Real Man 3.

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Ethical Issues of the Literary Case Study
The literary case study could be seen as a method of introducing medical anomalies to the
general public. The case studies conducted by Oliver Sacks demonstrate an unethical and
demeaning portrayal of his subjects. Sacks genre of romantic neurology distinguishes the
disorder being studied from the actual patient being evaluated. Supporters of Sacks often credit
him for portraying his subjects in a sensitive and sympathetic way. In The Cases of Oliver
Sacks: the Ethics of Neuroanthrpology, Couser writes, Sacks has a reputation for treating his
subjects scrupulously and sensitively, adopting generous estimates of their capabilities, and
presenting them compassionately (Couser 1-12). However, there are several instances in The
Man who mistook his Wife for a Hat and the Autist Artist that challenge this positive review
of Sacks writing.
As I read The Man who mistook His Wife for a Hat and The Autist Artist, I noticed
that Oliver Sacks was trying to cater to two different audiences simultaneously. The Man who
mistook his Wife for a Hat was a recollection of several observations that Sacks made while
observing his patient, Dr. P. In the opening paragraphs of this essay, his discourse was written for
other scientists within his field of neurology. Thomas Couser described Sacks as presenting
strange neurobiological conditions to a lay audience using nonclinical language (Couser 1-12).
Psychological conditions such as ataxia and agnosia are not general knowledge terms and the
average reader may not know the definition. Sacks attempts to give the reader a brief overview
on the research done concerning damage to the left hemisphere of the brain and how ablations to
the right hemisphere have often been ignored by neurologists. This overview is insufficient for a

lay audience because the medical terms that Sacks uses are not commonly known to an
individual who is not part of his profession. Medical terms such as aphonia, aphemia, agnosia
and aphasia can be found within Sacks story, but are not defined for those who dont understand
the conditions.
The role of the audience is often ignored when discussing the problems concerning
narrative medicine. It can be argued that doctors such as Sacks are only giving the people what
they demand, which is an inside view of unique and strange case studies. The reader is fascinated
by these stories that they would have otherwise not known about and are given inside knowledge
on the patients and their conditions. In his essay, Narrative Medicine and Negative Capacity,
Terence E. Holt states that the reason these stories exist is because people are willing to pay good
money to read them. The lay audience now has access to the secrets of the examining room and
the operating room- all of these rooms once closed off- now so readily accessible (Holt 318333). However, its in this revealing of case studies that causes a disruption in doctor-patient
confidentiality. The patients privacy is being violated by the same doctors they thought they put
their trust in when they first revealed their conditions. With the introduction of this new genre,
doctors like Sacks are no longer held responsible for respecting the privacy of their patient or
adhering to traditional medical guidelines. However, Sacks did receive permission from Dr.P as
well as the legal guardians of Jose before writing his stories.
Rita Charon offered another view of narrative writing in medicine in her essay,
Narrative Medicine: Form, Function, and Ethics. Rita herself is a physician that writes stories
about patients that have unique disorders. Her relationship with the patient was altered after she
had begun the narrative writings. She became more confident in her ability to understand what
was wrong with her patients. But unlike Sacks, Rita actively engaged with her patients and asked

for feedback when writing her stories. The patient was allowed to read and review the stories
before they were published, and often times the patient would respond with you forgot
something or we left something out (Charon 83). Charon avoided the breach in doctor-patient
confidentiality by obtained informed consent from the patient before sharing her stories with the
public.
The initial encounter with Dr. P was told in a comical manner. Examples of this were his
inability to recognize faces within his classroom as well as patting the heads of fire hydrants and
parking meters that he mistook as children. Also, the incidents of him trying to partake in
conversations with inanimate objects in his house could be seen as an embarrassing part of the
story for Dr. P. I understand that Sacks is giving the reader a back story to his patients condition
and may be trying to get us familiarized with Dr. Ps antics. However, I think he could have went
about explaining these situations in a more respectable way. Dr. P is described as delusional to
his own medical condition and was the running gag for the people who had come into contact
with him and witnessed his blunders.
When evaluating Dr. P in his office, Oliver Sacks claims to have known there was
something peculiar about him only after talking to him face to face. He noticed how the patient
only fixed his sight on parts of his face, such as the nose or ear lobes. The problem with this is
Sacks can easily look back on that moment in hindsight and say he knew all along that Dr. P had
the inability to view an object as a whole. This part could have been included to further
dramatize the story and makes Sacks inference skills seem better than they actually are.
Even in the scene where Dr. P mistakes his shoe for his foot, Sacks is including dialogue
between the two that may or may not have actually occurred. Whether or not this conversation

actually took place, Dr. P was presented in a foolish manner and the line Ah! I thought that was
my foot seems to have been included for comedic purposes. The comedic element can also be
seen when Dr. P nearly shakes hands with his grandfather clock, only to correct himself after he
hears the voice of Sacks.
The moment in which Dr. P mistakes his wife for a hat showcased his wifes
obliviousness to her husbands condition, she was described as noticing nothing wrong with her
husbands behavior. The audience may depict the wife as uncaring or incompetent because she
wasnt able to identify her husbands problem without the help of Sacks. A similar situation had
occurred later on in the story when Sacks was filing through Dr. Ps art collection that was
organized in chronological order. He noticed that throughout the years Dr. Ps paintings were
originally drawn in a naturalistic and very detailed manner, while later they evolved to abstract
cubist art and finally into confusing and nonsensical designs. Mrs. P attributed this change in
style as her husbands evolving art development. Similar to the previous example mentioned,
some readers might consider Mrs. P foolish for not making a correlation with Dr. Ps abnormal
behavior and the drastic changes in his art work.
Throughout both The Man who Mistook his Wife for a Hat and The Autist Artist,
Sacks has made a comparison between his patients and children. Dr. P was given a glove and
Sacks asked him to what the object is. Dr. P was unsure of what he was holding and instead spent
time describing what he saw in parts instead of associating the object as a whole with a glove. At
one point he thought it could possibly be a coin holder due to it having five slots. Sacks
mentioned that a child would have been able to look at the glove and identify it as glove without
much trouble. In The Autist Artist, 21 year old Joses drawing of the fish was referred to as
primitive by Sacks and similar to the artwork illustrated by a child. Being compared to a child

could be seen as demeaning for grown men such as Dr. P and Jose even if they are unaware of
their conditions and what a normal person should be able to do.
At the conclusion of both stories Sacks fails to resolve the problems that his patients are
suffering from and suggested a nontraditional treatment. In The Man who mistook his wife for a
Hat Sacks advice for Dr. P was to continue being a musician and make music the center of his
life. The reason for this was because Dr. P was only able to associate objects when they were
accompanied by sound. Dr. P almost shook hands with a grandfather clock until Sacks began to
speak. Dr. Ps inner music is what drove his perception of the word and if that inner music
stopped he would become confused again. He also recognized the movements of his students and
identified them based on that. If a student remained still it would be impossible for him to know
who it was.
However despite happy ending, Dr. P will live continue to live the rest of his life in
confusion and disorder because Sacks was unable to keep in touch with him. The conclusion of
The Autist Artist is similar in that Sacks documented the life of Jose but failed to improve it in
anyway. He discussed how Jose should use his talent of photographic memory and artistry and
become an illustrator. But Sacks made no mention of informing Joses relatives or the hospital
attendees of his recommendation to put Joses talents to use. Its as if he obtained his information
of these patients and stopped caring as soon as he got enough material to write his literary case
study.
The issue of ethics was introduced when Oliver Sacks administered several evaluation
tests for Dr. P to take part in, most of which were thought up on the spot. When he asked Dr. P to
watch a television program and describe the facial expressions of the actors. Dr. P was unable to

recognize any emotion on their faces. In response to this strange observance, Sacks refers to Dr.
Ps comments as positively Martian. To be Martian means that youre figuratively from
another planet. This instance of poor word choice ties in with the freak show element of his
works and he tries to maintain a sense of bewilderment with his subjects. There are several
examples of questionable language that can be seen in The Autist Artist.
When criticizing Oliver Sacks dialogue throughout both of his stories, it should be noted
that the norms and politically correct terms we follow today did not exist when these works were
created. Also be aware that the morals held by a society are relative to the time frame in which it
existed. However Sacks was in the wrong when he referred to Jose as a sort of being, a
strange species and a creature. He is alienating his subjects and is distinguishing their
behavior from what he considers to be normal.
This issue introduces the problems involving ethics of narrative medicine. Thomas
Cousers approach to discussing the ethics of Sacks literature is to first make a distinction
between the genre of romantic science and writing a psychological journal. According to
Couser, there is a difference between retaining ethical ideals and maintaining ethical obligations.
Sacks role as a life writer differs from his role as a physician, which means he is not obligated to
uphold ethical guidelines. In response to the critics Couser writes, In any case, it may be unfair
to criticize him too harshly for failing to reach the very high standards he has developed on his
own , in deviation from the standards of his profession (Couser 1-12). Perhaps with the
introduction of this newly created genre of narrative medicine, Sacks struggles to walk the line
between portraying his patients medical condition for the lay audience, and offending those
within the disabled community that he is representing.

The creation of a new genre should not grant Sacks immunity from following the ethics
of the medical field and failing to uphold patient-doctor confidentiality. Rita Charon agrees that
writers of nonfiction medical writing should be required to obtain informed consent from their
patients before publishing their stories to the public. She writes, Even though names, dates, and
similar information might be changed, the affiliation of the author points to a given institution,
and the highly singular clinical details of illness make patients recognizable, even if only to
themselves, their families , and those who work in an authors institution (Charon 83). Dr. P
and Jose are patients with very unique medical conditions and stories that are unlikely to be
attributed to many other people.
In the conclusion of The Autist Artist, Sacks was describing various jobs that Jose
could partake in given his condition, such as being an illustrator for various different
publications. But Sacks goes on to say that Jose will most likely go on to do nothing and spend
a useless, fruitless life, as so many other autistic people do, overlooked, unconsidered, in the
back ward of a state hospital (Sacks 1-10). Also within the opening paragraphs of the story, he
recalls a conversation he had with a hospital attendant that calls Jose an idiot (Sacks 1-10).
This could be seen as offensive to the workers of the hospital he visited in his story as well as
criticizing Joses family for allowing him to spend the rest of his life in the hospital and not
reaching his full potential. It can be considered that Sacks critique of hospitals and the
undervaluing of people like Jose may cause them to change the way they treat their patients and
acknowledge the gifts that they possess.
Another problem that needs to be considered when evaluating Sacks literature is the way
in which his patients are represented. In Paradigms Cost: Representing Vulnerability, Thomas
Couser writes, Such representation poses ethical problems, especially when the conditions in

question render the subjects unable to represent themselves or even to collaborate in an informed
way with others who undertake to represent them (Couser 19-30). This best represents the case
study of Jose, whose autism rendered him unable to effectively represent his true emotions and
feelings to Sacks.
In The Autist Artist, Joses only form of self-representation comes from his illustration
abilities. When Sacks asked Jose to sketch the picture of the fish from the photo, Jose was ability
to draw the fish with a distinct personality. Joses ability to transform the photograph using his
imagination distinguished him from other autistic children who lacked those abilities. Also,
unlike other autistic children who are diagnosed with the disease before they turned three years
old, Jose lived a normal life until the age of nine. Sacks believes Jose knows what it was like to
be social and attend school like a normal child, and thats something other autistics cannot
understand. Joses life changed after being diagnosed with verbal auditory agnosia, a disease
that rendered him unable to understand the speech of others and had caused him to become mute.
The problem with The Autist Artist is the way in which Sacks interprets the life Jose
may or may not have lived, and believed he knew what was best for him. The first instance of
this is when Sacks uses Joses chart records to create aback story. Constant seizures and
deteriorating mental functioning had caused his parents to move his room into the basement,
where he would be isolated from normal life. Joses only true connection with the outside world
was a national geographic magazine that he loved to look at. However, a violent outburst by Jose
made his parents decide that it would be best if he is sent to a mental hospital. The problem here
is not in the back story itself, but the reason Sacks gives to explain Joses sudden change in
behavior. Sacks believes that Joses outburst was a final, desperate call for help. He also thinks

Jose moving out of his parents basement was a lifesaving experience, and there is no doubt that
Jose feels the same way.
Obviously the issue with that assumption is that nobody knows what Jose is actually
thinking because he is incapable to representing himself. Couser stresses this point by stating,
Individuals with disabilities that preclude or interfere with self-representation are thus doubly
vulnerable subjects (Couser 19-30). Sacks also infers that Jose was tempted to make some form
of interaction with others, but felt he restricted himself due to the fact that he lived in a basement
for so many years. Living in solidarity became the norm for Jose. Sacks took his assumptions
even further after he asked Jose to redraw the picture of the fish. Unlike last time, Jose drew a
second fish in the picture that was not previously there, along with a tidal wave in the
background. Sacks felt the bigger fish in the drawing symbolized him, and Jose drew himself as
the smaller fish. The wave in the background was described by Sacks as angry and avenging.
Sacks is unable to discover the true meaning behind Joses actions because any
conclusion that he reaches will be based on assumption and not on facts. Joses attempt at
speaking was also attributed to the progress he made within the hospital. Sacks believes Jose
lacked the motivation to speak with others and was hopelessly accepting of his impairments. This
may or not be the truth, but Sacks should not jump to these conclusions without proper evidence.
In the final paragraphs of The Autist Artist, Sacks tells the reader that Joses illustrative talents
will most likely never be put to use, and he will live the rest of his life in the hospital. Thomas
Couser discusses this exclusion of the abnormal in his writing by stating, Representation that
deploys the social paradigm tends to be beneficial because it acknowledges that disability is
everybody's business and that disability may be better addressed (more effectively and
universally) by accommodation than by rehabilitation (Couser 19-30). Placing Jose in the

hospital is essentially separating him from the real world. That comment is not directed towards
Sacks, but to society as a whole that prefer to exclude people like Jose and place them in mental
institutions, rather than accommodating them into their society.
Another problem with the portrayal of subjects is trying to represent not only that person,
but the entire community of people with similar disorders. At the time of writing, The Man who
mistook his Wife for a Hat, Dr.P was the only known case involving someone with severe visual
agnosia and prosopagnosia. However, in the stories postscript, Sacks gave several examples of
patients who demonstrated similar characteristics of Dr.P. One patient was unable to distinguish
the faces of his cows, and another patient mistook his reflection for an ape in a museum diorama.
One subject in particular was unable to recognize faces as a whole, which was similar to what
Dr.P was experiencing. The only way this patient was able to distinguish between people was by
the sound of their voice and distinct physical traits. He identified three of his coworkers with an
eye blinking tic, a large mole on their cheek, and the tall stature of the third employee. Even
though the condition shared by these individuals is very rare, narrative writers must
accommodate to all of them even if they are only documenting a single case.
On the other hand, Jose is even trickier to represent because of his unique abilities that
separate him from other autistic children. Thomas Couser identifies the problem of associating
certain individuals with a larger community, he states, How is membership determined and by
whom? Is mere possession of a particular impairment enough, or does membership involve
conscious affiliation? (Couser 19-30). Although Jose doesnt share similar traits to the average
autistic patient due to his imaginative abilities and interpretations, being classified as autistic
would be enough to associate him with the entire group.

The final medical narrative written by Oliver Sacks that will be closely examined is
titled, Witty Ticcy Ray. The main subject of the story is named Ray, and the disorder that he is
suffering from is tourettes syndrome. People who are diagnosed with tourettes often experience
uncontrollable tics, strange impulses and outrageous outbursts, the severity of which varies on a
case to case basis. Tourettes was once thought to be a very rare disease that affected one in a
million people. However, Sacks discovered that the disorder was much more prevalent than
anyone had previously thought. Unlike people with conditions similar to that of Dr.P and those
with autism, patients with tourettes syndrome are fully aware of their condition and often play in
active role in spreading awareness of their disorder in an attempt to alter the publics perception
of them and see them in a more positive light.
Sacks describes Rays personality as witty and charming, as well as demonstrating a high
intelligence. These characteristics allowed Ray to successfully complete college and get married.
However, his violent tics and constant outburst of profanity had caused him being stigmatized by
his employers. This resulted in Ray being fired from numerous jobs and was unable to form any
meaningful social connections after graduating from college. People started to judge him on his
disorder and not by his character. Ray was even able to diagnose himself with tourettes after
reading an article from the Washington Post, this was something Dr.P and Jose were unable to
accomplish themselves. The title of the story, Witty Ticcy Ray was a nickname that Ray had
given himself due to him constantly referring to himself in the third person.
Witty Ticcy Ray shares similarities with, The Man who mistook his Wife for a Hat,
in that Sacks adds a humorous element to both stories. After Ray was prescribed with a drug
called haldol, his reaction time and coordination were greatly reduced. He ran full speed into a
revolving door and stumbled along the way, resulting in a black eye and a broken nose. Sacks

said the reason he injured himself was due to the fact that patients with tourettes are attracted to
spinning objects. This could be offensive to people with tourettes syndrome because its
describing them as injury prone and sporadic in their behavior.
However, the largest ethical concern of this story occurs during Sacks weekly
conversations with Ray to convince him to keep taking the haldol. Sacks asked Ray to imagine a
life without tourettes syndrome. Compared to the life he has now, this tourettes free life would be
a change for the better, opening new doors for Ray, socially and economically. After the three
month session with Sacks, Ray decides he will take the medicine everyday in an attempt to live a
normal life. After conquering the symptoms of tourettes, Ray stabilized his marriage and his
friends no longer refer to him as a accomplish tourettes clown.
There are several issues regarding the section of this story. Tourettes syndrome is being
perceived as an undesirable trait and Sacks was giving a sense of hope in overcoming the
disorder. The problem is that people within the Tourettes Syndrome Association are trying to
spread awareness and acceptance of their disorder. Sacks is essentially portraying the opinion
that a tourettes sufferer is better off getting rid of the disease entirely than to continue living with
it. This can cause the public to lose empathy for those with tourettes, believing its a disease that
can be fully managed and making public acceptance for the disorder harder to obtain. Thomas
Couser uses the example of the film Million Dollar Baby in which the protagonist a boxer who
becomes a paraplegic after being sabotaged by an opposing boxer. And it is misleading to
suggest, as the film does, that her decision is for the best and a truly free choice. While
presumably no actual paraplegics were harmed in the production of the film, it may be fair to say
that all paraplegics were harmed by it (Couser 19-30). The main character decides that being
taken off life support and dying was a better fate than living her life as a paraplegic. Putting a

tourettes patient on a drug like haldol is essentially taking away their true personalities and
transforming them into socially acceptable individuals. Ray himself noticed that he no longer
possessed the same characteristics he had throughout the majority of his life. He lost his music
prowess, his fast reaction time, his trademark outbursts, and his killer instinct during sporting
events. He decided to only take haldol during the weekdays where he would need it for his job.
However, on weekends he will not to take the drug and no longer be tied down by social
constructs and being told how he should or should not act. He would rather be his old wild and
frenetic self, even if its only for two days.

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