2003 Vohs and Lawrence Awards
& A Focus on New Products:
••Spring 2004/Vol. 8, No. 2

Medical Ethics

Stories Tell Us What We Need To Know: Perspective for Ethical Dilemmas
--The Story Study | to pdf>>

By Tom Janisse, MD

(Portions of the text, and the first story study, are excerpted from Ethics Rounds 2003-04 Winter;13(14), and from The Permanente Journal 2003 Winter;6(1) and The Permanente Journal 2004 Winter;8(1).

Narrative in Ethics

We hear stories and tell stories every day we practice medicine without appreciating that the resolutions we seek in ethical dilemmas often unfold from the stories of our patients, their families, and our colleagues. A story holds so much life, and knowledge in context leads to better understanding. Yet, misguided, we search for detail in chemical blood levels, shadows in a radiographic image, rising and falling numbers on a graphic. More distracting are assumptions and perceptions from our single-minded perspective.

Relevance of Narrative Medicine

Physicians and health care professionals who read and write narratives of clinical encounters can improve their diagnostic and communication competence. By listening closely to patients' stories, physicians and health care professionals broaden their perspective and organize and integrate complex situations, leading to solutions to dilemmas. Stories clear the mind.

The Value of the Subjective

In medicine, we often speak of wanting objective data or evidence, thereby relegating the subjective realm to ineffectuality or to marginal value at best. Using S.O.A.P. notes, however, belies this devaluation. "S"--the subjective--is the history, the story. It is in this area, our medical elders constantly remind us, that we will find the diagnosis 90% of the time. Further, the subjective and objective are interdependent and, when embedded in a context, lead to the assessment and plan of care.

Story as Case Study

Using a clinical case study as educational methodology is embedded in medicine as a highly effective, relevant, and engaging intervention. It brings to life the interdependent factors at play in the application of medical knowledge in context. The story study is a dramatized case study that gives you an experience and, because of that, experiential knowledge and a lived perspective.

Several elements enhance the effect: you witness people's behavior; you hear their perceptions and beliefs expressed in dialogue; and, when beliefs and behavior are linked, your understanding improves.

The following two narratives are excerpts from short fiction based on true stories. They are annotated with clinically relevant commentary related to common ethical lapses, issues, and dilemmas.

Assess the value for you of the story study approach to broaden your perspective and your understanding of clinical encounters.

Case: "Just Missed"¹ Dementia and Depression






References

1. Janisse, T. excerpt from "Just Missed," unpublished manuscript, 2003.
2. Janisse, T. "You'll Never Get Off the Table," Perm J, 2003 Winter , 7(1):72-5.

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