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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Decent LifeA Delicate BalanceA Fragile LifeA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Mirror Is for ReflectionA Mirror Is for ReflectionA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Tapestry of ValuesA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst MarriageAgainst 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Rita Charon describes narrative medicine as a clinical practice, "defined as medicine practiced with the narrative competence to recognize, absorb, interpret, and be moved by the stories of illness." The idea of narrative medicine is a fine one: emphasize the role of narrative (and thus meanings, life histories, and emotions) in medicine, and especially physician-patient interactions. It's a fundamentally humanist approach, with the goal of treating the whole person rather than the disease. Charon is the driving force behind narrative medicine, and by all accounts she is a tireless advocate, knowledgeable and passionate about her cause. She has been editor-in-chief of the journal Literature and Medicine. The whole of narrative medicine is non-reductionist, nuanced and interdisciplinary. So there's a great deal to like about the project. What's more, all the reviews I have found of Narrative Medicine have been positive, and mostly glowing.
Yet the first time I tried, I found Charon's book almost impossible to read the whole way through, not because it uses difficult concepts or language, but largely because I found it so unclear what narrative medicine is meant to be, and what claims she is making. Often, different theorists and traditions rush by in a few sentences, and she lumps together ideas that do not fit well together. When her claims are clear, they often seem inconsequential or mundane. All through the book, Charon assumes that narrative is a positive force, and that once doctors pay attention to it, care will be improved. She pays remarkably little attention to how narratives often limit people, reinforce existing power structures, and offer an impoverished way of living. While she occasionally mentions post-structuralism or post-modernism, she does not discuss the need to struggle against language and meaning. My strongest disagreement with Charon's admirers is over her writing style: several other reviews mention her fine style, yet most of the book is full of jargon with a portentous air, needlessly peppering her paragraphs with quotations from other authors, when she could say what she intends much more simply and directly. The style is no worse than most academic books, but it is no better either.
A friend of mine asked me about the book since I was carrying around it with me, and I explained its basic ideas. He commented that most doctors would find its proposals ridiculous: they already have pressures on their time, and they do not want to be having patients tell them their life stories. I found myself defending Charon's ideas, arguing that narrative medicine could improve clinical practice and could even be more efficient, since it would improve patient compliance with doctor's orders, and it could avoid misunderstanding between the doctor and patient. More fundamentally, we do need a health care practice in which the doctor recognizes the full humanity of the patient and does not treat the disease. A visit with a physician should not make one feel like a car being taken to an auto-mechanic.
Charon's goals are admirable. The question is whether narrative medicine can achieve those goals. In particular, we need to ask whether it can address psychological, sociological, and ethical issues in medicine, and especially those relevant to the patient-physician relationship, in a coherent way. The skeptical worry it faces is that it is just a catchy gimmick that deemphasizes the science in psychology and sociology and that depoliticizes our understanding of medical problems. Indeed, we may worry that it simply adds confusion. One might compare George Engel's biopsychosocial model of medicine, to which most textbooks in psychiatry and clinical psychology pay lip service, but which has not has not done much to help us combine psychological and sociological aspects of a patient's condition. It serves as a prod to consider non-biological aspects of a case, but that's about it; clinicians are left on their own in working out how to combine them. Engel's work was certainly a useful episode in modern medicine, but to call his approach a "model" is really an exaggeration. Similarly, we might similarly worry that narrative medicine might add up to no more than a reminder that it is helpful for doctors to listen to patients and to tell their own stories to each other. Of course, doctors should listen to patients and each other, but we knew that already.
So how does Charon set out narrative medicine, and does she provide an apparatus that manages to meet this challenge and worries? She divides the narrative features of medicine into five categories: temporarility, singularity, causality/contingency, intersubjectivity, and ethicality -- the awkwardness of these labels is a good example of the difficulty that Charon's text presents. These categories do provide a way to think about stories, but they are so loosely defined that they are just place-holders; one could use a range of other labels just as well. One might suggest, for example, context, events, consequences, love, and hope. Nothing is ruled out.
One of Charon's practical contributions is the invention of the "Parallel Chart," in which doctors write down their experiences and stories in treating patients that they cannot put on the standard patient's chart. Charon claims that such writing is intensely valuable for doctors and gives several examples.
Charon seems to embrace every theory she has ever encountered. Everyone has a valuable perspective and something important to say. This may be a wonderfully inclusive vision, but it is cloying. It also means that there's almost nothing distinctive about the idea of narrative medicine except its main claim that stories help.
The only time Charon makes critical comments about a theory is in her chapter on ethics, where she shows disdain for the limitations of conventional bioethics and especially principlist bioethics. She argues that narrative bioethics has a distinct advantage in its display of respect for attention, representation, and affiliation, the three movements of narrative medicine. She paints a picture of an alliance between her work that that in "feminist ethics, communitarian ethics, liberation ethics, hermeneutical ethics, casuistry, virtue ethics, and care ethics" (208), since "these complexly differing approaches share a commitment to narrative truth and to the power of telling and listening." (ibid.) Charon never explains why these approaches have a greater commitment to narrative than Kantian ethics or utilitarianism, or indeed how narrative ethics does any better at arriving at solutions than standard bioethics.
While Charon several times mentions approvingly work in post-structuralism and psychoanalysis, she does not seem to take on board the implications of those movements for the limitations of narrative. Consider Hilde Lindemann Nelson's important work Damaged Identities, Narrative Repair (2001). While Charon is concerned almost exclusively with the healing power of narrative, Nelson spells out how narrative can be co-opted to oppress and limit people's lives, and how telling the truth about one's life is far from simple. The concepts with which we build our narratives may themselves be problematic, and we may need to work to formulate alternative approaches. In literary theory and sociology, there's considerable work being done on counter-narratives. Yet Charon never addresses these concerns directly, preferring to focus on a happier humanistic notion of narrative, and this is an important limitation of her approach.
So Charon's book is best not seen as a careful assessment of the value and limits of narrative in medicine, but rather a passionate work of praise and celebration of narrative. Its ideal readers are doctors who are looking for an alternative to reductionist medical approaches, and who want a medicine that sees into people's souls, acknowledging their suffering and their strengths, with room for their spirituality. The book gives a reasonably detailed impression of a way of doing narrative medicine, and it has a good collection of stories of physicians and patients. However, the case for the transformation of current medicine into narrative medicine has yet to be made.
Link: The Program in Narrative Medicine, Columbia University
© 2009 Christian Perring
Christian Perring, Associate Professor of Philosophy, Dowling College, New York.