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Pediatric Bioethics

May 2019

William Carlos Williams and The Use of Force

 

 John D. Lantos, MD | Director of Pediatric Bioethics | Professor of Pediatrics, UMKC School of Medicine

Eighty years ago, pediatrician and poet William Carlos Williams wrote a short story about a clinical encounter that he had while making a house call. (http://www.classicshorts.com/stories/force.html). The story is dated in some ways, timeless in others. In just about 1,500 words, Williams memorably portrays some of the central ethical issues that pediatricians face. He shows that our societally sanctioned power over children can be a double-edged sword. We sometimes save children’s lives, but sometimes use that power in ways that are harmful, even as we do so with the best of motives.  

Williams sets the stage succinctly, “They were new patients to me. All I had was the name, Olsen.” He didn’t know them. They didn’t know him. He quickly makes an assessment of the family dynamic. The mother was “clean and apologetic.” The child was sitting in her father’s lap. “They were all very nervous, eyeing me up and down distrustfully.”                    

The story begins to hint at the dark turn it will take when Williams comments that the child was “an unusually attractive little thing, and as strong as a heifer in appearance ...” We sense, then, that the doctor’s emotions and unconscious motivations might become an important part of the story. Remarkably, Williams the writer is aware of this while Williams the doctor seems blissfully, and then tragically, unaware of his own dark side.  

Both Dr. Williams and the parents know that there has been a local outbreak of diphtheria. Children have died. He explains to the child and the parents that he needs to examine her throat. She refuses to open her mouth. The parents, as parents do, coax her by telling her that he is “a nice man” and that, “He won’t hurt you.” Williams cringes at the parents’ wheedling and coaxing. He says, “For heaven's sake, don’t call me a nice man to her. I'm here to look at her throat on the chance that she might have diphtheria and possibly die of it.” He is not there to be anyone’s friend. He has a job to do. To do it, he may have to forego niceness. 
            
Even his tone suggests that he is putting kindness aside and brutally articulating the fears that everyone shares, but that nobody had dared to speak aloud. His angry outburst has made clear what is at stake. He raised the stakes by threatening the child with the use of force. “Look here, we’re going to have a look at your throat. You're old enough to understand what I'm saying. Will you open it now by yourself, or shall we have to open it for you?”    

He tries to get the father to hold her still. The child is screaming “Don't, you're hurting me. Let go of my hands. Let them go I tell you. Stop it! Stop it! You're killing me!” The father’s dread of hurting her makes him unable to immobilize her, a weakness that infuriates Williams, “I wanted to kill him.” Instead, he orders the father to be strong and demonstrates the determination and cruelty that is necessary in such situations. “I grasped the child's head with my left hand and tried to get the wooden tongue depressor between her teeth. She fought, with clenched teeth, desperately! I got the wooden spatula behind the last teeth and just the point of it into the mouth cavity, but before I could see anything she came down again and gripping the wooden blade between her molars, she reduced it to splinters before I could get it out again.”   

Williams then brings the deep moral ambiguity home. He writes, with honesty, self-insight, and shame, “Now I also had grown furious—at a child. I tried to hold myself down but I couldn't. Perhaps I should have desisted and come back in an hour or more. No doubt it would have been better.” But he doesn’t. Instead, he does what doctors do. He justifies his own abusive rage as beneficence, “I have seen at least two children lying dead in bed of neglect in such cases, and feeling that I must get a diagnosis now or never I went at it again.” This is a concise description of the conflicting motivations that lie at the heart of pediatrics. On the one hand, we devote our working lives to doing what is best for children. Our job is to save children, even from their parents, even from themselves. The work is emotionally stressful. Sometimes, to help children, we have to do terrible things to them. We don’t always know where to draw the line. If we go too far, out of the best motivations, we can harm the very children we are trying to help.     

The next scene gets horrific. The child's mouth is bleeding from the jagged broken tongue blade. She is screaming in wild hysterical shrieks. But Williams orders the mother to get a metal long handled spoon. He says to himself, “The damned little brat must be protected against her own idiocy. Others must be protected against her. It is a social necessity. And all these things are true.” But something else is equally true, and he recognizes that as well, “I had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her. My face was burning with it. In a final unreasoning assault I overpowered the child's neck and jaws. I forced the heavy silver spoon back of her teeth and down her throat till she gagged. And there it was--both tonsils covered with membrane.”    

The ending of the story seems to justify the doctor’s use of force by showing that it sometimes leads to a good outcome. Knowing the diagnosis, he can now institute treatment. But the story doesn’t tell the outcome. We don’t know if he saves her life or not. The point is that, often, we must act in heartless ways for worthy ends while not knowing, as we act, whether our heartlessness will achieve those worthy ends.