Essay: Goodbye, Dr Doug Ross. Even Nietzsche will miss you

George Clooney is about to leave `ER' for ever, in controversial style. In a week in which `Casualty' too hit the headlines, Dr Richard Horton looks at other great hero-medics, and the conditions they treat
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What do Dr Doug Ross, the agonistic alter ego of George Clooney in ER, and Friedrich Nietzsche have in common? For a start, they were both terribly misunderstood characters. Vain, selfish, petulant, and unlucky with women, for sure. But as Clooney exchanges TV studio for film set in a tragicomic flurry of ER emotion - and don't read on if you don't want to know what happens - he courageously puts a patient's dignified death before his own career. It is an intense, almost operatic, television moment, although Carol Hathaway, his tolerant and much put-upon girlfriend (played by Julianna Margulies) calls it "narcissism elevated to a high art." As I say, the poor man was just plain misunderstood.

Nietzsche too. "A sick person is a parasite on society," he claimed, in a typically shocking summing-up of medical morality in Twilight of the Idols. But a gentle scratch beneath the varnished surface of his writing reveals that Nietzsche was not quite the barbarian he at first appears to be. "For love of life," he pleads, "one ought to want death to be different, free, conscious, no accident, no ambush ..." Dr Ross would have agreed, I'm sure, and the case for mercy killing would have been won without further question. But alas, those precious Clooney moments are to be had no more.

Medicine and its serpentine practitioners have always offered rich stimulus to writers. So rich, in fact, that the subject has become transformed into an academic industry. The scholarly journal Literature and Medicine is published twice a year and includes papers that would provide untilled ground for the imaginations of ER scriptwriters. "Spontaneous combustion and the sectioning of female bodies"; "Walt Whitman and the prostitutes", "Eugenic anxiety in Henry James's Washington Square", and "I actually don't mind the bone saw". The plot-lines are endless.

So endless that sometimes doctors object. Last week, a report suggested that television viewers copied scenes of self-poisoning, the latest example being on Casualty. The Oxford psychiatrist who led the study, Keith Hawton, clearly frowned on the media for displaying acts of suicidal behaviour. "Those responsible for writing and producing such programmes must take this seriously," he rather nannyishly intoned.

The writers of Casualty and Michael Crichton, the creator of ER, may not make it into Literature and Medicine. But they deserve to. Crichton has done more to bring medicine to masses of readers and television viewers than any other writer this century. He began, medical students take note, in his final year at Harvard with The Andromeda Strain (1969), a ridiculous tale about a rapidly mutating particle that threatened a careless world. His story told of ignored early warnings, lazy public health responses, the it-can't-happen-to-us syndrome, and then the barely-concealed terror as sporadic cases of infection risked ballooning into an uncontrollable epidemic. Thirty years after Crichton's novel came mad cows and new-variant Creutzfeldt-Jakob disease.

Is the novelist's world full of Dr Rosses? Sadly, no. The writer is often more concerned with casting the physician as a cipher for some larger purpose. Ordinary doctoring is simply too dull. One Ross-like hero does stand out, however. He is Dr Bernard Rieux, Albert Camus's chief protagonist in The Plague (1947). From the moment he steps on a dead rat, we know that Rieux is to be the incarnation of good pitted against the evils of the coming plague.

Crichton and Camus have a long line of respected literary predecessors, the first of whom wrote far more devastating fiction than anyone else since. Daniel Defoe's Journal of the Plague Year is a mix of scientific treatise (he documented with astonishing precision the thousands of deaths that took place in London at the time of the 1665 epidemic), political tract, and private tragedy. Defoe's narrator is HF, a witness to the horror of the plague's outbreak and its appalling course. The deaths began slowly, taking in only a few people at a time. But by the summer of 1665, "the weather set in hot, and from the first week of June, the infection spread in a dreadful manner".

This "mischief" brought out hordes of quacks, an opportunism that was repeated when HIV engulfed us in the 1980s. "A wicked generation of pretenders to magic," Defoe says. They sold trinkets to protect the sick, who were only later "carried away in the dead carts with those hellish charms hanging about their necks."

The way in which medicine is handled in literature is perhaps the best means we have of understanding how beliefs about our bodies have changed over the centuries. And the absence of a literary footprint is almost as telling about a disease as its presence. There have been few natural human diseases that have stolen the lives of 40 million people. But this century there has been one such event - the catastrophic influenza epidemic of 1918-19. Entire generations of young men and women, from the USA to India, were eliminated by this oddly virulent bug.

Given the vast contemporary literature on HIV and Aids, one might have expected great libraries of material on influenza. And yet I can only find one piece of prose fiction that refers directly to the 1918 epidemic - Katherine Anne Porter's 1939 story, "Pale Horse, Pale Rider". Was the epidemic so horrific - its worst damage was done in the space of only six months - that writing about it proved impossibly painful? Did the atrocities of World War I eclipse all other subjects for writers of the time? Or does the epidemic's relative obscurity simply reflect a lack of writers left alive to commit the memory into lasting words? These questions remain strange mysteries to this day.

If you want to know less about disease and more about doctors themselves, two giants of medical writing stand out. William Carlos Williams was a New Jersey GP, more famous for his poetry than his prose. But his reflections on the brutal ordinariness of medical practice have the power to bring the reader to heel even today. And Richard Selzer's accounts of surgical life, whether they involve memories of sewing the ears of an obstreperous patient to the stretcher or reflections on "The Grand Urinal of the Elks" reveal more about the inner mind of the doctor than any fictional warp.

So should we mourn the end of Dr Ross? A little. Doctors sometimes get rather stuffy about medical dramas on television. We don't like the way we are portrayed as uncaring brutes who are only in medicine for power, money, and sex. We are lying, of course.

But hospital is a perfect setting for television drama. There is action all the time. Doctors do not just sit at desks doing paperwork, although there is more of that in the NHS of today than ever before. People die in hospitals and we react in the ways the characters do in ER, sometimes compassionately, sometimes cruelly. Most doctors are committed to doing their best for patients, but a few do see sick people as fodder for ambitious research careers and personal glory.

One reason ER is so successful is that it is largely all too true. But not wholly. The American writers have sanitised the sexual intrigue. Which is one good reason why we will miss Dr Ross.

Dr Ross leaves `ER' on Thursday (Sky 1).

Dr Richard Horton is editor of `The Lancet'.

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