CharlesTaylor, phronesis, and medicine: ethics and interpretation in illness narrative

This paper provides a brief overview and critique of the dominant objectivist understanding and use of illness narrative in Enlightenment (scientific) medicine and ethics, as well as several revisionist accounts, which reflect the evolution of this approach. In light of certain limitations and difficulties endemic in the objectivist understanding of illness narrative, an alternative phronesis approach to medical ethics influenced by Charles Taylor's account of the interpretive nature of human agency and language is examined. To this end, the account of interpretive medical responsibility previously described by Schultz and Carnevale as "clinical phronesis" (based upon Taylor's notion of "strong" or "radical evaluation") is reviewed and expanded. The thesis of this paper is that illness narrative has the ability to benefit patients as well as the potential to cause harm or iatrogenic effects. This benefit or harm is contingent upon how the story is told and understood. Consequently, these tales are not simply "nice stories," cathartic gestures, or mere supplements to scientific procedures and decision making, as suggested by the objectivist approach. Rather, they open the agent to meanings that provide a context for explanation and evaluation of illness episodes and therapeutic activities. This understanding provides indicators (guides) for right action. Hence, medical responsibility as clinical phronesis involves, first, the patient and provider's coformulation and cointerpretation of what is going on in the patient's illness narrative, and second, the patient and provider's response to interpretation of the facts of illness and what they signify-not simply a response to the brute facts of illness, alone. The appeal to medical responsibility as clinical phronesis thus underscores the importance of getting the patient's story of illness right. It is anticipated that further elaboration concerning the idea of clinical phronesis as interpretive illness narrative will provide a new foundation for medical ethics and decision making.     

Glossed Over

I open the glossy cover of my alma mater's alumni magazine. Images of new frontiers in medicine abound—state‐of‐the‐art research buildings and the latest in high‐tech hospital innovations. Nestled among the articles on cutting edge medicine is a feel‐good story about medical students. The article profiles volunteer medical students and their uninsured patients with chronic health conditions. At one site, they are touted as providing “the only medical care.” Indeed. I think back to my medical student days and cringe.     

Affect and the “Really Real”: The Politics of HIV/AIDS Framing in South African Theater

Funding in South Africa privileges HIV prevention campaigns underpinned by individual behavior change goals, despite over two decades of intervention but little reduction in national HIV prevalence. In response, civil society has begun calling for innovative interventions and ways of speaking about the epidemic. Employing framing theory, I analyze differences in how HIV/AIDS is characterized in public media and interrogate the knowledge politics underpinning a group of artists’ emerging attention to the nexus of affect, intersubjectivity, and epidemics within performance. I suggest this focus challenges but also complements dominant HIV intervention models by destabilizing common content, relations of power, and hierarchies of knowledge that shape normative health discourse and practice. Simultaneously, such performances reveal deep disparities between the neoliberal principles undergirding most global public health ideology, South Africa’s current political economy of HIV intervention, and the dynamic concerns of its HIV-affected constituents.     

Levinas and the patient as other: the ethical foundation of medicine

The thesis of this paper is that because the significance of Western medicine lies in its ability to enhance the health of persons within a society, the practice of medicine is foremost an ethic and only thereafter a science. In support of the priority of an ethical perspective in medical practice, the paper explores the socio-cultural nature of knowledge, upon which science itself is constructed. Next, it draws from Levinas' philosophy, which illumines the problem of ontological and epistemological priority. Specifically, it examines Levinas' rendering of the human face and of language, as they found the case for the priority of justice, or ethics. Finally, the paper offers the practice of narrative discourse as one solution that elevates the status of ethics within the institution of medicine and that has the potential to counteract the tendency in medical practice to employ a universalizing methodology based in science's power to control the human Other.     

The Power of the Single Story: Surrogacy and Social Media in Israel

Analyzing interviews with 20 Jewish-Israeli gestational surrogates who gave birth in 2014–2016, I examine the common narrative structure of their personal stories and the way that this becomes what Adichie calls a “single story”. This idealized, romanticized, utopian story includes: 1. an intimate bond between surrogate and intended parents; 2. an epic birth; 3. a happy ending, told publicly. After illustrating this structure, I present the consequences of this single story for surrogates whose experiences diverged from, yet were constantly compared to, the “perfect journey” narrative. Anthropologists of reproduction must pay careful attention to digital storytelling as a new reproductive technology.     

Truth Telling,Companionship, and Witness: An Agenda for Narrative Ethics

Narrative ethics holds that if you ask someone what goodness is, as a basis of action, most people will first appeal to various abstractions, each of which can be defined only by other abstractions that in turn require further definition. If you persist in asking what each of these abstractions actually means, eventually that person will have to tell you a story and expect you to recognize goodness in the story. Goodness and badness need stories to make them thinkable and to translate them into individual and collective actions. Yet after more than two decades of considering the issue, I do not believe that a collection of stories can by itself guide actions in ways that are sufficient to respond to ethical troubles in institutional settings. The question will always remain open for me, but my present belief is that narrative bioethics is always hyphenated, in the sense that guidance from stories needs to be allied with other ethical guidance. Each side of the hyphen qualifies the other side. The hyphenation I will argue for in this essay is “narrative‐deontology.”     

Illness, biomedicine, and alternative healing in Brittany, France

Through the lens of an illness narrative, this article focuses on the complex relationships between biomedicine and alternative therapies in Brittany, France. Themes drawn from the illness narrative highlight Breton ideas about the body, the source of healers' legitimacy, and the authority of the biomedical system. I argue that in this region, both biomedical and religious authorities are perceived to be allied to non-local elites, and both are subject to antagonistic criticism. Nonetheless, resistance to biomedicine through recourse to alternative therapies is mixed with ongoing dependence on the biomedical system, since patients seek strategic combinations of both systems to maximize health and other benefits. Pursuing alternative therapies empowers patients by enabling them to negotiate treatment options and to choose among competing narrative constructions of illness. By highlighting parallels between the Breton material and published work based elsewhere in Europe and North America, I argue that this case study has useful implications for anthropologists and medical practitioners working in broader Western contexts.     

Bluffing, puffing and spinning in managed-care organizations

I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.     

Beyond health care accountability: the gift of medicine

E. Haavi Morreim's book, Holding Health Care Accountable, insightfully describes several features of the current crisis in malpractice in relation to the health care marketplace. In this essay, I delineate the key and eminently practical guide for reform that she lays out. I argue that her insights bring us to more fundamental aspects than immanent medical economy and accountability--aspects that are ignored at present. I describe the features of immanent economy and how they tend to cover over epistemological and existential finitude in medicine, show how economy can in fact create new medical knowledge, and show that necessary error is a real feature of day-to-day medical practice. The current system, even with Morreim's reforms, remains at the level of immanent economy, but with modifications may point to the features of medicine that transcend medical knowledge and economy. The gifts of medicine cannot be reduced to the immanent medical economy, and any attempt to do so results in crisis. A health care that points to finitude and fallibility is one that points to the mystery of human existence and mortality. Any health care financing system that helps to delineate finitude--both epistemological and existential--is one that will give patients a new lease on living and dying.     

“The Tools of Your Chants and Spells”: Stories of Madwomen and Indian Practical Healing

ABSTRACT

A longstanding trope in Indian psychiatry, and in popular representations of it, involves the efficacy of incantations and exorcism in healing afflictions of the mind, notably hysteria. In many accounts, from nineteenth century medical journals to twenty-first century popular films, a medicine deemed at once ‘Western’ and universal is granted the ability to diagnose neurotic afflictions, but rendered incapable of curing them, while bodily techniques referred to as ‘Indian’ are granted efficacy. In this article, I explore the subtleties and implications of this recurrent knowledge paradigm. I argue that a particular arrangement—one in which difference is established through equivalence—undergirds the terms by which medicine comes to be viewed as a cultural encounter. As these progressive formulations are often founded on stories about women’s madness, I ask, what are the implications of an arguably pragmatic ethos founded on an uneven—and deeply gendered—resolution to postcolonial knowledge problems?     

Competent professionals and modern methods: state medicine in British Columbia during the 1930s

Little has been written about the formation of state medicine in early-twentieth-century Canada, particularly during the Depression era. Indeed, many historians and policy analysts have assumed that this was a time of stagnation and retrenchment in state health provision. To foster a more nuanced analysis of the formation of the Canadian medical state during the Depression decade, this article focuses on British Columbia and the public health initiatives brought in by the provincial Liberal government of T. D. Pattullo. In B.C., an energetic cadre of policymakers and bureaucrats sought to reform existing services by using professionally educated personnel, centralized administrative hierarchies, community education, and the surveillance of target health populations. Funding from the provincial government and the Rockefeller Foundation permitted considerable expansion in a range of public health sectors that included vital statistics, rural health centers, tuberculosis and venereal disease treatment schemes, and laboratory services. This article tells the story of this important period by bringing together details of the professional and personal lives of key individuals--the majority of whom were men--and exploring the new provincial health programs that were developed in B.C. during the interwar years.     

Undocumented Motherhood: Gender,Maternal Identity,and the Politics of Health Care

ABSTRACT

Undocumented Mexican immigrants have had to regularly confront a prohibiting health care system despite alienation, marginalization, and the threat of deportation. In this article, I explore the impact of political exclusion and alienating discourses on the health habitus of undocumented Mexican mothers through the narrative of one mother, Marta Garza, who finds herself at the painful intersection of political and medical alienation. Marta’s narrative reflects an analytical framework that centers undocumented motherhood as a space of necessary resilience and strain, wherein she is forced to advocate for her children’s health despite prohibitive barriers and dangerous potential consequences.     

"Looking for children": the search for fertility among the Sara of southern Chad

Despite the long history of infertility and childlessness in Central Africa, and the ongoing demand for treatment of fertility-related problems, the interpretations and experiences of the men and women living in the region vis-à vis the inability to have children remain largely unrecorded. In this paper I examine what the Sara, one of Chad's largest ethnic groups, have to say about fertility problems, and how these views are linked to changes in the social, cultural, and economic landscape of southern Chad in the 20th century. I describe the iterative and inductive process, commonly referred to by the Sara as "doing research," that the Sara use to explore the reasons for the inability to conceive or bear children in the face of multiple reproductive threats. The Sara's causal constructions convey a holistic and multifaceted perspective on this demographic anomaly--a perspective that is missing from most demo graphic and epidemiologic accounts and that has important implications for public health policy and practice.     

Demonology, neurology, and medicine in Edwardian Britain

The idea of a conflict between demonology and psychiatry has been a foundational myth in the history of medicine. Nineteenth-century alienists such as J.-M. Charcot and Henry Maudsley developed critiques of supernatural phenomena in an attempt to pathologize religious experience. Modern historians have reanalyzed these critiques, representing them as strategies in medical professionalization. These accounts all maintain an oddly bifurcated approach to the perceived conflict, treating demonology, as a passive and unchanging set of practices, while medicine is depicted as an active and aggressive agent. An examination of early twentieth-century demonological literature reveals a very different story. Fundamentalists and Pentecostalists engaged with the problems of conversion and possession, developing sophisticated models of the normal and the pathological in spiritual experience. Their writings drew upon medical and psychiatric sources ranging widely from Pastorian germ theory to Jacksonian neurology. This article explores the points of contact between the medical and demonological communities in order to demonstrate the contested nature of biomedical innovation.     

"I have learnt ... a different way of looking at people's health": an evaluation of a prevocational medical training program in public health medicine and primary health care in remote Australia

The purpose of this study was to gain insight into what prevocational medical practitioners (PMPs) learnt during a six-month public health medicine and primary health care training program (the Program) in remote Aboriginal Australia in 2001-2002. The Program's curriculum objectives included clinical and public health management of sexually transmitted infections, immunization, clinical audit and quality improvement, primary health care in remote Aboriginal communities, and working as part of an interdisciplinary team with health and non-health professionals, and lay people. The mode and location of delivery of these objectives was determined by the healthcare needs of the Kimberley population, and availability of safe, supported workplaces. Qualitative data from a variety of sources, including PMPs' reflective journals, were examined in the context of the Program's curriculum objectives and by conducting a content analysis of journal notes. Findings are presented using the curriculum objectives and other comments that emerged while examining the data. Preliminary data indicated that PMPs gained knowledge and practical experience in clinical and public health management of sexually transmitted infections, immunization and primary health care in poorly resourced remote Aboriginal settings. Deeper understandings of health and illness in a cross-cultural setting also developed, along with professional and personal growth, as illustrated by the following quotations from PMPs: "I have learnt ... a different way of looking at people's health ... I was encouraged to think more deeply than before about the whys and wherefores of medical practice, and thus consider the most effective ways of influencing patients' behaviours for the better." "I was encouraged to examine the thought processes behind the ways ... healthcare was provided ... [after leaving the Kimberley] I am constantly questioning the reason why we are practising medicine in a certain way in the big city hospitals-much to the consternation of my colleagues ... ." The Program was successful in teaching its first four PMPs the basic tools of public health medicine and remote area primary health care.     

Understanding autonomy relationally: toward a reconfiguration of bioethical principles

Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies in the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patient's self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality.     

A commentary on 'Informed consent to septoplasty: an anecdote from the field'

This paper is an analysis of the events recounted in 'Informed consent to septoplasty: An anecdote from the field.' As a commentary, it assesses the behavior of many agents who are parties to the story - physicians, nurses, friends of the patient, the patient's wife and the patient himself. This story is interesting for being mundane. The medical condition involved and the failures of care are not momentous. The patient's role as a medical ethicist led him to see things in particular perspective and motivated or influenced his conduct sometimes not in the smartest of ways. Several accounts of informed consent are reviewed and used as measures of what happened. The moral vision behind informed consent, the rights and duties it implies and the elements of its contents are identified. No account was fulfilled. Some of the reasons and causes for this are discussed. Many sources of information and forces acting on the situation are explored. Post-operative experiences include severe irritation and discomfort as well as severe frustration and a sense of alienation and abandonment. The case communicates a hint about what physicians do not know in order to have informed consent occur. Physicians' lack of awareness about, e.g., post-operative experience means that they will not provide what the informed aspect of informed consent requires. Patients can feel abandoned and perhaps are abandoned in a variety of ways, subtle and not so subtle. A few issues besides informed consent are discussed (the roles of wives in working at their physician-husband's front desk, the language of reassurance).     

Medical history for the masses: how American comic books celebrated heroes of medicine in the 1940s

When comic books rose to mass popularity in the early 1940s, one segment of the industry specialized in "true adventures," with stories about real people from the past and the present--in contrast to competing books that offered fantasy, science fiction, superheroes, detectives and crime, funny people, or funny animals. This study examines the figures from both medical history and twentieth-century medicine who were portrayed as heroes and role models in these comic books: first, to call attention to this very popular, if unknown, genre of medical history, and second, to illustrate how medical history was used at that time to popularize scientific and medical ideas, to celebrate the achievements of medical research, to encourage medical science as a career choice, and to show medicine as a humane and noble enterprise. The study explains how these medical history stories were situated in American popular culture more generally, and how the graphic power of comic books successfully conveyed both values and information while also telling a good story. Attention to this colorful genre of popular medical history enriches our picture of the mid-twentieth-century public's enthusiasm for medical progress.     

On evoking clinical meaning

It was in the course of one particular clinical encounter that I came to realize the power of narrative, especially for expressing clinically presented ethical matters. In Husserlian terms, the mode of evidence proper to the unique and the singular is the very indirection that is the genius of story-telling. Moreover, the clinical consultant is unavoidably changed by his or her clinical involvement. The individuals whose situation is at issue have their own stories that need telling. Clinical ethics is in this sense a way of helping patients, families, and, yes, health providers to discover and give voice to those stories. In this way, clinical ethics is an evoking of meaning. Kierkegaard understood this well: Indirect communication is the language for the unique and the otherwise inexpressible.     

The social life of psychiatric practice: trauma in postwar Kosova

This article traces the social life of psychiatric practice in the context of war and postwar societies. It is argued that although psychiatric knowledge and practice is situated and grounded in particular cultural, social, and political contexts, it is important to examine how transnational networks situate local systems of meaning in much larger settings. I illustrate this claim by examining discourses and observations concerning health-seeking behaviors of Kosovar Albanian women and ways in which Kosovar health practitioners help them by employing, adapting, and changing the psychiatric tools and lessons learned during (trauma) training provided by international health professionals during the Yugoslav war and postwar eras. Thereby, I hope to contribute to a better understanding of how local health beliefs and practices are nested in the processes involved in international health policymaking and, thereby, relate to higher level structures such as international political economy, regional history, and development ideology.