In the paragraphs which follow, we will be discussing the ways in which two pieces of speculative fiction, the science fiction film Star Trek IV: The Voyage Home, and the novel The Tiger’s Wife use diagnostic and prognostic certainty as part of their creative narratives. In both cases, the confidence vested in the diagnosis and its outcome is contrasted to the “diagnostic illusory” of contemporary medicine.

Even while diagnosis is medicine’s primary classification tool, it is far less circumscribed than diagnostic taxonomies suggest, as well as the power afforded those who diagnose. Even very material conditions have porous boundaries (Jutel 2013) which muddy the waters in a system that is based on tidy categories. Sarah Nettleton and her colleagues have developed the term “diagnostic illusory” to describe how medicine invests in generalisation as a way of understanding disease. In the diagnostic illusory, for the cases that resists classification, or perturb a diagnostic category, one turns to ever-more sophisticated forms of technology, with the belief that it’s just a matter of time before the explanation will become clear, and the diagnosis justified. Nettleton and her colleagues raise the idea of “illusory” to highlight the “ambiguities and nuanced complexities associated with the biomedical imperative to name and classify” (Nettleton, Kitzinger, and Kitzinger 2014).

In this short essay, we will explore how two speculative texts represent diagnosis, highlighting through their respectively futuristic and supernatural approaches the yearnings of contemporary medicine, and the society it serves, for diagnostic certainty.

 

Star Trek IV: The Voyage Home and the Tricorder

In the science fiction epic Star Trek IV: The Voyage Home (Nimoy 1986), the Starship Enterprise and its crew have come back to planet earth in 1986 to save the humpback whale from extinction and by extension, to save planet earth from destruction in the future. This year is both the year the film was produced and three centuries earlier than the narrative starting point for the film, 2286 BCE. While they are in 1986, Chekov, one of the crew members is gravely injured, and is taken to a 1980s San Francisco hospital by emergency services. When the spaceship crew learn of Chekov’s predicament, the on-board medical doctor, McCoy, pleads with the Admiral: “Jim, you’ve got to let me go [to the hospital]. Don’t leave him in the hands of twentieth-century medicine!” Even the hyperrational Spock butts in: “Admiral, may I suggest that Dr. McCoy is correct? We must help Chekov….It is the human thing to do.”

This exchange introduces an implicit distinction made by the characters but that the viewers will clearly understand: twentieth-century medicine is old-fashioned, ineffective, and even barbaric. Admiral Kirk faces the choice of leaving one of his crew members to the backward and ultimately deadly grasp of the medicine contemporaneous to the film’s viewers. He agrees they can go to Chekov’s rescue.

In order to save Chekov, Kirk and McCoy dress as twentieth-century surgeons and enter the hospital where Chekov has been admitted. They masquerade as surgeons so as to obtain access to otherwise off-limit parts of the hospital, and to exercise power and authority over security personnel and other medical staff. Fans of the show will be able to predict what will ensue: the superior power of the twenty-third century medicine will enable the U.S.S. Enterprise doctor to save his crewmate in minutes. There is never any doubt; the scene employs a narrative strategy to observe with expected wonderment McCoy’s futuristic diagnostic skills and therapies. In other words, the narrative pay-off of the deployment of medicine as practiced by McCoy in the Star Trek series (and in the television series) is the speculative projection into a better future wherein technologies have resolved many of the limitations of medicine present for those watching the film.

Since this film is set simultaneously in the future and in the present, the filmmakers are able to stress this point even further as if in acknowledgment to the position of the audience watching the film. How better to show the superiority of future medical knowledge and technology than to contrast these explicitly with those of the present?

To underline this contrast, even before Chekov is saved, when McCoy—dressed as a surgeon and on his way to save his starship colleague—is stopped by an elderly woman who has been left waiting in an hospital corridor. “What’s wrong with you?” he asks. She replies: “kidney dialysis” as if this constituted some kind of diagnosis. McCoy is morally outraged: “Dialysis? My God. What is this, the dark ages?” He hands a pill to the woman, gently taps her face a few times and adds “Here. Now you swallow that, and, if you have any more problems, just call me.” Shortly afterwards as he overhears doctors talk about 20^th century cancer treatment (“radical chemotherapy”; “image therapy”) he comments” “Unbelievable.…It sounds like the goddamn Spanish Inquisition to me!”

McCoy has access to advanced technologies and medication yet he understands twentieth-century medical practices and hierarchies even if they are to him archaic and criminal. Once at Chekov’s side in the operating theatre, he will whip out the medical “tricorder,” a hand-held device McCoy regularly uses in the television series to diagnose his patients. As McCoy deploys this tool, the twentieth-century surgeons are puzzled — in contrast to the viewers who know all about it, and even its name, which explains why when the surgeon asks what the instrument is, McCoy does not need to answer. “My God, man. Drilling holes in his head is not the answer… Put away your butcher knives and let me save this patient before it is too late” and later “We are dealing with medievalism here!” Of course, Chekov is saved through McCoy’s diagnostic technologies and superior array of treatments.

But as we have shown, this scene makes a nod towards the audience who can recognise the portrayal of their medical institutions and practitioners and can fully concur with McCoy’s perspective of an antiquated and dangerous context for practicing medicine.

 

The Tiger’s Wife and The Deathless Man

The deathless man is a fictional character in Téa Obreht’s novel The Tiger’s Wife (2011). The Tiger’s Wife is narrated by Natalia Stefanović, a doctor, and the grand-daughter of Dr. Leandro, whose story this novel sets out to relate. That these two prominent characters are doctors, of Western biomedicine and of the contemporary era, is an important point of contrast, as in Star Trek IV, to the speculative prognostic practices we will see as the story unfolds. In this case, contemporary medicine is not barbaric, but limited. It seeks, and indeed sometimes achieves certainty, but a certainty which pales in comparison to the certainties that the deathless man can deliver.

In this novel, the certainty of speculative diagnosis is predictive. It is underlined by regular encounters of a distinguished medical doctor, Leandro, and a mysterious supernatural physician, the deathless man. Their evolving relationship as the former progressively comes to accept the latter, punctuates the limits of Leandro’s medical prognostic capacity, and the omniscience of the deathless man.

The novel starts at Leandro’s death. In the Balkans, where the novel is set, people believe the soul has forty days after death to retrace its life before returning home, to settle in with the people it left behind. It is a journey which involves the home and its inhabitants, as the soul rummages through the drawers, the memories, the closets of the place in which it dwelled during life. As the grandfather died far from home, for reasons which elude his family, Natalia goes in pursuit of his body and belongings, to bring them home to the family. While she does so, she takes the narrative pathway her grandfather’s soul might have, relating the stories he had shared with her about his life. Woven through this narrative is the tale of the deathless man, who is the supernatural diagnostician upon whom we will focus in the paragraphs to come. The reader cannot help reflecting upon how the supernatural trumps conventional medicine in terms of what matters most: life and death.

The deathless man, Gavran Gailé, is also a doctor. He received this profession as a coming-of-age gift, from his uncle, Death. His diagnostic skills surpass those of Western biomedicine, because he can tell whether a person will live or die. He discerns this by the use of a magic coffee cup, also gifted by his uncle, the dregs from which will either point towards life or towards death after a person has drunk from it. Gailé is to break the cup of those whose dregs point towards life, and leave intact the cups of those who will die. But, he fails in his task by falling in love with a dying woman, whose death he rejects. He assists her to break the cup, time and again, so that she will not die. As punishment, Death ends up claiming the woman, and prevents Gailé from ever dying himself.

The deathless man then travels to people who are ill, and tells them of their diagnosis and their impending death. “If they know—if they have thought about it—sometimes the struggle is less and less” (p. 187), he explains to Dr. Leandro.

The deathless man only appears in this novel to Dr. Leandro. Leandro is himself a fine doctor, who is known for his skill in training expert diagnosticians, and also for memorably saving the life of the Marshall. He was at a wedding party for a colleague, but was the only sober doctor when the innkeeper came looking for help for a dying man. Leandro quickly diagnoses a ruptured appendix, and saves the man’s life. He will forever be known as the man who saved the Marshall. This diagnostic moment cements a hierarchy. Leandro’s diagnosis replaces that of an incompetent herbalist, who believed the Marshall was suffering from food poisoning. Leandro knew “instinctively” that this was a ruptured appendix that he would fix surgically. His exceptional diagnostic skills, however, cannot compete with those of Gailé.

When Gailé first appears in the novel it is because Leandro has been asked to come see about a “new development” in a village where people are coughing blood. He expects he will be diagnosing tuberculosis. Gailé has died, but at the time of his funeral, sits up in his coffin and asks for water to drink. Someone, fearing the devil, shoots him dead again. However, Leandro finds that Gailé is neither dead, nor ill, and has a long talk with him. Gailé explains to Leandro the circumstances: a man tried to kill him, by first drowning, then shooting him, because he was upset at the news Gailé had given him: “He was dying of tuberculosis…I only came to tell him, to help, to be here when it happened. Come now, Doctor—blood on pillows, a terrible cough. What was your diagnosis even before you came here?” (p.70)

The deathless man and Dr. Leandro will meet repeatedly over the course of the novel. To start with, Leandro is completely sceptical, and will even test Gailé’s claims of immortality by trying to drown him. However, by the end, the two talk together, complicit as almost-colleagues, about the importance of diagnosis.

At Gailé’s last appearance in the narrative, he stops diagnosing. He chooses to conceal, rather than announce the arrival of death. This plays out in a scene where Gailé and Leandro meet by chance at a restaurant in a town to which Leandro has returned nostalgically during the war. It was here he ate lobster on his wedding day. When he sees Gailé, he wonders if the latter is here to announce Leandro’s own death, accepting finally, Gailé’s supernatural skills. He is not. Gailé has come to await the deaths of those who will perish in the upcoming siege of Sarobor. The old and distinguished Muslim waiter at the restaurant in which they meet is amongst those who will meet their fate. “I am not warning that man because his life will end in suddenness. He does not need to know this, because it is through the non-knowing that he will not suffer” (p. 300) says Gailé. He resigns himself to no longer diagnosing the dying, but rather to keeping them happy in advance of their death.

In the Tiger’s Wife, the traditional purveyor of biomedical certainty, Leandro, is juxtaposed to a certainty, Death, over which he has no control, and no clear knowledge. Nothing is certain in life but death, and Gailé’s ability to pronounce its arrival is placed in stark contrast to the illusory certainty of modern medicine.

We wrote this essay to highlight examples of how speculative fiction deals with the problem of diagnostic certainty. Both Star Trek and The Tiger’s Wife count on a viewer who is certain, even if the setting leads to some confusion. This is particularly vivid in Star Trek, where Trekkies can read Dr. McCoy’s crankiness as a sign of his certainty about things not being as they should. They wait expectantly for him to swipe out the tricorder, as he does, time after time in episode after episode of the series. McCoy’s credibility as a medical practitioner is in great part measured by his at-times antiquated and hysterical appeals to humanity throughout the entire series. It’s a moment of light relief, as the viewers see this in-the-future doctor shove the 20^th century doctors out of the way (literally – they get locked up in the scrub room), but it’s never a moment of doubt. The tricorder’s diagnostic powers will triumph, and the crew member will be saved.

Contrast that to the tension and anxiety of the contemporary doctors, as they labour over Chekov. While they may be certain about his diagnosis (the drill poised to release a sub-dural hematoma is the clue), the film underlines the fallibility of the diagnosis and certainly McCoy’s distrust of the other physicians, as it gets superseded by the tricorder’s readings. The speculative nature of this diagnosis is less important than the measure of the gap between the medicine of the future and today’s medicine. It doesn’t really matter what machine Dr. McCoy uses to practice medicine in 2286, it is more about the fact that in the future, our present medicine will look archaic.

Paradoxically, perhaps, it is more the humanity of the Star Trek crew, and of the characters of The Tiger’s Wife, that end up being highlighted by these speculative practices. In The Tiger’s Wife, the metaphysical certainty of death appears in the guise of a physician. We shouldn’t be surprised. From the advent of scientific medicine, doctors have been afforded a putative authority in the definition of the future. Their pronouncements in relation to diagnosis are referred to as “truths,” revealing the moral content of the clinical relationship, and instilling the doctor with a God-like authority. But the human doctor will have to shuffle aside.

Leandro is displaced by death. Not only because he dies himself—indeed the entire novel is based on seeking solace for his recently-dead soul. As a biomedical doctor, the limits of his episteme are clearly accentuated. He may try to outwit death, announce death, but Gailé has a connection to death that conventional medicine could never access. Being immortal also prevents Gailé from being human, a condition he craves, as it alone allows the expression of love he felt for the woman whose death he wished to prevent.

Both of these examples reveal medical diagnosis as a kind of “sociotechnical imaginary”  (Jasanoff and Kim 2015). Contemporary diagnosis fails in the two areas that these speculative diagnoses succeed, that is to say in production of an absolute certainty of cause (so that a remedy can be put in place), and in the absolute link to prognosis (tomorrow you will die). When we say “tell me the truth doctor” we are usually asking for answers to these questions: what does this diagnosis mean, and how long have I got? The answers are commonly inadequate in medicine but are handily managed in these speculative texts.

These are creative constructions, not didactic ones. By considering a future or a supernatural medicine which could be certain, we find a pleasant sense of reassurance. Indeed, this comfort has seeped out into medical innovation, where new forms of diagnostic technology are frequently referred to, maybe tongue in check, as “tricorders.” We don’t see this as evidence of what Ari Schick (2016) has referred to as science-fictionality, “a cognitive/perceptual mode in which the imagined future begins to exert increasing degrees of influence on the present” — we see this instead as recognition of Nettleton and the Kitzingers’ diagnostic illusory. It sheds a light on the degree to which certainty in diagnosis, and in its associated social goods — treatment and prognosis — are an always-elusive and a paradoxical ambition to which contemporary medicine aspires.

 

References

Jasanoff, Sheila, and Sang-Hyun Kim. 2015. Dreamscapes of modernity: sociotechnical imaginaries and the fabrication of power. Chicago ; London: The University of Chicago Press.

Jutel, Annemarie. 2013. “When pigs could fly: influenza and the elusive nature of diagnosis.” Perspectives in Biology and Medicine no. 56 (4):513-29. 

Nettleton, S., J. Kitzinger, and C. Kitzinger. 2014. “A diagnostic illusory? The case of distinguishing between “vegetative” and “minimally conscious” states.” Soc Sci Med no. 116:134-41.

Nimoy, Leonard. 1986. Star Trek IV:  The Voyage Home. Paramount Pictures.

Obreht, Téa. 2011. The tiger’s wife : a novel. New York: Random House Trade Paperbacks.

Schick, A. 2016. “Whereto speculative bioethics? Technological visions and future simulations in a science fictional culture.” Med Humanit no. 42 (4):225-231. 

 

Thierry Jutel is Associate Professor of Film at Victoria University.  He has recently published on the diagnostic moment in film.  He writes about contemporary film making and production culture.