Dr. Groninger is faculty affiliate, Center for Biomedical Ethics and Medical Humanities, University of Virginia, Charlottesville, Virginia; e-mail: email@example.com
Not long ago, sitting at the bedside of a dying man, I had the opportunity to observe an unfortunate absurdity unfold.
Mr. Potter* lay quietly delirious from sepsis, the most recent complication of his end-stage HIV/AIDS. Mr. Potter was middle-aged, African American, unemployed, and without partner or children. He had lived virtually his whole life in Washington, DC, just a few miles from this hospital room where he would spend the final hours of his life.
He was accompanied by his mother—frail and fatigued, but very composed. Mrs. Potter wore a violet dress and held her leather-bound family Bible on her lap. There, at the patient's bedside, we had met for nearly an hour. We had just come to an agreement about her son—in spite of his failing blood pressure and waning cognition, he would not be transferred to the medical intensive care unit for aggressive therapies. In fact, we would stop his antibiotics and tailor our care to his comfort. We agreed that he was actively dying.
For a time, I stayed there with them in the silent private room, watching him in his peaceful delirium, and her with her stoic grief. Everyone knows a parent should never have to witness the dying of her child. And in the intervening 20 minutes or so, during this poignant moment in one man's life, I became witness to entrances into and exits from this room like a vaudeville show:
* An aide (to check vital signs in a dying man)
* A resident (to complete a cursory physical exam)
* A food services worker (to pick up the untouched breakfast tray and leave lunch)
* Housekeeping (to empty the trash receptacle full of yellow isolation gowns and gloves)
Voices chatting and then laughter could be heard in the hallway. Finally, Mrs. Potter turned to me: “Do they all have to do this?” she asked. “Do they not understand what is happening in here right now to my son?”
Reflecting on this difficult encounter, I realized similarities with Pieter Bruegel's landscape, completed in 1558. On first glance at the painting, our eyes tend towards figures in the foreground: a farmer with horse and plow, a shepherd and dog, perhaps the fisherman peering into the water. All are engaged in their activities, engrossed in their own thoughts. The large ship faces away from us towards other ships and a port city in the distance.
We could stop right here, were it not for the artist's title, Landscape With the Fall of Icarus. To understand the painting, we have to recall the myth of Daedalus, who made wings of wax and feathers for himself and his son, Icarus, to escape imprisonment by King Minos. In spite of his father's warning, Icarus flew too close to the sun, melting the wax and sending him plunging to his death in the ocean.
So perhaps the title is our only clue to Bruegel's narrative. We have to search to see Icarus' legs flailing alone in the corner of the work, ignored by onlookers and nearly overlooked by us. Once we find the painting's central character, what had passed for self-absorption in the other figures may take a new, more troublesome perspective: They actively turn their attentions away from this tragedy.
As I sat at Mr. Potter's bedside, I had no good answer to his mother's question. Could this resident physician not see the futility in one more auscultation of the lungs at this very moment? Should the nursing aide not stop to see a family member's tears and think to pause and return later? I shared Mrs. Potter's frustration. I finally asked people outside the room to lower their voices and I closed the door, but even then, I knew that, like everyone else at hand, I am no saint. My mind can wander too (What can we fix for dinner? Do I have that meeting tomorrow?), or focus too quickly on the task at hand (One more quick consult and we can go home!). Or, perhaps even more salient, I may choose emotional self-protection, when it is easier to turn away than to face the pain of others.
Isn't it interesting that, rather than depicting the tragedy of Icarus in Greece, Bruegel chooses to set it in his own era? But the artist recognizes that, just as suffering is timeless, so is the human tendency to carelessly avoid confronting it when it is not our own. As poet W.H. Auden1 noted in this excerpt from his reflection on the work:
… everything turns away
Quite leisurely from the disaster; the ploughman may
Have heard the splash, the forsaken cry,
But for him it was not an important failure; the sun shone
As it had to on the white legs disappearing into the green
Water; and the expensive delicate ship that must have seen
Something amazing, a boy falling out of the sky,
had somewhere to get to and sailed calmly on.
Hunter Groninger, MD