Narrative Medicine as Power

In the seminar that I’m co-teaching, we’re reading an article I published in 2013, “From sick role to practices of health and illness” (J of Med Education, 47:18-25). It’s more than a decade since I actually wrote that article, and my moment of satisfaction at how well I think it holds up was superseded immediately by a sense of fear at how well it’s held up. The article starts in an academically neutral way, reviewing for non-social scientists the core ideas of four theorists whose work informs healthcare research: Talcott Parsons, Harold Garfinkel, Michel Foucault, and Pierre Bourdieu. I offer a dense but, I hope, accessible version of their ideas, in briefest form. Then things get scary, at least for me rereading.

I frame the discussion within a definition of theory as the work of relating the observation of particular scenes of human activity to what Max Weber called the “fate of our times”. Weber coined that phrase at the end of World War I; to have lived through that war was the fate of his times. Creatures live, inevitably, in times that are fateful, and I understand a crucial task of sociology–maybe the crucial task–to be helping people to reflect upon the fate of their times. That’s one reason why most people instinctively pull away from sociology: one effect of the period of modernity is thinking of ourselves as self-determining, not the playthings of some gods, not subject to history that is fateful. One description of the fate of the present times, the 21st century, is that people have had to go, quickly, from the post World War II luxury of believing they could, within an opportunity structure, live lives of their own choosing, to understanding that a terrorist attack, or a global pandemic, or maybe a war can come along and severely constrain those choices. And as I write, we’re nervously watching a war that’s still elsewhere, and wondering how many people will be caught up in it, at what cost to themselves. None of us–us moderns–likes to think of ourselves as subject to the fate of our times, but we need to live with what we don’t like; it just is.

Without belabouring that further, let me offer three points of recognition about narrative medicine, as I think of it. And in thinking of it, I’m accepting the term narrative medicine even though I would probably have chosen to call it something else. No label is perfect, and maybe a usefulness of the narrative-medicine label is that we’re constantly called to reflect on what’s inadequate about it, what it biases toward and against.

First, medical/clinical settings are sites of narrative contest. Here I need to specify what I mean by narrative. (1) Narrative involves privileged and dis-privileged forms of narration. The readiest example of privileged narration is medical trainees learning the rhetorical format of case presentation in rounds: what to include or leave out, passive voice construction, and so on. Most settings have expected forms of narration, and settings differ in rigidity/flexibility in what forms of narration are expected and permitted. (2) Narratives are premised on, and then reinforce, what Pierre Bourdieu calls Illusio, which is who takes what seriously. That again is about what’s included or excluded; inclusions and exclusions express what counts and what ought to count for both teller and listener. Proper, fully accredited participants in a setting are those who know what counts and who act in ways that reinforce that counting, to the exclusion of whatever else. (3) Narratives involve casting of character types, with normative evaluations of different types; that is, good guys, bad guys, and bit players. These types subdivide; for example, trainees may be potential good guys who are, at present, error prone, or, family members who may be well-intentioned but ill informed. In this casting, the nature of narratives is to understand the world as antagonistic relations. That generates drama in storytelling, but it generates conflict as those stories are enacted in life. Finally, (4) any narrative points toward and presumes some “promised end”, to use a phrase at the end of King Lear, when Kent asks, “Is this the promised end?” He means the story he believed in and committed his life to was not supposed to end as it is ending. Being caught up in a narrative is a commitment to a promised end, although that may be more or less articulated. One reason for clinicians not asking patients or families what their goals of treatment are is the unreflected-upon need to avoid making explicit a discrepancy between different players’ sense of the right promised end. Better not to ask that to have to deal with what you don’t want to hear–that’s the line rejected by narrative medicine.

Second, narrative medicine is about power. It seeks a redistribution in relations of power. I’m drawing on both Foucault and Bourdieu here, as their ideas are presented in my 2003 article. At the core of narrative medicine is the claim that stories previously regarded as not counting for medical/clinical purposes are actually of crucial importance in that work. Thus, the ability to tell a different kind of story, a previously untellable and unheard story, and the ability to hear and respond to that story, suddenly has value as forms of capital. That involves a new distribution of capital between the patient as storyteller and the clinician as listener, and a new distribution of power among clinicians, giving listening a new value. Bourdieu’s metaphor of capital is appropriate, because in medical/clinical settings as in law firms, time is money, down to the minute. Allocating time–curricular time in clinical education, clinical time in healthcare practice, research time–is to take time away. There is a zero-sum aspect to this contest, which is what power is, as it is lived as practice.

Third, I get back to the fate of our times. The scariest part of my 2003 article, reading it today, is when I quote Salmon Rushdie, from his 2006 novel, Shalimar the Clown. Rushdie writes: “Everywhere is now part of everywhere else. Our lives, our stories, flowed into one another’s, were no longer our own, individual, discrete. This unsettled people. There were collisions and explosions” (p. 37). That was before right-wing populist politics, before “freedom” convoys and protests, before the insurrection of January 6 in Washington, D.C.

The fate of our times, I would now say, is radical disjunctions in what different groups count as reality–especially what different groups count as trustworthy depictions of what’s real, with the “group” defined by who believes in that reality. This has at least four aspects: (1) intensified individual commitments to particular shared narratives as the foundation of personal identity; (2) reduction of narratives to slogans beyond which people feel no responsibility to think, only adherence by repetition is called for; (3) in the conflict of narratives, the increasing impossibility of any meta-position that might give both sides common ground for dialogue; and (4) to return to Weber, increasing reliance on what he called the “ethic of conviction”, that is, ethical justification of any act based on whether it supports the end demanded by a certain conviction. In the ethic of conviction, collateral damage is perfectly acceptable, even expected; that’s the logic of terrorism.

If you think these points don’t apply to medicine, recall the recent scenes of protests outside hospitals, even including assaults on healthcare workers. In some places in Canada, healthcare workers have been advised not to wear identifiable work uniforms while in public. How could people act like that? Consider my four points, above.

Narrative medicine presents itself both as taking a side in these conflicts, and also as a product of the times that give rise to such conflicts. A very great deal is at stake, and no particular end is promised.

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