Medicine as business and patient welfare: Thomas Mann dissects the conflict of interest.

Abstract

^Medicine as Business and Patient Welfare: Thomas Mann Dissects the Conflict of Interest Renate G. Justin In his 1924 novel The Magic Mountain, Thomas Mann creates two physidan-diaraders, Dr. Behrens and Dr. Krokowski, who have lost sight of the main purpose of their relationship with patients. Patient welfare is not their main concern; economics preoccupies them and directs their treatment plans. What effect this confusion of priorities has on the doctorpatient relationship is among the subjects that Mann dissects in his story. He describes the conflict of interest that the physidans of the tuberculosis sanatorium face, and he studies and illuminates the doctor-patient relationship in light of the irreconcilable pressures of economics and patient welfare. With keen observation, Mann describes the difficulties that patients and doctors endure when business and medicine compete for attention . The Magic Mountain takes place in a tuberculosis sanatorium in Switzerland before World War I, a unique setting for studying human relationships , including those between dortors and patients. The sanatorium houses both doctors and patients under the same roof; twenty-four hours a day they live in proximity, for years at a time. Such a setting provides a singular opportunity to develop a long-term dodor-patient relationship, such as would be considered advantageous and therapeutic by primary care physidans. On the magic mountain, however, in spite of physical proximity, a close, trusting, honest relationship never develops between the guests, or patients, and the physidans. Dr. Behrens and Dr. Krokowski are employees of the owners of the sanatorium, and their incomes are diredly related to the number of patients residing there. Their concern with keeping the house full is a destructive influence on their relations with the patients. These doctors have Literature and Mediane 7 (1988) 138-47 © 1988 by The Johns Hopkins University Press Renate G. Justin 139 no concept of loyalty or patient autonomy, nor do they have concern for patient privacy or informed consent, all important features of contemporary medical ethics. Although they have little respect for their patients, the patients do respect them to a degree. Both doctors are single, frequently appearing together but not interacting with each other. As colleagues, they maintain professional distance and protocol, not permitting their long-term relationship to ripen into friendship. The frequent interactions both have with their patients over periods of years do not develop into the trusting, warm doctorpatient relationship that the German Hausarzt (family doctor) of their time often maintained. Mann's choice of nicknames for his two physidans is important to an understanding of their role on the mountain. He calls them Minos (Krokowski) and Rhadamanthus (Behrens) after the two judges of the dassical Greek underworld. These judges are in charge of the fate of those who die, and they settle disagreements that arise amongst the dead. In dassical Homeric literature, Rhadamanthus lives in the Elysian fields, which have some characteristics in common with the sanatorium in which Behrens dwells. The inhabitants of the Elysian fields "lived in abundance and [with] such happy, self-chosen activities as pleased them,"1 without the compulsion to work for a living. They have few restraints and enjoy an existence away from daily problems of family life and politics, similar to the lifestyle enjoyed by residents on the magic mountain. Socrates explains that these two judges exist because Zeus realized that mortal judges are fallible; he therefore created immortal or godlike judges. Thus, Mann emphasizes the distance between the physician and patient on the mountain in an ironic comparison of Krokowski and Behrens to aloof, godlike creatures, full of hubris, who judge the patients and make decisions for them. When the physidans pronounce a sentence of injections two times each week, for example, the patient has no power or knowledge to question or alter that judgment. Settembrini, the philosopher -patient of the novel, understands that there is no correlation between a patienf s state of health and the number of months or years he or she spends at the sanatorium. Other more passive characters in the novel do not dare to question the physidans' motives, but the reader cringes every time Behrens announces a sentence—three more months, six more months—for the elusive...