Tell Us What We Need To Know: Perspective for Ethical Dilemmas |
Tom Janisse, MD
Ethics Rounds 2003-04 Winter;13(4).
Narrative in Ethics
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; 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.
In Stories Matter, Dr Susan Rubin, ethics consultant, has written:
"Each individual develops impressions based on the elements of
the case with which they are familiar, and unavoidably there are parts
of the story they simply do not know. In this way, each individual can
claim to hold only a piece of the story."1
number of physicians and health care professionals write about their
subjective experiences with patients and colleagues to enhance self-awareness.
Through this reflective process, they gain perspective in clinical encounters
that are routinely reduced to medical record facts. Dr Rita Charon,
Columbia University internist, notes in her JAMA article: "The
effective practice of medicine requires narrative competence, that is,
the ability to acknowledge, absorb, interpret, and act on the stories
and plights of others. Medicine practiced with narrative competence,
called narrative medicine, is proposed as a model for humane and effective
approach can be a useful ethics tool in the initial descriptive construction
of the case and subsequently in normative reflection. Dr Rubin notes:
"Narrative methods can sharpen our attunement to issues of how
the narrative of a case or ethical dilemma are constructed, whose voices
are given authority, which plot lines are considered relevant, and which
possible resolutions are given consideration. The virtue of using a
narrative approach is that it forces us to expose our assumptions and
biases, to confront them, and to bring competing allegiances into dialogue
with one another."1
Relevance of Narrative
to using narrative to enhance the ethics process, physicians and health
care professionals who read and write narratives of clinical encounters
can improve their diagnostic and communication competence. Findings
in a randomized, controlled trial of medical students writing in a "parallel
chart" indicate significantly improved awareness of patients' perspectives,
empathy, and clinical skills in caring for individual patients, including
interviewing and forming therapeutic relationships.3 Physicians
confront many dilemmas in their clinical practice: moral, ethical, legal,
social, human rights, religious, and economic. At these times, they
may question their personal values. By listening closely to patients'
stories, physicians and health care professionals broaden their perspective
and organize and integrate complex situations, leading to solutions
Interpersonal and Communication Skills section of the New Competencies
for Internal Medicine, the American Board of Internal Medicine cites
the importance of using "effective listening, nonverbal, questioning,
and narrative skills to communicate with patients and families."4
schools, such as University of Virginia Health Science Center, now require
narrative courses as part of their Practice of Medicine curriculum.
"The patient's story is the human voice in medicine. It is critically
important to the physician's approach to and care of the patient. What
we call the 'story' is the narrative created by the patient to describe
and interpret what has happened (is happening) to him or her, this being
the reason the patient is now seeing the doctor. In this session, we
explore how the physician's narratives about the patient are derived
the patient's story, then come to represent the patient and to influence
the physician's diagnosis and plan for treatment."5
recent American Society of Bioethics and Humanities annual meeting,
two of several accredited presentations relating to the importance of
narrative in ethics were: The Patient Tells, the Doctor Reads, the
Writer Shares, by Martin Winckler, MD, French internist;6
and Writing Well, by Abraham Verghese, MD, MFA, an internist
who also authored an article, "The Physician as Storyteller,"
in the Annals of Internal Medicine. In it he writes: "A
sense for the stories unfolding before us will perhaps allow us to be
more conscious of bringing people to the epiphanies that their stories
require. By being attuned to character, not just through appearance
but particularly through dialogue, we will remember the voice of the
patient, even though it is the voice of medicine that we record in the
chart."7 AIM also published an article, "Writing
for Our Lives: Physician Narratives and Medical Practice," by Kate
Scannell, MD, TPMG internist. In relation to stories she writes: "Writing
and speaking about doctoring can save your life. By this I do not mean
that they can prolong life, but, rather, that they can prove deeply
An Integral Model for
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
subjectiveis 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
Integral Model, developed by philosopher and psychologist Ken Wilber,
integrates the core of the world's wisdom traditions.9 This
model is a concrete way to understand the place and value of the subjective
and the objective in ethics. It establishes a foundation to appreciate
the narrative--people's subjective stories--in the resolution of ethical
dilemmas. The individual subjective (Table 1, upper left quadrant) includes
our interior beliefs, intentions, and perceptions. Likewise it is the
realm of our patients' beliefs, intentions, and perceptions. The individual
objective (upper right quadrant) represents our exterior behavior, and
in this realm we play out our professional health care roles. If we
belong to The Permanente Medical Group or Kaiser Foundation Health Plan,
we are a collective (lower right quadrant). If our group holds shared
values and culture, then we share a collective interior (lower left
quadrant). If, finally, our group shared values resonate with our personal
values and beliefs, we have reached a truly integrated state.10
of the interior subjective (left quadrants) is the domain of the social
sciences--psychology, sociology, and anthropology--with a rich literature
of qualitative evidence to offer the medical sciences and system sciences
(right quadrants) of conventional medicine to resolve ethical dilemmas.
Because the subjective both informs and drives the objective realm,
it is necessary for physicians to probe the individual personal and
the collective family. Ultimately, understanding both the subjective
and objective realms, and their connection, is necessary for integrated,
Benefits of Narrative
for Doctors in Day-to-Day Practice
doctors and health care professionals have potential ethical lapses
and issues, so it is not just for major ethical dilemmas that exploring
people's narratives can bring benefit. We may create ethical dilemmas
out of ethical situations by not fully understanding the narratives
of the people involved. Doctors may obviate this progression with preventive
"narrative insight," by probing more deeply their patients',
families', and colleagues' stories. Just as at times we explore several
family members' views in the course of diagnosis and treatment, we also
need to explore several subjective facets of each patient's personal
narrative--their needs, beliefs, preferences, values, intentions, and
perspectives--to create a shared understanding that can resolve dilemmas:
ethical, clinical, social, psychological, cultural, medical-legal, and
Narrative Medicine Workshops
Permanente Journal (TPJ) has created a series of narrative
medicine educational workshops, called: Writing for Our Lives,
to take place in the first quarter of 2004. Two workshop objectives
are: 1) Describe how writing narratives or telling stories of clinical
encounters improves one's ability to articulate patient perspectives
and demonstrate caring behaviors toward patients; and 2) Learn writing
and storytelling tools and their application to improve narrative skill
process can also benefit patients as evidenced in The KPNW Severe Obesity
Management Program. Through a collaboration with the nonprofit organization
Write Around Portland (WRAP), they provided patients undergoing bariatric
surgery a writing process for self-expression while in the program.
In addition to offering an opportunity for individuals who were possibly
previously voiceless, the patients' insights and feelings expressed
in their writing contained many messages for clinicians.11,12
Just as TPJ published writing by patients, it looks to publish
writing by clinicians in its Soul of the Healer section.
narrative medicine workshop, on February 28, in Oakland, California,
is copresented by TPMG Physician Satisfaction/Wellness Committees and
the Kaiser Permanente Northern California Ethics Department; the second,
on March 31, in Portland, Oregon, is copresented by the NWP Health and
Renewal Program (HARP), the NWP Physician Health and Worklife Committee,
and the NWP CME and Professional Development Department; and the third,
on April 6, in Maui, Hawaii, is presented as a session of the KP National
Primary Care Conference.
S. Beyond the authoritative voice: casting a wide net in ethics consultation,
in Charon, R, ed, Stories Matter: The Role of Narrative in Medical
Ethics, Routledge, New York, 2002
R. The patient-physician relationship. Narrative medicine: a model
for empathy, reflection, profession, and trust. JAMA 2001 Oct 17;286(15):1897-902.
R. "Narrative medicine," Narrative Medicine A Colloquium,
Columbia University, New York City, May 2003.
Competencies for Internal Medicine, American Board of Internal Medicine.
MD, Mohrmann ME. "The practice of medicine I: narrative medicine,"
University of Virginia Health Science Center, September 2002.
M. "The patient tells, the doctor reads, the writer shares,"
American Society of Bioethics and Humanities Conference, Montreal,
A. The physician as storyteller. Ann Intern Med 2001 Dec 4;135(11):1012-7.
K. Writing for our lives: physician narratives and medical practice.
Ann Intern Med 2002 Nov 5;137(9):779-81.
K. The eye of spirit: an integral vision for a world gone slightly
mad. Boston: Shambhala Publications; 1998.
T. Through conventional medicine to integral medicine: challenges
and promises, Integral Medicine: A Noetic Sciences Reader, Churchill-Livingston/Elsevier
Sciences, New York, in press.
D. Write around Portland: What do we gain? What do we lose? Perm J
L. Write around Portland: Sometimes the first step is all you need.
Perm J 2003 Spring;7(2):75-8.
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