Cool intimacies of care for contemporary clinical practice

The practices of medicine across history and culture illuminate the centrality of the physical intimacy of touch in the expression of the healer’s care. Yet much of modern western medicine diminishes the value of intimacy in the expertise of the clinician, and marginalises emotionally inflected practices into categories of care that are separate from the expertise of the clinician. Can such a divide between the objectifying clinical gaze and the intimacy of emotional care be made without losing something vital to the therapeutic processes of healing? To reinvigorate debate about the place of intimacy for contemporary clinical practice, we look back to medieval literature, which illuminates two traditions in understanding intimacy and its inter connections with healing. One of these traditions has become dominant in modern health care; we call for a re-engagement with the second in contemporary clinical practice.

The physical intimacy of touch held special power in the medieval period, and perhaps this is unsurprising since at this time medicine was limited almost exclusively to palliative care. In the medieval world, not only were cures rare but also illness itself was perceived as deeply mysterious, often attributed to supernatural causes. Medical texts mainly comprise treatises rooted in classical humoral theory, compendia of ailments and treatments, and collections of remedies. It is literature, and especially Romance literature—the imaginative fiction of the Middle Ages—that offers insights into cultural attitudes and ideas.

Medieval writing reflects the hope for divine intervention or medical marvel in its repeated images of healers possessed of holy or magical powers. Touch is the instrument in all these cases, reflecting both its importance in palliative care and its prominent role in the healing miracles of Judaeo-Christian tradition. Expressions of the intimacies of the healing touch are, however, subtly differentiated. The connection between touch and the intimacy of personal attachment is repeatedly emphasised in medieval Romance, where women tend and heal the wounds of their beloved knights. Sir Thomas Malory in his Le Morte Darthur (1485) emphasises the conjunction of medical knowledge and romantic love in describing how Sir Tristram’s wounds are healed by his lady, La Beale Isode, who is “a noble surgeon”. By contrast, Malory depicts the healing of the poisoned wounds of Sir Urry as effected not through the personal attachment of the healer, but through a more abstract intimacy between the healer as instrument of the divine and the human sufferer. Of all King Arthur’s knights, only “the beste knyght of the worlde” Sir Launcelot succeeds, and the miracle of healing reflects his spiritual perfection. This spiritual perfection comprises an intimate connection to the divine and an abstract love for his fellow knight, and is manifest emotionally through his virtue and humility. The degree of personal involvement with the sufferer differs in these two instances of healing, yet crucial to each is the expression of intimate connections, enacted in the deep probing of wounds. In one case, the carer and cared-for are connected through bonds of secular love, in the other through Christian love and spiritual perfection.

Why might these literary representations of intimacy and healing be relevant for contemporary questions about intimacy in medical care? We suggest that they illuminate two traditions of understanding intimacy and its interconnections with healing. This first, linked to emotional love, has become dominant in modern society. By contrast the second idea—of an impersonal attentiveness to humanity, what Evans and Macnaughton term “cool intimacies”—deserves greater attention and may have a relevance for clinical practice. The development of nursing practice has built on the first of these intimate connections. Beyond romantic love, the physical intimacy of touch is generally associated with childhood and nurturing and is traditionally regarded as more maternal than paternal. Outside of family and are most often delivered by nursing provision or home carers. The professionalised understanding of care mimics the intimate relationships of familial or romantic bonds.

This model was first advocated within British medical care by Florence Nightingale, who emphasised the importance of ministering to the body:

“The amount of relief and comfort experienced by the sick after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed. But it must not be forgotten that the comfort and relief so obtained are not all. They are, in fact, nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them.”

Although Nightingale stated explicitly that care for the intimate hygiene of the body is a crucial part of the healing process, and not merely palliative, the emergence of a nursing profession has coincided with a closing-down of the everyday physical intimacies of touch outside the bonds of familial or romantic affection. The sociologist Julia Twigg, writing on bathing and care in the community, comments on this cultural change:

“modern western society is less tactile compared with non-western societies and the historical past…touch in modern life has become increasingly confined to erotic relations, so that adults, particularly men, live in a world that is largely atactile except for sex”.

This understanding of the intimate connection of touch linked to emotional love leaves clinical practice fraught with anxiety and ambivalence. To touch even the surfaces of the body may be potentially threatening or inappropriate, and at the very least, embarrassing. As a result, the legitimate settings for intimate care and clinical examination are firmly delimited. For the medical professional the intimacies of physical contact are tightly managed through ritualised spaces and practices. Frances Rapport and colleagues refer to the examination area in doctors’ surgeries as a “sacred space”. This demarcation of a sacred space can enable physical intimacy to be distanced from its awkward associations of emotional love. Moreover, the use of instruments further distances the examination procedure from the contemporary eroticism of personal touch. Such efforts reflect a caring concern for the sensitivities and protection of both patient and practitioner. However, they may also facilitate non-caring practices. They may contribute to the much-criticised objectification of the body in clinical practice and consequently to a depersonalised care that lacks attention to the sentient individual.

The healing of Sir Urry by Sir Launcelot in Malory’s Morte Darthur can illuminate a different notion of intimacy, which we suggest might raise useful questions about touch in clinical care. This is an abstract intimacy in which the act of healing is infused with a less personalised and non-romantic love that attends to humanity. Such an understanding finds contemporary parallels outside modern western medicine, in eastern healing traditions and in such religious practices as the laying on of hands in Pentecostal faith healing. Unlike the deep probing of medieval wounds, here touch is limited, but involves a similar type of transformative connection. Some studies have reported the healing value of “gentle touch” to alleviate pain and stress in conditions that include musculoskeletal disorders and cancers. As in the healing of Sir Urry or the lifting of oppression described by Nightingale, while touch is the overt medium of healing, it is an expression of presence, watching, and sensitivity to the other. Clare Weze and her colleagues describe gentle touch as relational rather than technique with an emphasis on attentiveness:

“From a client’s perspective, the touch enables awareness of the healer’s attentiveness to each area of their body in turn. The lingering of the healer on places where disease has been reported by the client, or recognized by the healer, evidences the especial attention being paid to those places.”

Efforts to distance the clinical examination from contemporary notions of intimacy need not of necessity lead to an objectification of the patient. In poet Kathleen Jamie’s account of the clinical examination of her husband, the physician’s stethoscope makes a connection to the patient that enables a cool intimacy that is both intensely caring in the attentiveness to the specific body and impersonal and abstract in the application of generic knowledge.

“Leaning across the bed behind him, the doctor placed her stethoscope at precise points on Phil’s back, and began to listen. As she listened she created around herself a screen of privacy. Her eyes disengaged. She folded herself into the stethoscope, in toward Phil’s back, attending to the sound as a musician might. Then she began concentrating on an area midway down his right side. She was tracking something within his body, moving the stethoscope an inch to the left, and inch to the right, as if comparing two notes. Suddenly she was satisfied, and leaned back, tugging the stethoscope out of her ears.”

The abstract intimacy expressed in the spiritual healing of Sir Launcelot or in the ministering to the body of Nightingale can have resonances for an alternative understanding of intimacy in the spaces of clinical examination. This we have termed the “cool intimacies” of clinical practice characterised by a close and caring attentiveness to the body. In this working of the idea of intimacy, apparent tensions between the physical proximity of touch and professional objectivity dissolve. Drawing on this understanding, we argue for a reinvigorated notion of cool intimacy in the contemporary practices of mainstream, technologised clinical care.