limits of knowledge, at any given stage, are temporary. Endurance for him is no more than a form of experience, and experience is, by definition, reflective. It may be that in certain respects he is prepared to settle for comparatively little – for an obscure country practice, for a quiet domestic life, for a game of golf as relaxation. (In fact on occasion he revolts even against this: four years ago he had himself accepted as the doctor and cameraman for an Antarctic expedition.) Within his outwardly circumscribed life, however, he is continually speculating about, extending and amending his awareness of what is possible. Partly this is the result of his theoretical reading of medicine, science and history; partly it is the result of his own clinical observations (he was, for example, observant enough to notice that Reserpine, given as a sedative, appeared also to cure chilblains and so might be useful in the treatment of gangrene). But above all it is the result of the cumulative effect of his imaginative ‘proliferation’ of himself in ‘becoming’ one patient after another.
We can now define the bitter paradox which provokes the disquiet Sassall feels at the contrast between himself and his patients and which can sometimes transform this disquiet into a sense of his own inadequacy.
He can never forget the contrast. He must ask: do they deserve the lives they lead or do they deserve better? He must answer – disregarding what they themselves might reply – that they deserve better. In individual cases he must do all that he can to help them to live more fully. He must recognize that what he can do, if one considers the community as a whole, is absurdly inadequate. He must admit that what needs to be done is outside his brief as a doctor and beyond his power as an individual. Yet he must then face the fact that he needs this situation as it is: that, to some extent, he chose it. It is by virtue of the community’s backwardness that he is able to practise as he does.
Their backwardness enables him to follow his cases through all their stages, grants him the power of his hegemony, encourages him to become the ‘consciousness’ of the district, allows him unusually promising conditions for achieving a ‘fraternal’ relationship with his patients, permits him to establish almost entirely on his own terms the local image of his profession. The position can be described more crudely. Sassall can strive towards the universal because his patients are underprivileged.
From time to time Sassall becomes deeply depressed. The depression may last one, two or three months. He is not sure of the reason for these depression
s. They could be organic in origin; conceivably they could be part of a still recurring but mostly hidden neurotic pattern established in childhood.
Yet if their origin is mysterious, their maintenance – if one may use the word – is revealing. By maintenance I mean the conscious material which his depressions requisition in order to justify and perpetuate themselves. With the fatal a-historical basis of our culture, we tend to overlook or ignore the historical content of neuroses or mental illness. Extreme examples in the distant past are sometimes admitted. One grants that there was a connection in the fourteenth century between the outbreaks of St Vitus’s Dance and the suffering caused by the Hundred Years’ War and the Plague. But do we appreciate, for example, how much Van Gogh’s inner conflicts reflected the moral contradictions of the late nineteenth century? Vulnerability may have its own private causes, but it often reveals concisely what is wounding and damaging on a much larger scale.
Sassall’s depressions are maintained by the material of the two problems we have just been examining: the suffering of his patients and his own sense of inadequacy. As reflected in his depression this material is distorted, but much truth remains even in the distortion.
He is working well. In a particularly complicated case he senses the number of disparate factors involved, and begins to trace the logic of their connection. He is planning some general improvement in his practice – the acquisition, say, of a cardiograph. He feels himself master of his own experience to date. The extent of what remains for him to do in the Forest is a confirmation of the rightness of his being there. He is always observant, but in this state of mind he notices far more than he can name or explain. Everything seems significant. And the stimulus of this so speeds up his selection and application of a myriad necessary routine responses and checks that he has time to speculate about what he is doing as he is doing it. He is working creatively.
The disillusion that he is about to suffer is likely to be triggered off by a minor setback with no serious consequences at all. A serious crisis could not have the same effect, for it would engage all his attention. As it is, he becomes slightly more self-conscious than usual about his responsibility. Something has not gone exactly as he would have liked for a patient. Yet the patient is quite unaware of it. He remains grateful or continues to grumble exactly as before. It is impossible for Sassall to tell him what he feels about the setback. Not for reasons of tact or medical etiquette. But because the patient would not understand and would still remain satisfied. Sassall is more sensitive to his patients’ interests than the patient himself. He is more troubled by the setback than the patient will ever be inconvenienced by it. Thus Sassall’s heightened awareness, instead of supplying him with new evidence and data – as it does when he is working well – suddenly draws attention to its own distinction. He has momentarily reached the threshold of mild paranoia. In the normal course of events the moment would pass with perhaps an ironic comment made to himself. But if at this moment he is unconsciously seeking a justification for being depressed, he can now begin to crush himself in the contradiction between his developed sensibility and the underprivileged life of his chosen patients. The challenges which have encouraged and confirmed him now seem proof of his presumption.
Guilty, he becomes increasingly susceptible to the suffering of others. This suffering, demanding its question about the value of the moment, reveals the comparative emptiness of his own life. To deny this, he tries, as we have seen, to compete with the intensity of suffering. He will work as hard as they suffer. His attitude to his work becomes obsessional.
Soon he is sufficiently depressed for his reactions to be slowed down and his power of concentration to have diminished. It seems to him that he can no longer meet the elementary demands of his practice. The challenge of what remains to be done – even the fabricated ethical basis of his obsession with work – suddenly seems to belong to another, vanished world. He believes that he cannot perform as a doctor on any level.
In fact he can and is probably still, at such moments, offering treatment which is better than the national G.P. average. But he can only partially overcome his conviction of inadequacy by admitting it. And so, to those of his patients who are in a state to be able to accept his confession, he admits his crisis. He throws himself on the mercy of their tolerance. He depends upon the fact that their demands are minimal. The circle is complete. And, as often, the completed circle is the seal of conscientious suffering.
Sassall is nevertheless a man doing what he wants. Or, to be more accurate, a man pursuing what he wishes to pursue. Sometimes the pursuit involves strain and disappointment, but in itself it is his unique source of satisfaction. Like an artist or like anybody else who believes that his work justifies his life, Sassall – by our society’s miserable standards – is a fortunate man.
It is easy to criticize him. One can criticize him for ignoring politics. If he is so concerned with the lives of his patients – in a general as well as a medical sense – why does he not see the necessity for political action to improve or defend their lives?
One can criticize him for practising alone instead of joining a group practice or working in a health centre. Is he not an outdated nineteenth-century romantic with his ideal of single personal responsibility? And in the last analysis is not this ideal a form of paternalism?
He himself is aware of the implications of such criticism. ‘I sometimes wonder,’ he says, ‘how much of me is the last of the old traditional country doctor and how much of me is a doctor of the future. Can you be both?’
I wish I could write a conclusion to this essay, summing up and evaluating what has been noticed. But I cannot. It is beyond me to conclude this essay. I could end with another story about Sassall and perhaps most readers would then not notice the omission. It is to reasoning that the poetic gives most of its famous licence.
However, it is perhaps more to the point to analyse why the essay cannot be concluded – always assuming that the obstacles are not purely within myself.
Nothing has in fact been concluded. Sassall, with the cunning intuition that any fortunate man requires today in order to go on working at what he believes in, has established the situation he needs. Not without cost, but on the whole satisfactorily. In it he is working. He is working now at this moment as I write. He may be prescribing a routine cure to a routine infection, he may be listening, taking a few drops of blood from a thumb, imagining himself to be the woman or man opposite him, talking to a sales rep from a drug firm, testing some urine, hoping to learn more, learning more.
I have described something of the situation he has established for himself: but finally this can only be judged in relation to the work he does in it. And I cannot evaluate that work as I could easily do if he were a fictional character. In a certain sense, fiction seems strangely simple now. In fiction one has only got to decide that a character is, on balance, admirable. Of course there remains the problem of making him so: and the effect you achieve may be the opposite of what you intended. But still – outcomes can be decided. Whereas now I can decide nothing.
I am in the exactly opposite situation to the autobiographer because he is even freer than the novelist. He is his own subject and his own chronicler. Nothing, nobody, not even a created character can reproach him. What he omits, what he distorts, what he invents – everything, at least by the logic of the genre, is legitimate. Perhaps this is the true attraction of autobiography: all the events over which you had no control are at last subject to your decision. Now, by contrast, I am entirely at the mercy of realities I cannot encompass.
It is true that biographies, as distinct from autobiographies, are also sometimes written about living men and that these in their fashion come to a conclusion. But the subjects of such biographies are either famous or infamous. They are our future prime ministers, or the foreign politicians of whom we must take note. Both reader and writer before they begin the book know why the book has been written. It is because X is the famous X. And the sto
ry naturally concludes when he has achieved his present power, which is a form of apotheosis.
Sassall is not such a man.
And supposing he were dead? you might ask. But if he were dead I would write a different essay. It sounds absurd to say that a man’s life is utterly transformed by his death, but I mean for those who knew him, or even knew of him. The simplest confirmation of this is what happens when an artist dies.
The painting you saw last week when you assume the painter was alive is not the same painting (although it is the same canvas) you see this week when you know that he is dead. From now on everybody will see the painting you see this week. The painting of last week has died with him. This may sound excessively metaphysical. Yet it is not. It is simply the result of our gift – or the necessity for us – of abstract thought. Whilst the artist is alive, we see the painting, although it is clearly finished, as part of a work in progress. We see it as part of an unfinished process. We can apply epithets to it such as: promising, disappointing, unexpected. When the artist is dead, the painting becomes part of a definitive body of work. The artist made it. We are left with it. What we can think or say about it changes. It can no longer be addressed to the artist – not even to the absent artist whom we have no reasonable chance of ever addressing; we can now only think and speak for ourselves. The subject for discussion is no longer his unknown intentions, his possible confusions, his hopes, his ability to be persuaded, his capacity for change: the subject now is what use we have for the work left us. Because he is dead, we become the protagonists.