Physician Rita Charon on how stories matter to medicine

Tasks like discerning difference between modern and postmodern illness would prove difficult for anyone without appropriate training in the arts and humanities. What is and what isn’t a fact has never been obvious or uncontroversial. There was no golden age of truth. Given the present day notions of post-truth in an era of decreasing trust towards authorities, physicians and other professionals in the field of health care find themselves faced with understanding humanity's struggles in several different points of view. As I sat in the crowded audience of the Warner Theatre in downtown Washington D.C., I was lost in thought. Staring at the paintings that physician and literary scholar Rita Charon discussed, I reflected upon their aesthetic and moral value as they related to medicine. According to Charon, the field of narrative ethics seeks to address these issues. 

David Morris, a contributor to Rita Charon's book Stories Matter, the modern perspective is "biomedical": we are our genes, our organs, our laboratory measurements. The postmodern perspective is "biocultural": we are made of stories. These stories have dimensions that are cultural, familial, emotional, interpersonal, psychological, and biological. 

Two weeks ago I had the amazing opportunity to attend Charon's 2018 Jefferson Lecture in the Humanities "To See the Suffering: The Humanities Have What Medicine Needs." As Charon projected Whistler's painting "Sea And Rain 1865" before my eyes, she commented how the painting demonstrates, "the human scale of physicality, the cosmic scale of the oceans and relativity, and the existential dilemma of meaning are together in the universe and in each individual human body." By the end of the lecture I found myself wanting to sit down and stare at paintings, read books, and spend the rest of my life in this intellectual bliss to cultivate my undergraduate passions I once had.

"Sea And Rain 1865" - James Abbott McNeill Whistler
As physicians treat patients, uncover the nature disease, and set educated standards in the field of health care, they create stories. These stories, when physicians create them, become the way of "reading" as Charon describes. Physicians and medical ethicists come together and, through the notion of constructionism that we are narratively constructed, we create meaning from the world and form a deeper understanding of medicine. A diagnosis becomes less about treating a patient like they're a biological or physiological problem and more of a human. This gives rise to the ethical dilemmas, epistemic purposes, and other issues grounded in speculation a physician would encounter. Charon herself studies this issues from the point of view of both a physician and literary scholar. Shedding light on this humanistic discourse of medicine, these narratives constructed by narrative ethicists are a modified version of postmodernism. In this sense, narratives don't constitute persons themselves, but they are the most effective way of accessing persons. Those who learn from fiction, literature, poetry, philosophy, and the arts gain a nuanced, heavy understanding of medicine they can use in any physician's context. Doctors who embrace these techniques get the truest, most humanistic vision into what makes a patient a patient. They can attack fundamental ideas of disease and health such that those concepts carry appropriate meaning in a 21st century world of post-truths.

The self is within the narrative. One cannot look for one without finding the other. Searching for meaning as a physician would be like creating a pattern of a fabric interwoven that only becomes clear when one takes a step back and looks at the entire picture, or declaring a line as beautiful from points of data on a graph. Charon herself notes that "the self cannot be created -- or even found -- independent of narrative activities." Still, other scholars might argue that a true self is to be found if one looks close enough or reflects for long enough. Regardless, physicians should understand how similar they themselves are to patients to practice with both their own objective professionalism alongside the personal, intimate stories of a patient. With characters that have their own backgrounds, morals, beliefs, and even blood type, physicians can make the most informed decisions to adequately provide for patients.

In the packed Warner Theatre of downtown Washington, D.C.,  I sat on the edge of my seat. I grasped my chin as I fell deep in thought and immersed every moment of time and inch of space into Charon's speech. Inside of me a feeling erupted. I began to see elegant patterns between both science and the art. With this robust interconnected knowledge of both sciences and the humanities, I felt as though I could transcend both disciplines, and I sat in awe at how Charon used craftiness and wisdom to weave medicine and humanities in such a way that she could engage anyone with the pure intentions of learning and making the world a better place.

Physicians have a duty to recognize the principles that govern their profession, most notably beneficence, non-maleficence, justice, and autonomy. The role these concepts play in medical ethics and bioethics issues and the exact relationship among those principles serve the basis for decisions physicians make. But the narratives and principles physicians use are often at odds with one another. Marginalized groups of people have their own voice in narrative ethics which blurs the lines between human differences while "principlist" ethics lays down ethical rules by the fundamental principles themselves. Physicians and scholars can view the world through the absolutes of principlism or the gray area of narrative ethics. Taking the narrative to the extreme, in not just the lives of physicians but placing the narrative at the heart of all knowledge, provides a fundamental in the way scientific research is performed, as well. As medical ethicists take note of how these senses of constructionism and pirnciplist ethics govern medicine, they extended these narrative techniques to the sciences as well. The narrative of the sciences takes this human form to research. As more and more physicians and medical students realize the power and value of the humanities in their work, the more humanized, mature, and ethical approaches physicians can make in whatever task they may have to do.

Debra Malina of the New England Journal of Medicine, writes "Many of the contributors to Rita Charon's Stories Matter are major players in this narrative movement. Here, they practice what they preach, building their essays on stories of patients who want to conceal their medical conditions from their families, 60-year-old women who want to use assisted reproductive technology, parents of infants born with neurologic injuries who want to let them die -- stories on whose proper endings reasonable people might disagree. The authors do agree on certain concepts -- the emphasis on particulars, multiple perspectives, context, and emotional as well as rational understanding. Many stress the obligation incurred by hearing a story of suffering."

It's difficult to establish clear rules and guidelines for physicians developing narratives. If anything, the way to form narratives that encompass the humanistic side of medicine is more about physicians and medical students developing senses of right and wrong, aesthetics, purpose, intention, and motive in whatever they do. What procedure a physician chooses to take, especially in the details of a story such as character development and plot, may not be set in stone, but the implications and premises upon which those conclusions are reached hold a great amount of value for the meaning of that story. Techniques from literature that become essential for physicians become the actions of physicians themselves such as the way doctors obtain consent from patients or debate among themselves on ethics committees. The variation could be seen as something that makes the process all the more humane, and embracing the uncertainty provides physicians the way to understand the human condition all the more. Physicians, however, need to account for this sort of ambiguity in the work that they do.

The crises people face today, brought upon by postmodernism and post-truth dialogue, mean it's difficult for Charon and the other contributors to Stories Matter to give single, perfect answers to the specific issues physicians face, and, instead, provide a framework to manage the relationships among physicians and patients. However detached disillusioned one may be with these limitations, addressing them in a sense based in reality gives the reader some solace and connection to the thoughts of the contributors. Some of the contributors argue that going over different perspectives that seem to contradict one another is sufficient, while others maintain physicians should return to a narrative-based approach on the principles of medical ethics. The perspectives, research, anecdotes, and reasoning by the contributors can provide physicians with a place to start when understanding their profession on a more humane level. 

Charon's writing and lecture gave me a greater appreciation for the work of physicians given my background in both the sciences and the humanities. It made me all the more excited to tackle the intellectual issues of the 21st century.