As I write this just before the mid-term elections, I can't help focusing on the unwanted side effects—a flurry of computer-generated phone calls, a mountain of political fliers in our mailbox, and TV ads extolling a candidate or attacking an opponent (more of the latter where we are). The anger level among some is over the top in these difficult economic times. I have been through enough election cycles to wish for an election system, as in some European countries, that limits political campaigns to a few weeks.
But these annoyances are relatively minor compared with the steady diet of dissembling, half-truths, and lies we are swamped with. The politicians' earnest faces and promises of less government, more jobs, and today's version of “a chicken in every pot,” promises that we and they know they cannot keep, can make us cynical about the process.
This led me to recall an article by Lee Siegel I had read in the New York Times a year ago (11 Oct 2009). I dug out the clipping because it deals with the same issues raised by campaign politics and because I saw some parallels in medicine, namely transparency and secrecy; one might say transparency vs. secrecy.
Siegel's article was prompted by his seeing Shakespeare's play Othello, in a version directed by Peter Sellars. He focuses on the behavior of the character Iago, who is the villain of the play. To refresh your memory, Iago is aide-de-camp to Othello, who is a general in the Venetian army. He becomes very angry when he is passed over for promotion and schemes to destroy Othello who he feels has betrayed and belittled him.
He is a sly and coolly calculating avenger who conceals his true intentions with a patina of appearing to be helpful, loyal and with good will toward Othello. Here is what Iago says to the audience:
For when my outward action doth demonstrate
The native act and figure of my heart
In compliment extern, ‘tis not long after
But I will wear my heart upon my sleeve
For daws to peck at: I am not what I am.
Siegel comments: “For Iago, success lies in never being what he seems. He manipulates appearances, lies without remorse, and cultivates opacity the way some men work on their abs. He is the ideal forerunner of so many contemporary dissemblers—the deceitful politician, clergymen, athlete, or entertainer; the conniving money manager, the prevaricating realtor; the online sexual predator…[Iago] becomes the ultimate keeper of secrets, the man whose petty grievance doesn't match his outsize fury. He is driven by ‘motiveless malignity.'”
OK, so Iago is a bad guy through and through and the depth of his anger and vengeance is extreme. But that isn't the end of the story. Siegel points out that Shakespeare's play reveals the complexity of transparency and secrecy; they are not simply opposites, but that they interact, each reinforcing the other.
Othello's naïve trust in outward appearances, his “free and open nature,” as Iago calls it with contempt, not only feeds Iago's feeling of superiority, but also leads Othello to be untrue to himself and to obliterate everything he cherishes.
In the remainder of the article Siegel discusses the tension between transparency and secrecy, openness and opacity, in present times. His bottom line is that both actions are quantitative—i.e., you can have too much or too little of either.
Iago is at one extreme of the spectrum, along with others in everyone's experience, but the other extreme—too much transparency—can be nearly as bad.
One Siegel example is that openness in the name of democracy can lead to the invasion of privacy, an important competing right. How we tell a patient bad news—the setting, manner, and degree of detail—varies in the hands of a sensitive and experienced physician.
There are times when sudden, complete transparency would be overwhelming for a patient or family, though all relevant facts must be disclosed at some point.
The same is true in dealing with colleagues. One can criticize a colleague or a trainee with too little or too much candor, transparency, and secrecy. I have seen fellows crushed on rounds by attending physicians' sharp criticism in front of colleagues and/or patients.
On the other hand I have had personal experience at the sharp end of the knife with surgeons. One was so narrowly focused on the lab results that he failed to disclose several important facts that would have made the whole process easier. My wife has had more than her share of surgical procedures, so we have seen the entire spectrum of physician skill, or lack of it, in providing sufficient information at the appropriate time and in the appropriate detail. This is not an easy task, but it can be learned if one is willing.
Like so many things in life, human behavior has a spectrum of possibilities. Moderation is usually best. But for Iago, moderation was precisely what he didn't want…he wanted to destroy Othello, and he succeeded. In the matter of transparency and secrecy, an evil heart knows no moderation. An arrogant physician with an oversize ego dismisses moderation.
An experienced, temperate, and humble physician has his sensors sharply tuned to the patient or colleague or trainee so he may say the right thing or make the right choice at an appropriate time. I have watched physicians who are masters at this delicate dance…I have tried to emulate them.