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The Beetle and the Giant

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Rebecca Holt, BA

Vincent Valentine, MD

University of Alabama Birmingham
Birmingham, AL, USA

CLAUDIO: Death is a fearful thing.
ISABELLA: And shamed life a hateful.
CLAUDIO: Ay, but to die, and go we know not where;
To lie in cold obstruction, and to rot;
This sensible warm motion to become
A kneaded clod; and the delighted spirit
To bathe in fiery floods, or to reside
In thrilling region of thick-ribbed ice;
To be imprisoned in the viewless winds,
And blown with restless violence round about
The pendant world; or to be worst than worst
Of those lawless and incertain thought
Imagine howling-'tis too horrible!
The weariest and most loathed worldly life
That age, ache, penury, and imprisionment
Can lay on nature is a paradise
To what we fear of death.

Have you ever felt wedged between a rock and a hard place? If you work in healthcare, your answer is likely yes. The adage refers to a situation offering two objectionable outcomes. As clinicians, we are forced into this uncomfortable and distressing environment daily. With arduous patient diagnoses, insurance regulation and universal healthcare, we often fight with a double-edged sword. Among the sea of urgency, the physical and emotional demands are challenging enough. With physicians, patients and families are forced to make tough decisions where results could render both negative outcomes. For patients suffering from disease, it's either morbidity or mortality. Long after treatment, patients are still dealt the hand of the Joker, and at times, families have to play God.

On both sides of the spectrum, physician and patient, there is a catch-22. Over 400 years ago, Shakespeare provided a quintessential illustration of this wholesale dilemma in his play Measure for Measure. In this early seventeenth century play, the town of Vienna parallels our world of today with lawless leadership, immoral justice and capital punishment. The antagonist, Angelo, is delegated by the Duke to cleanse the town of all sin and corruption and to achieve "mortality and mercy in Vienna." He starts by sentencing Isabella's brother, Claudio, to death for impregnating his future bride out of wedlock. Isabella, a proposed nun, is distraught over the condemnation and pleads to Angelo for her brother's life. In turn, Angelo offers her a deal: sleep with him then her brother's life will be spared, otherwise decline and her brother will be hung.

Now, we may not have the hand of virginity, but we can clearly see the hypocrisy and immorality in Angelo's bargain. Like most of our patients, and us providers, Isabella is forced to choose from two degenerate outcomes. She can either lose her virtue and innocence because of societal demands, or she can remain pure and kill her brother. There is no right choice. Luckily, the Duke disguised as a Friar enters the scene with a more wicked plan to save Claudio. He tells Isabela to agree to submit to Angelo as long as the lights are off and no one speaks of it. Meanwhile, the Duke plots for Angelo's ex-fiancée, Mariana, to take the place of Isabella in the dark. Now, Angelo will have committed the same "crime" as Claudio, eye for an eye. The only issue is that Angelo never intended to take up his side of the bargain. Instead, he planned to kill Claudio no matter Isabella's choice (this goes to say for women's rights in Vienna at the time), and he requests for Claudio's head as confirmation.

In the face of recalcitrance, how does one govern a city, or for that matter, oneself? The title of the play reminds us that judgement does not fall to man, perhaps to nature. In an environment with grotesque extremes (often reflected in the time between World Wars I & II), tensions are heavy as we often experience with patients and ourselves. Like Isabella, we are offered a potentially corrupt bargain with chronic consequences. In healthcare in particular, there is a continuous stream of economic opportunity, harvesting constant apathy and impassivity. This spearheads immoral decisions, ineffective communication and distrust. Whether we realize it or not, we are infinitely bound within borders. So how do we get out from the proverbial rock and "hard place," if it is our Rock of Gibraltar? Numerous great scientists and writers warned us of humanities' self-destruction, yet here we are with Angelo in the flesh. Perhaps, the solution is to impeach the "hard place."

So, what is Shakespeare trying to say with Angelo's power over life and death? Is Angelo put in charge as a test for his character, or does the Duke think Angelo's judgement is genuine? In healthcare, we are often given the role of both Angelo and Isabella. We are expected to enforce and abide by the rules, even if we do not necessarily agree. Many critics argue this in Angelo's character; he is not merciless or corrupt, but rather a human who can mess up. However, we see the compliance to one viewpoint of justice leads to the abuse of power and failure of equality.

As providers and patients, are we equipped to respond to an emerging threat, whether it be disease or human frailty? On average we retort to shortage of resources, money and manpower, but these issues are urgent crises, not evolving, venal environments. To save Claudio's life, the Duke dressed as the friar decides to execute another criminal in his place to please Angelo. The prisoner called on, drunken Barnardine, is not too thrilled, and insists he is "not fit" for hanging because he is too hungover. Like Melville's Bartleby the Scrivener, Barnardine reminds us of the person who constantly "prefers not to." Shakespeare insinuates that Bernardine is already living in hell. Barnardine's blunt and comical refusal to die is the antithesis to Angelo and the Duke's hypocrisy and morality. Luckily, they were able to substitute another prisoner's head for Claudio's.

While there is minimal evidence on healthcare moral judgement, Terry Hill reports on the topic in her article "How Clinicians Make (or Avoid) Moral Judgments of Patients: Implications of the Evidence for Relationships and Research." Here, Hill explores the contextual dynamics of moral judgement in healthcare including age, race, gender, sexual orientation and economic status. She highlights how clinicians can inadvertently judge patients based of these demographics and place them in moral jeopardy. She mentions that "Carl May and colleagues found that physicians quickly make evaluative judgments of patients' motives, the legitimacy of their symptoms, and the congruence between the physician's and the patient's conceptual model of illness."

While Angelo is a barbarous, unethical leader, the Duke is just as errant with his own sanctimonious platitudes. Beyond hiring Angelo, the Duke spies on the town of Vienna while impersonating a friar. Not just imitating, but actually performing confessions and giving advice. When Isabella finally is able to speak justice against Angelo, the Duke arrests her and pretends not to believe her. Only until the Duke is re-disguised as the friar, is he able to confirm Isabella's story. At the time, a woman publicly speaking about sex was stepping out of society's social norms and restrictions. It should be remembered that the Duke's conspiracies and Angelo's hypocrisy put Isabella in this situation to begin with. Similarly, today we see the economic and social issues regarding governmental regulation on sex and gender.

Shakespeare's dark comedy illustrates justice in the wake of corrupted power. We all have our Angelos and Dukes. Though at the hands of authority, Isabela is forced between unpleasant alternatives. Despite the Duke's actions, Isabela still sought justice as Angelo is sent to the guillotine for fornicating (What about Mariana? Left dangling by "Measure"). Though not large, the beetle is able to squeeze through cracks and escape from being smashed by the giant or crushed by the wall. We must choose to not innately be the giant, but rather the beetle. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. Hill, Terry E. "How Clinicians Make (or Avoid) Moral Judgments of Patients: Implications of the Evidence for Relationships and Research." Philosophy, Ethics, and Humanities in Medicine?: PEHM 5 (2010): 11. PMC. Web. 28 Feb. 2018.
  2. Shakespeare, William. Measure for Measure. The Complete Works of William Shakespeare, shakespeare.mit.edu/measure/full.html.

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