the chief concern of medicine

The Chief Concern

of Medicine
The Integration of the Medical
Humanities and Narrative Knowledge
into Medical Practices

Ronald Schleifer and Jerry B. Vannatta

with Sheila Crow and
a contribution by Seth Vannatta

The University of Michigan Press

Ann Arbor
Copyright © by the University of Michigan 2013
All rights reserved

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Library of Congress Cataloging-­in-­Publication Data

Schleifer, Ronald.
  The chief concern of medicine : the integration of the medical humanities
and narrative knowledge into medical practices / Ronald Schleifer and
Jerry B. Vannatta with Sheila Crow and a contribution by Seth Vannatta.
   p. ; cm.
 Includes bibliographical references and index.
  isbn 978-­0-­472-­11859-­5 (cloth : alk. paper)—­isbn 978-­0-­472-­02886-­3 (e-­book)
 I. Vannatta, Jerry. II. Crow, Sheila. III. Title.
[dnlm: 1. Narration.  2. Physician-­Patient Relations.  3. Ethics, Medical.
4. Medical History Taking.  w 62]
616.07'51—­dc23 2012033644
to our students and colleagues
and the years of our working friendship
Preface

The Chief Concern of Medicine aims at enlarging our sense of the profession
of medicine and, more important, enlarging its effectiveness and service, by
including a self-­conscious awareness of the nature of narrative within a work-
ing definition of the way medicine understands itself as a profession and its
very activities. Medicine seeks to heal, to care, and to comfort, and we be-
lieve that each of these goals is improved with the understanding of how
narrative functions, both in general and within medical practices. To this
end, we offer, first of all, a pragmatic understanding of the science on which
medicine is based, particularly in relation to the larger theme of Part 1 of the
book, the definition and the practical and ethical strategies of what Aristotle
calls phronesis (translated often as “practical reasoning” and sometimes even
as “practical wisdom”). Aristotle believed that phronesis was the means to a
“good life” (eudaimonia), and one of his chief models for the accomplish-
ment of phronesis was successful doctoring. We argue here that phronesis is
closely related to narrative—­to its structures and, most notably, its purposes,
particularly the “end” or “concern” of any particular narrative. We also argue
that the logic of hypothesis formation that informs medical diagnosis closely
aligns itself with narrative and what we are calling “narrative knowledge.”
Thus Part 1 of The Chief Concern of Medicine aims at enlarging our
sense of science and scientific understanding and procedures in order to
complement evidence-­based medicine. Evidence-­based medicine aims, ide-
ally, at what Atul Gawande has called “the idea that nothing ought to be in-
troduced into practice unless it has been properly tested and proved effec-
tive by research centers, preferably through a double blind, randomized
controlled trial” (2007: 188). We hope to complement—­not replace—­
evidenced-­based medicine with what we are calling “schema-­based medi-
cine.” The schemas we set forth—­on the model of schemas as they appear in
cognitive psychology and artificial intelligence—­are schemas of narrative,
ethical actions, and procedures for the medical interview. In appendix 1, we
even suggest that schemas might allow us to understand what might be called
“humanistic understanding” more generally, in terms of a model of discipline
building in the humanities. The simplest, but perhaps most profound, of
these schemas is the suggestion, as we note in both the introduction and
chapter 3, that doctors elicit a patient’s chief concern as well as a chief com-
plaint in the formal procedure of conducting the History and Physical Exam
and eliciting the History of Present Illness. We believe that the understand-
ing of the schemas and procedures we describe in this book that grow out of
humanistic understanding can find their place alongside scientific under-
standing in governing how physicians and health care workers conceive of
and go about their everyday encounter with people who are suffering, in
distress, and in need of help.
For this reason, it is our contention that the nomological sciences—­law-­
governed understandings, based on thoroughly repeatable experiments or
large-­scale statistical measurements—­can be complemented by the human
sciences, which depend on schematic understanding of forms and structures
that govern cognition, experience, and judgment more generally. A model
for such complementarity is the science of evolutionary biology, whose re-
sults are widely accepted by physicians, medical-­school faculty, and students
aspiring for a career in medicine, even though the kind of randomized con-
trol trials that epitomize evidence-­based medicine is rarely possible in the
study of evolution. Evolution, Stephen Jay Gould has persuasively argued
(see especially 1986, 1989), is not a nomological science—­rather, he says, it
is a historical science—­yet it still bases itself, at times, on retrospective evi-
dence (see Weiner 1995 for remarkable empirical evidence of generations of
finches on the Galapagos Islands). A third category of science—­what we sug-
gest, early in the book, seeks functional knowledge—­bases itself on the prag-
matic achievement of goals in the systematic pursuit of understanding. Inso-
far as it does so, we suggest, it is a species of narrative science (or at least
systematic analyses of narrative), which is based neither on the deductive
laws and quantifiable evidence of nomological science nor on the inductive
retrospective understanding of evolutionary-­biological science but on the
schemas of the humanities in general and of abductive logic more specifi-
cally. (In chapter 4, we closely examine Charles Sanders Peirce’s “logic of
abduction,” which is a systematic understanding of hypothesis formation.) In
Part 1 of The Chief Concern of Medicine, we trace the functioning of such
schemas in the ethical understanding of Aristotle’s phronesis, in the

viii  /  preface
evolutionary-­structural understanding of narrative cognition (or “narrative
knowledge”), in a general accounting of narrative structures, and in Peirce’s
logic of abductive reasoning. This is more or less the theoretical or philo-
sophical basis of The Chief Concern of Medicine.
In Part 2, we examine the particular everyday practices of medicine in
relation to narrative. Almost all medicine, we note, begins with the encoun-
ter of patient and physician, and this encounter is organized around the His-
tory of Present Illness (HPI). Such a history begins, of necessity, with the
patient’s chief complaint, but as we already mentioned, we argue that in the
physician’s encounter with the patient, the chief complaint should be for-
mally complemented with the inclusion of the patient’s chief concern as well.
That concern is the patient’s awareness of what his illness means in relation
to the ongoing story of his life, and because of this, its inclusion within the
History and Physical Exam—­something that physicians would routinely ask
in the way that family history is a routine part of the History and Physical
Exam itself—­would make conscious awareness of narrative an important tool
of medical diagnosis and treatment growing out of the patient-­physician en-
counter. As we note in chapter 3 and argue throughout Parts 2 and 3, a sig-
nificant feature of narrative and narrative cognition is the deliberation be-
tween its teller and its listener—­an important feature of narrative, we note,
is a witness who learns—­and such collaborative deliberation, we believe, is
at the heart of good doctoring. Deliberation is also at the heart of Aristotle’s
conception of phronesis. Thus the chapters of Part 2 examine the scene of
narrative, which is the patient-­physician relationship, the understanding of
narrative, and the engagement with and responses to narrative available and
proper to the practice of medicine.
Finally, Part 3 spells out schemas of narrative and ethical behavior that
can help physicians pursue their work most efficiently, compassionately, and
comprehensively in the face of human suffering. These schemas are orga-
nized in relation to the theoretical sense of science and understanding that
Part 1 describes and the empirical sense of what happens—­or ought to hap-
pen, given its goals and practical organization—­in practices of medicine.
Throughout all these chapters, we distinguish between everyday or “popu-
lar” narrative and aesthetic or “art” narrative, and we do so with the assump-
tion that while narrative cognition is, indeed, part of our human inheritance
as a species, the development of aesthetic narrative forms allows us to see
more clearly how narrative works and how we can be more consciously atten-
tive and receptive to the stories patients tell and to the narrative knowledge
they present. Moreover, we argue, aesthetic narrative creates vicarious expe-

preface  /  ix
rience in its readers-­listeners more clearly than does ordinary narrative. Such
vicarious experience offers a strong, pragmatic reason to include narrative
knowledge within the range of skills and tools a physician needs—­within the
education and practices of health care workers—­because it allows people to
learn from the experience of others and, in actual situations of telling and
listening, to create trust and honesty between people. Moreover, such vicari-
ous experience participates in the schemas of narrative insofar as those sche-
mas function—­explicitly in cognitive science and provisionally in the work of
the humanities—­to grasp structures and forms that condition experience it-
self. In addition, as we argue in chapter 9, vicarious experience is a central
element in a moral education. In any case, because of these strengths of art
narrative, we describe throughout The Chief Concern of Medicine the im-
portance and usefulness of literary narrative to the education of health care
workers—­though these chapters also offer a good number of ordinary or
“popular” medical narratives or vignettes based on actual medical cases—­
and conclude with a close, pragmatic-­aesthetic analysis of Leo Tolstoy’s no-
vella The Death of Ivan Ilych.
The Chief Concern of Medicine has an interesting narrative history itself.
In 1999, Dr. Jerry Vannatta, then executive dean and vice-­provost for medi-
cine at the University of Oklahoma and professor of internal medicine, ap-
proached Ronald Schleifer, professor of English, about the possibility of de-
veloping a course on literature and medicine. Dr. Vannatta had discovered in
years of teaching and practicing medicine that remarkably bright students
and colleagues had not been fully trained in engaging with their patients and
the stories they told. After teaching the course for four or five years, we were
joined by our colleague Sheila Crow, associate professor at the University of
Oklahoma College of Medicine and director of the Office of Educational
Development and Support, in developing a DVD, Medicine and Humanistic
Understanding: The Significance of Narrative in Medical Practices. The
DVD was an essentially pragmatic project, in which the pedagogical experi-
ence of health care students engaging with literary narrative that we created
in our course on literature and medicine was reproduced in a format that
could supplement medical-­school courses rather than replacing them. In
The Chief Concern of Medicine, Schleifer and Vannatta have reconceived
and rewritten the DVD as an intellectual-­scholarly argument, suggesting
ways that medicine might include the skills (or technē, as we call it in Part 1,
taking up Aristotle’s language) of phronesis, narrative knowledge, and abduc-
tion within the practices and procedures of medical education and medical
practice. These skills have always had a place in the best medical practices,

x  /  preface
but we believe that their explicit and mindful inclusion within medical edu-
cation and their formal inclusion within medical practice will allow more
people to achieve them more quickly.
The rewriting has been as thorough as we hope the inclusion of these
humanistic skills within medicine will be in thoroughly provoking and oblig-
ing the rethinking of many of the ordinary and routine practices of medicine.
In transforming a pedagogical text into an argumentative one, we have taken
up many of the examples of Medicine and Humanistic Understanding to new
purposes, so that while the texts we quote in many instances remain the
same, the meanings have been transformed. Throughout our argument, we
maintain that an important feature of narrative is its end—­by which we mean
not only its conclusion but its “goal” or “point” or “concern”—­and that this
purposive end transforms the relationships among the meanings of its parts.
In a similar fashion, in rewriting the DVD, The Chief Concern of Medicine
has transformed itself into a different document with a different meaning, a
different “concern.” This is apparent in the document itself: almost half of
the book, Part 1 and the appendixes, is entirely new; in the remaining chap-
ters (growing out of the DVD), examples have been added and deleted, and
virtually every sentence has been rewritten for this new context, our new
argument, in a manner that makes the examinations of earlier materials sub-
stantially new as well. This is most notable in our overarching framework of
schema-­based analyses and our argument that suggests formal procedures
and protocols for medical practices, both of which were not part of the DVD.
In this, we have changed the pedagogical purposes of the DVD into an argu-
mentative study, transforming the pedagogy embodied in its very DVD for-
mat that brings together language, interview, and enactment into the larger
purposes of the pragmatic arguments of The Chief Concern of Medicine. We
hope that its insistence on the universality, teachability, precision, and focus
on explanation that we find in phronesis and narrative will come to inform
the ways that physicians and medicine as a profession conduct themselves
and pursue their ends of healing, care, and comfort. To this end, as well as
advocating the revision of the structure of the History and Physical Exam
with the formal inclusion of the chief concern, we have developed a series of
simple checklists (presented in appendix 2) to help govern physicians’ atten-
tion and behavior in encounters with patients growing out of the discussions
of this book. (We also compiled a list of the schemas developed and pre-
sented in The Chief Concern of Medicine, provided in appendix 3 for easy
reference.) The hope for our book, then, is to integrate humanistic under-
standings (including narrative knowledge), based as they are on schemas of

preface  /  xi
experience and comprehension, into everyday practices of medicine, just as
scientific knowledges, based as they are on rigorous testing and epidemio-
logical evidence, have been integrated into everyday practices of medicine
with the emphasis on evidence-­based medicine introduced in the 1990s.

Acknowledgments

The production of this book, allowing us to work together about things we

both care about, has been a wonderful and exciting intellectual endeavor. In
addition, we worked with many other people as well. As we have mentioned,
our writing of The Chief Concern of Medicine grows out of our work with
Sheila Crow on the DVD Medicine and Humanistic Understanding, and we
acknowledge our shared—­and remarkably fulfilling—­work together in that
earlier endeavor on the title page of this new book. There also we acknowl-
edge the important contribution to The Chief Concern of Medicine by Seth
Vannatta, who, working with Dr. Vannatta, created the original draft for
chapter 1, which we revised as part of our argument for the reality and im-
portance of narrative along with other kinds of evidence in treating patients.
In addition to these hands-­on contributors, the physicians and others we met
and interviewed for the DVD—­many of whom have continued to be friends
and correspondents—­have greatly shaped our thinking and, indeed, our con-
cern. Dr. Rita Charon shared with us her excitement and innovation in bring-
ing together medicine and narrative and in creating the phrase “narrative
medicine”; Dr. John Stone provided us with kindness and insight that in-
forms far more in this book than our discussion of his poem; Dr. Abraham
Verghese and Dr. Rafael Campo helped us to continue to see the poetry
within doctoring. In addition, meetings with Dr. Oliver Sacks, Professor
Kathryn Montgomery, Professor Anne Hunsacker Hawkins, Professor Anne
Hudson Jones, and Dr. Richard Selzer informed our thinking and argument
in this book. Dr. Steve Orwig joined us on the DVD and helped organize two
interviews included in this book.
Along with these colleagues and friends who participated in the develop-
ment of Medicine and Humanistic Understanding, a good number of other
people have also substantially contributed to our thinking and writing in this
book. Jim Bono, Francis Steen, James Phelan, Mike Hanne, Peter Barker,
Tim Davidson, James Hawthorne, Ann Jacobs, David Levy, Amanda Rook,
Robert Schleifer, and Nancy West all read and commented on particular as-
pects of our new thesis. In addition, many students in Dr. Vannatta’s courses

xii  /  preface
in internal medicine have trained in and helped develop many of the prac-
tices we advocate in their education, and a good number of his colleagues at
the University of Oklahoma Health Sciences Center and at local hospitals in
Oklahoma City have begun to make patients’ chief concerns a formal part of
their early encounters with patients. Thomas Dwyer, our editor at the Uni-
versity of Michigan Press, has provided us with fine support and imaginative
energy while we brought this project to fruition. Finally, both of us—­and the
project as a whole—­have benefited from the patience and wisdom of our
wives, Nancy Mergler and Melinda Lyon.
Much of the new material has benefited from the ongoing work of the au-
thors. The introduction is based on Ronald Schleifer and Jerry Vannatta, “The
Chief Concern of Medicine: Narrative, Phronesis, and the History of Present
Illness,” Genre 44 (2011): 335–­47; chapter 1 on Seth Vannatta and Jerry Van-
natta, “Irony, Vocabulary, and Reality: A Pragmatic Defense of Narrative Med-
icine,” a paper presented at the 2010 biannual conference of the International
Society for the Study of European Ideas in Ankara, Turkey, which is also the
basis of Seth Vannatta and Jerry Vannatta, “Functional Realism: A Defense of
Narrative Medicine,” forthcoming in Journal of Medicine and Philosophy 38,
published by Oxford University Press; chapter 2 on Ronald Schleifer, “Mo-
dalities of Science: Phronesis, Narrative, and the Practices of Medicine,” Dan-
ish Yearbook of Philosophy 44 (2009): 77–­101; chapter 3 on Ronald Schleifer,
“Narrative Knowledge, Phronesis, and Paradigm-­Based Medicine,” Narrative
20 (2012): 64–­86; and chapter 4 on Ronald Schleifer and Jerry Vannatta, “The
Logic of Diagnosis: Peirce, Literary Narrative, and the History of Present Ill-
ness,” Journal of Medicine and Philosophy 31 (2006): 363–­85, published by
Oxford University Press. Like the chapters based on the DVD, these essays
have been thoroughly revised for inclusion here. We thank the editors and
publishers for their kind permission to include this work in our book.
This book is the result of more than a dozen years of working together,
working with students and colleagues, and, in the end, clarifying for each
other what we most value in our intellectual work, in caring for patients and
students, and in building friendships and relationships as we pursue our ev-
eryday vocations. For both of us, this project—­including the work and
friendships that have contributed to it—­has been one of the great fulfill-
ments of each of our professional careers. We dedicate this book to these
remarkable years, our students and colleagues, and our working friendship.

Grateful acknowledgment is made to the following authors, publishers,

and journals for permission to reprint previously published materials.

preface  /  xiii
 “The Couple” and “What I Would Give” from Landscape with Human
Figure by Rafael Campo, pp. 70 and 16. Copyright © 2002 by Rafael Campo.
Reprinted by permission of the publisher, Duke University Press. www
.dukeupress.edu. Reprinted by permission of Georges Borchardt, Inc., for
the author.
“Doctor Kervorkian” from Diva by Rafael Campo, p. 28. Copyright ©
1999 by Rafael Campo. All rights reserved. Reprinted by permission of the
publisher, Duke University Press. www.dukeupress.edu. Reprinted by per-
mission of Georges Borchardt, Inc., for the author.
“Everything Is Going to Be All Right” by Derek Mahon. By kind permis-
sion of the author and The Gallery Press, Loughcrew, Oldcastle, County
Meath, Ireland, from New Collected Poems (2011).
“He Makes a House Call” by Dr. John Stone, from In All This Rain. Re-
printed by permission of Louisiana State University Press.
“The Red Wheelbarrow” by William Carlos Williams, from The Collected
Poems: Volume I, 1909–­1939, copyright © 1938 by New Directions Publish-
ing Corp. Reprinted by permission of New Directions Publishing Corp. Re-
printed by permission of Carcanet Press Limited.
“Let’s Talk about It” by David Rinaldi, from Annals of Behavioral Science
and Medical Education 1, no. 2 (1994): 118. Copyright © the Annals of Be-
havioral Science and Medical Education. Reprinted by permission of the
Annals of Behavioral Science and Medical Education.
“Manuel” from What the Body Told by Rafael Campo, p. 67. Copyright
© 1996 by Rafael Campo. All rights reserved. Reprinted by permission of the
publisher, Duke University Press. www.dukeupress.edu. Reprinted by per-
mission of Georges Borchardt, Inc., for the author.

Every effort has been made to trace the ownership of all copyrighted
material in this book and to obtain permission for its use.

xiv  /  preface
Contents

Introduction: Medicine, Narrative, and Schema-­

Based Understanding 1

part 1. Phronetic Skills: The Technē of Medicine

1. The Functional Realism of Medicine 35
2. Modalities of Science: Narrative, Phronesis, and the
Skills (Technē) of Medicine 57
3. The Chief Concern of Medicine: Narrative Knowledge
and Schema-­Based Practice 83
4. The Logic of Diagnosis: Peirce, Literary Narrative,
and the History of Present Illness 111

part 2. T
 he Work of Narrative in Practices of Medicine
5. The Patient-­Physician Relationship: The Scene of Narration 137
6. The Patient’s Story: The Apprehension of Narration 168
7. Doctors Listening and Attending to Patients:
Response and Engagement with Acts of Narration 211

part 3. Schema-Based Medicine

8. Narrative and Medicine: Schemas of Narration 247
9. Narrative and Everyday Medical Ethics: Schemas of Action 284

conclusion
10. Reading The Death of Ivan Ilych 329
Afterword: The Nexus of Literature and Medicine;
The Interactions of Patient and Physician 357

Appendix 1. Humanities as a Discipline 367

Appendix 2. Checklists for Skills in Listening, Interviewing,
and Action 374
Appendix 3. A Compilation of Schemas for Medical Practices 382

Notes391
Bibliography419
Index429

xvi  /  contents
introduction
Medicine, Narrative, and
Schema-­Based Understanding

For the past decade, we have been teaching a course on literature and med-
icine. Our purpose has been to make medical students and physicians more
cognizant of the role of narrative in medical practice and to help them de-
velop skills that make narrative knowledge a useful and important part of
their engagement with patients. To this end, in class and elsewhere (see Van-
natta, Schleifer, and Crow 2005, 2010), we have attempted to arrive at—­or at
least circumscribe—­a working definition of knowledge in the “humanistic
sciences” in relation to what we are (with others) calling “narrative knowl-
edge.” Such knowledge arises out of encounters with stories and storytelling,
including the narrative structures implicit in Aristotle’s conception of phro-
nesis, or “practical reasoning,” and in Charles Sanders Peirce’s conception of
abduction, or “the logic of discovery.” The Chief Concern of Medicine as-
sumes that, through the practice, analysis, and discussion of narrative (and
particularly of literary or “art” narratives), physicians—­and, indeed, all of
us—­can become better at recognizing stories, comprehending their parts,
rearranging them in new contexts, responding to them, and acting on the
knowledge we have gained. Narrative knowledge and practice, so defined,
can help medical practitioners become better physicians—­to become what
Aristotle has called a phronimos, a practitioner of phronesis—­particularly
through systematic study of narrative and by attending to the schemas of nar-
rative and experience within medical practices. It is often assumed that ph-
ronesis can only be the product of long experience, but we argue here, fol-
lowing cognitive psychology, that experience is not simply unique and
immediate but is mediated by schemas of experience that allow us to share
and learn “experience” from others—­even imaginary experiences. For this
reason, we argue that such understanding and experience derived from sche-
mas can help medical practitioners become “better” earlier in their careers.
By “better physicians,” we mean better diagnosticians in listening to and un-
derstanding the patient’s story; better and more fulfilled professionals in de-
veloping powerful relationships with patients; more sensitively responsible
doctors in the actions of everyday practice; and, perhaps encompassing all of
these, people who will bring greater care to those who come to them ailing
or in fear or faced with terrible suffering.
To be a physician in our—­and in every—­society is to occupy a privileged
position. That privilege is based on the fact that the physician encounters
almost daily what James Joyce calls “whatsoever is grave and constant in hu-
man suffering” (1966: 204). Those encounters almost always take the form of
storytelling, and we propose the inclusion of an important new item in the
patient record that is normally referred to as the “History and Physical
Exam,” namely, the “chief concern.” All medical students are taught to get
the “chief complaint” from the patient at the beginning of the interview. This
information is the starting point for the physician to facilitate the patient’s
story, and as such, it properly helps determine the focus of the interview as a
whole. We are suggesting that in the process of facilitating the story that
brought the patient to the doctor, the physician should explicitly attempt to
ascertain the patient’s chief concern and record it along with the chief com-
plaint. This process, we believe, will demonstrate to the patient that the doc-
tor knows the difference between symptoms and concerns. It will also serve
early in the interview to aid in the physician’s engagement with the patient.
Finally, it will serve as the basis for the patient-­physician negotiation of the
ends of the medical practice: in relation to the chief complaint, the physician,
with intensive training and years of practice, has great authority; in relation
to his chief concern, the patient is equally authoritative. By the “ends” of
medical practice, we mean the conception and goal of what would be “good
health” or whatever other outcomes the situation allows. Such a thoughtful,
explicit consideration of the ends of health care, in fact, as we argue in Part
1 of this book, is the very motor of phronesis, the “practical reasoning” or
“practical wisdom” that governs, in Aristotle’s understanding, the best and
proper practice of medicine.
In addition to the “chief concern” as an explicit category to be recorded
in the History and Physical Exam, we are introducing a new phrase into the
process of the medical interview and, to some extent, into the practices of
medicine in general, that of the “schemas” of experience and narrative,

2  /  the chief concern of medicine

which we describe in greater detail later in this introduction. In medicine,
we are suggesting, there are three crucial skills that can be brought to the
patient-­physician relationship, skills whose conscious pursuit can make that
relationship more informative, more efficient, and more fulfilling for both
patient and physician. These skills involve (1) the conscious comprehension
of narrative knowledge, (2) the conscious facilitation of the patient’s concern
and understanding of “health” in the medical interview, and (3) the conscious
actions (including ethical actions) growing out of these skills in medical prac-
tice. We believe—­and in Part 1, we explicitly argue—­that these skills can be
learned and, in some cases, habituated in terms of the “schemas” implicit in
their regular practice in medicine. Such learning and behavior, we believe,
will enrich the medical encounter between physician and patient and im-
prove the outcomes of that encounter. By “enrich” and “improve,” we mean
that the experience of the encounter by the patient and the physician will be
more effective, that the physician will more likely make the correct diagno-
sis, and that the physician will more likely address the patient’s “chief con-
cern.” Our purpose in introducing the idea of schemas for medical practice
is that these schemas can be taught and easily learned, that they can be ha-
bituated within the everyday practices of medicine—­ that they can and
should be routinized within the protocols and procedures of the medical
profession. Moreover, we believe that they provide a “road map” for physi-
cians to become narratively competent, a process that, for most physicians,
takes years of practice, earlier in their careers. In the three parts of The Chief
Concern of Medicine, the intellectual foundations of these schemas, their
practical enactment, and their detailed articulation are described. In addi-
tion, these schemas are listed in appendix 3 and are set forth in the form of
useful checklists in appendix 2.

Definitions of Health

We should say something more here about medicine’s “chief concern.” The
chief concern we are identifying pertains to the ends of health care, what
Martha Nussbaum describes as “a vague end, health”; the issue in medicine,
she says, “will be to get a more precise specification of the end itself” (2001:
98), namely, the “health” of the patient. Such a concern, articulated by the
patient with the facilitation of the physician, leads to the development of a
practical framework for the everyday practices of medicine, particularly in
relation to the patient’s awareness of what her illness means in the ongoing

Introduction  /  3
story of her life. The formal inclusion of the chief concern within the History
and Physical Exam (and the patient’s chart) would make routine the self-­
conscious awareness of narrative and the mutual patient-­physician delibera-
tion over the patient’s narrative; it would make these skills important tools for
medical diagnosis and treatment.
By advancing such a routine, we aim to suggest that the comprehension of
medicine as a learned profession may be complemented by also understand-
ing it as a collection of particular practices whose performances embody the
very action that is, for Aristotle, the heart of ethics in the pursuit of the well-­
being of a well-­lived life, what he calls eudaimonia. In medicine, eudaimonia
is the realization of the supreme ends of health care, health understood as the
alleviation of suffering, the restoration of well-­being, and the profound gift of
possibilities of simply carrying on. This last definition of health, the pragmatic
possibility of carrying on, is the most usual outcome of medical care. It is ar-
rived at by seeking to define, as precisely as possible, what goal the patient
and physician have in mind under the circumstances of the patient’s disease.
Such a goal involves a functional definition of heath, that which is possible as
an outcome of medical intervention in this particular situation. Still, all three
of these definitions of health, like eudaimonia itself, are always entwined with
successful narrative—­successful both in its execution and in its reception in
the relationship between teller and listener—­and, as we argue here by allud-
ing to the Nicomachean Ethics (in which Aristotle develops his conception of
phronesis), they entail ethical action in the world. In an important articulation
of definitions of health, Kenneth Boyd analyzes the “elusive” concept of
health from the vantages of the medical profession, literature, and philoso-
phy. Citing a physician-­professor, Marshall Marinker, he describes “three
modes of unhealth” (corresponding to the definitions we put forth):

disease, which is “some deviation from a [fixed] biological norm”;

sickness, which is “the external and public mode of unhealth” embodied
in more or less fixed “social roles” of unhealthiness; and
illness, which is the “entirely personal” feeling of unhealth. (2000: 9–­10;
see 15 for Boyd’s descriptions of “fixed norms”)

“Disease then,” he concludes, “is the pathological process, deviation from a

biological norm. Illness is the patient’s experience of ill health, sometimes
when no disease can be found. Sickness is the role negotiated with society”
(2000: 10).1

4  /  the chief concern of medicine

 The definitions of health we are offering—­the alleviation of suffering, the
achievement of well-­being, and the discovery of pragmatic ways of carrying
on—­correspond to Boyd’s three modes: the alleviation of disease, the attain-
ment of well-­being (which Boyd describes as the social apprehension of “the
image of the athlete as the image of health” [2000: 14]), and a definition of
“being healthy” as “instituting new norms in new situations” (George Can-
guilhem cited in Boyd 2000: 14). In this last definition, Boyd notes that “to
be healthy is not to correspond with some fixed norm, but to make the most
of one’s life in whatever circumstances one finds oneself” (2000: 14). Unlike
the descriptions Boyd sets forth, our definitions of health begin with the
particular actions of medicine and the importance of those actions within
human affairs. Moreover, such definitions emphasize what medicine can
learn from narrative and the important place of storytelling in the patient-­
physician relationship, the narrative drama of medical practices in relieving
suffering, healing, and caretaking (see chapter 8 and Mattingly 1998 for dis-
cussions of the narrative “drama” of medicine).
The action of medicine, as we see it, begins with the patient’s chief con-
cern. The chief concern is ultimately practical: the patient’s fear that an ail-
ment will keep him from performing his job; her concern that her medica-
tion will deprive her family of other necessities (a particular problem in the
United States); the dread of losing close relationships; an overwhelming be-
lief that quality of life is more important than its length; or the contrary sense
that everything possible, regardless of the cost in wealth and pain, should be
pursued in the face of life-­or experience-­destroying illness. Similarly, what
we are calling “art” narratives—­narratives that, in their aesthetic organiza-
tion, emphasize and highlight the cognitive power of narrative—­generally
articulate a chief concern. Thus, in the Poetics, Aristotle defines tragedy in
terms of its narrative form: it is a serious, complete, and significant (“weighty”)
action (possessing a beginning, middle, and end) that may lead to recognition
(or anagnorisis) on the part of the tragic hero and that provokes in the audi-
ence the katharsis of pity and terror (1968: 14, 19, 11).
Katharsis is a Greek term that usually occurred in ancient times in the
context of medicine. It has been variously translated into English as “to
purge,” “to purify,” or “to clarify,” and for centuries, scholars have argued
about what exactly Aristotle meant by it (see Hardison 1968: 133–­37; the fol-
lowing descriptions follow his analysis). All three of these definitions of ka-
tharsis (to which we return in chapter 8) also suggest particular definitions of
health and well-­being:

Introduction  /  5
 1. Rendered as “purgation,” katharsis allows the audience to experience
and then expel feelings of pity and terror in response to the tragic
narrative.
2. Rendered as “purification” of the audience’s emotion in general (not
simply pity and terror, but, as Aristotle says, any such feelings), ka-
tharsis does not expel the emotion but allows the audience to under-
stand and experience it in its “purest” state.
3. Rendered as “clarification,” katharsis suggests not clarification of the
emotional responses awakened by the narrative but the clarification
for the audience of the narrative action (comprised of incidents) it-
self. In The Fragility of Goodness, Nussbaum offers a fine philologi-
cal discussion of katharsis that emphasizes the more common under-
standing of the term in classical Greece as meaning “to clarify”
(2001: 388–­91). What is clarified, then, is not so much emotion but
incidents or events—­that is, the elements of narrative itself—­and
they are clarified insofar as they are now understood in relation to
the story as a whole and particularly in relation to the “end” of narra-
tive, its conclusion and point.

According to the third translation of katharsis, tragic narratives allow the

audience to recognize “pitiable and fearful incidents” that are part and parcel
of every person’s life. But in all the translations—­as purging or purification
or clarification—­katharsis touches aspects of human life that all people share
insofar as they are related to pity and terror. It is in this sense, as we note in
chapter 8, that Stephen Dedalus, Joyce’s main character in A Portrait of the
Artist as a Young Man, attempts to understand Aristotle. Stephen tells a
friend, “Pity is the feeling which arrests the mind in the presence of whatso-
ever is grave and constant in human sufferings and unites it with the human
sufferer. Terror is the feeling which arrests the mind in the presence of what-
soever is grave and constant in human sufferings and unites it with the secret
cause” (1966: 204). Moreover, all three definitions of katharsis are closely
related to Boyd’s definitions of health: (1) health as the absence of disease;
(2) health as “the complete physical, mental and social wellbeing, and not
merely the absence of disease or infirmity” (World Health Organization def-
inition cited in Boyd 2000: 12), which thus bars sickness; and (3) health as
pragmatically overcoming illness, nicely defined in Dr. John Stone’s poem
“He Makes a House Call,” where he describes “health [as] whatever works /
and for as long” (1980: 5). What is striking, finally, is that the connections

6  /  the chief concern of medicine

between narrative and medicine were felt and discussed from the beginnings
of the Western traditions of medicine and literature, as we see in Aristotle.

The Power of Narrative and the Practice of Medicine

The privileged art narratives of literature, like caring for people in ill health,
are a central aspect of all human communities. In fact, as we note in chapter
2, there is a wealth of evidence in evolutionary cognition that narrative orga-
nizations of cognition are inherited strategies of understanding in human ex-
perience. People tell one another stories just as they care for the health and
well-­being of one another, and such storytelling—­like practices of healing—­is
everywhere taken to be sacred, honorable, important, a special gift that is part
of our human inheritance. Like healing and health care, the power of story-
telling is often taken to be mysterious. Thus important connections between
practices of medicine and engagements with literature go well beyond Aris-
totle. As Anatole Broyard says in his posthumous book, Intoxicated by My
Illness, “all cures are partly talking cures. Every patient needs mouth-­to-­
mouth resuscitation, for talk is the kiss of life” (1992: 53). This description of
“talking cures”—­referring to Sigmund Freud’s early description of his medi-
cal practice—­emphasizes the fact that while medicine often aspires to be an
exact and methodological science, it is simultaneously engaged at the level of
person-­to-­person encounter, in a manner similar to the person-­to-­person en-
counter that narrative storytelling enacts and literature often provokes. This
real-­life engagement in medicine—­like its representations in literature—­
entails the honor, imagination, and value that the humanities attempts to
comprehend in the goal-­oriented understanding of narrative.
The values and skills of humanistic understanding are as teachable and
learnable as any of those we hope and expect to find in physicians and health
care workers. People can be taught how to recognize the difference between
pelvic inflammatory disease, gastrointestinal virus, and appendicitis; they can
be taught how to insert a central line into a patient. Atul Gawande describes
this learning in his own surgical education: “For days and days, you make out
only the fragments of what to do. And then one day you’ve got the thing
whole. Conscious learning becomes unconscious knowledge” (2002: 21). In
a similar fashion, people can be taught how to be attentive to articulated and
unarticulated meanings in personal encounters; they can be taught how to
recognize and respond to their own and others’ reactions to the dramatic

Introduction  /  7
situations of family, work, and illness; they can learn to acknowledge experi-
ences and values that grow out of the human situation—­including, alas, ex-
periences of suffering, fear, and pain. It is narrative knowledge, humanistic
understanding, that best conveys and imparts such learning. And the vehicles
that bring this learning, we argue, are the schemas of humanistic understand-
ing. These schemas are analogous to the evidence of evidence-­based medi-
cine and of evidence-­based guidelines, as we discuss in chapter 3.
When literary narrative and medicine are brought together, not only has
the study of literature much to teach medicine, but medicine, with its focus
on suffering and the causes of suffering, has much to teach literary studies.2
In any case, literature and medicine have as their primary intersection the
understanding and use of narrative. Great narratives—­those that cultures
cherish and pass on, from generation to generation—­offer to those engaged
with them important points or “morals” about the human condition. This is
another instance of what we mean by a “chief concern,” and it includes im-
portant advice about living in the world, the experience and wisdom of those
who have come before them, a horizon of what can be expected from their
lives, and simply consolation and laughter. Narrative fosters the apprehen-
sion of complex wholeness of phenomena simply because it articulates some
overriding concern, whether it be thematic meanings, practical advice, ac-
cumulated wisdom, senses of what the world offers, or basic and shared emo-
tions. To say this another way, in narrative, the whole is greater than the sum
of its parts, in the same way that a sentence is greater in meaning than the
meaning of its individual words or that a relationship between people can be
richer than simply the sum of the contributions each brings to it. Narrative
forms of understanding, as evolutionary cognition has recently demonstrated,
is also an inherited cognitive skill that we all share and that allows us to see
and experience these things individually and within communities.
Clinical medicine is basically organized around the story, the narrative
History of Present Illness (HPI) the patient (or sometimes others) almost
always brings to the doctor—­a form of narrative that comes up repeatedly in
these pages. This is usually a story with a beginning and a middle, but pa-
tients come to physicians in hopes of discovering or developing the “end” of
their particular story. They come with what Alasdair MacIntyre calls “a not-­
yet-­completed narrative” (1984: 223), and it is precisely in the negotiation
and apprehension of the end or chief concern of the patient’s story that nar-
rative knowledge can serve medical practices. (We note in chapter 2, follow-
ing Nussbaum, that such negotiation and apprehension, is the work of Aris-
totle’s phronesis and, moreover, that insofar as phronesis pursues an end, it is

8  /  the chief concern of medicine

related to narrative.) The HPI narrative is the most important diagnostic in-
formation. The more competent the physician is in understanding narrative
knowledge—­in apprehending the patient’s story—­the more accurately he or
she will diagnose the patient’s chief complaint and, even more important, the
patient’s chief concern. Narrative and narrative knowledge help the student
and practitioner of medicine to forge an honorable and effective—­by which
we mean medically effective—­relationship with the patient, by attending to,
comprehending, and respecting the patient’s story. This is accomplished
through careful engagements with narrative structures and narrative ethics
that are most powerfully achieved in the careful reading of literary texts.
Such engagements allow a fuller understanding—­a schematic understand-
ing—­of nonliterary texts as well. By way of example, we offer, in the follow-
ing paragraphs, a short narrative focused on a patient’s HPI that demon-
strates how knowledge of what we describe later as schematic structures of
narrative can help a physician comprehend what is unsaid as well as what is
said in a patient narrative. Dr. Vannatta narrates the following story, which
occurred in his practice.

A twenty-­year-­old mother of a three-­month-­old baby was admitted to

the hospital through the emergency room at eleven o’clock at night. The
admitting resident, intern, and medical student were tired and not too
empathic that late at night. The woman’s husband left her and took the
baby before the intern completed her evaluation, and he was therefore not
available for an interview.
The following morning, at check-­in rounds as attending physician, I met
the patient for the first time. The intern “presented” her case history in the
following manner:

This young lady was brought to the emergency room for abdominal pain last
night. The pain is described as “all over” and diffuse. She is completely un-
able to give any more detail about the pain. She has never had this pain be-
fore. She has had no surgeries and denies vomiting, diarrhea, and constipa-
tion. She has had no fever, takes no medications, and denies being pregnant.
She is vague about her family history, but it does not sound as if the pain is in
any way familial.
This lady and her husband are transients and in town looking for work.
They have little money, and it sounds as if they live from paycheck to pay-
check. Her examination is totally normal except for some very poorly local-
ized abdominal tenderness. The abdominal X-­rays are normal, as is the ad-

Introduction  /  9
 mitting laboratory examination. She has no evidence of infection, including
in her bladder.
Our assessment is that this lady is a “crock” and for some reason would
rather be in the hospital than at home. We do, however, want to rule out
cancer by doing a barium enema and a CT scan of her abdomen. If those
tests are normal, we want to discharge her to home.

Upon entering the room, I noticed a young woman with straight, oily
hair, who buried her face in the pillow even when spoken to. The intern
introduced me, but the young woman did not look up. She turned over
when addressed and responded to a few questions. She allowed me to
examine her abdomen. However, she always looked down when answering
the questions and never smiled or engaged in a meaningful conversation.
She spoke with a very quiet voice and appeared full of shame. The history
was as the intern had presented, as was the examination of her abdomen. In
fact, her history was unremarkable, and her examination was essentially
normal. She was in the hospital because her husband had left her in the
emergency room and because there was no way to contact him.
The intern and resident wanted to discharge her as soon as they
performed a diagnostic test called a barium enema, which is a radiological
procedure, and an expensive CT scan of her abdomen. Because there were
no good indications to do these procedures, I declined to allow them to be
done. I instead instructed them to interview the husband when he came to
visit, to see if any additional information could be obtained. The next day,
the resident reported that the husband had not come to the hospital all day
and that she did not know where he was. The pain had persisted, and the
examination had remained the same. They again wanted to discharge her,
but there was nowhere for her to go. I again would not allow them to do
expensive and time-­consuming tests for which there was no indication. Late
in the evening on the second hospital day, I went to her room to interview
her in private, knowing this would take about an hour. Again I found a
young woman lying in the dark, with her face toward the wall. She finally
turned over and began to talk to me. At first she was very shy and quiet, but
eventually she began to open up and talk more freely.
The story she told me of her abdominal pain fit no diagnostic category,
just as the intern had reported. Because I was getting nowhere pursuing a
biomedical diagnosis, I changed direction and explored the psychosocial
aspect of her history. I said, “Tell me about your family. Where did you
grow up?” I heard a story about her mother, sister, and two brothers in

10  /  the chief concern of medicine

North Carolina. She shared her story of leaving town after high school
graduation in search of adventure. After losing several jobs, she found
herself in a homeless shelter in Indianapolis, where she met her future
husband. She described how he convinced her to jump a freight train with
him and go find work. The relationship quickly turned to love and then
marriage, and within months, they had a new baby but no jobs. They now
found themselves in Oklahoma City, still out of work, hungry, and caring for
a three-­month-­old baby. At the pause in her story, I said, “You told me of
your family, but you didn’t mention your father.” She looked down,
frowned, and stated in a barely audible voice, “He wasn’t very nice to me.”
After twenty to thirty seconds of silence—­an amazing gap in a
conversation—­she continued, “He hurt me and was dirty with me.”
“Did he hurt you physically?”
“Yes, with a belt, many times.”
“Did he sexually hurt you, too?”
Looking down and in a very quiet voice, she replied, “Yeah.”
“I am sorry that happened to you; it is very difficult to live with, isn’t it?”
“Yes, but I think things are better now.”
I waited for a few moments. “Tell me about your husband. Does he hurt
you?”
At first she denied that her husband was anything but perfect, but after
some facilitation, she related that he was emotionally abusive and that she
was afraid that he was soon going to begin physically abusing her. She
related that every night when he was preparing for bed, he would take off
his leather belt and fold it in two, at which she would shiver with fright,
remembering her father’s belt and its hateful pain.
As I listened to the story of the abuse at the hands of the person she was
supposed to trust more than anyone in the world, I was reminded of the
central character, a young girl named “Bone,” in Dorothy Allison’s novel
Bastard Out of Carolina (2005), who was repeatedly beaten and abused by
her stepfather. My patient was the grown-­up version of Bone, one, it
seemed, who had learned to believe that she deserved to be with a man
who was mean and abusive. She fully expected him to begin to hurt her.
The anxiety of waiting for the beating to begin, combined with the stress of
raising a new baby with little or no resources, was pushing her near the
edge. She was seeking refuge in the hospital, a socially acceptable place, in
a socially acceptable manner, versions of Boyd’s illness and sickness.
During teaching rounds the next morning, the intern and the resident
once again insisted that nothing was wrong with this woman. “She is a crock

Introduction  /  11
and needs to go home,” they insisted. “But what is wrong with her?” I
cajoled. As they stood in the hospital hall frustrated, I handed them a
paperback copy of Allison’s book and said, “Read this and you will
understand your patient, and you will then easily discover what to do for
her.”

In the preceding narrative, what Dr. Vannatta expected the intern and
resident to understand about this patient by reading a novel was her chief
concern: what her condition (or situation) meant to her. In the narrative, that
concern is unspoken: it is the work of the physician to “facilitate” (as the nar-
rative says) its articulation. To do this, several things are necessary. First of
all—­and this is the point of this example and, indeed, a central point of this
book as a whole—­it is necessary that the physician understand that a patient’s
concern is as important to the physician’s work as the patient’s chief com-
plaint. When medicine conceives itself as a (physiological) science, it imag-
ines that the complaint is the object of its work. Moreover, if there is no
conceivable complaint, the patient can simply be dismissed as a “crock”; and
even when there is a conceivable complaint, the patient can also be under-
stood simply as “the stroke in room 5.” In this regard, it is notable that the
preceding narrative describes (in Boyd’s categories of unhealth) the patient’s
illness rather than her disease—­although it does describe her sickness insofar
as she seeks refuge by means of “socially acceptable” behavior. She indeed
suffers from illness—­a “feeling . . . of unhealth” that Boyd describes (2000:
10)—­but since the intern and the resident only seek the biological fact of
disease, they cannot notice their patient’s chief complaint (the illness of her
painful abdomen) as “real.” In any case, to make the patient’s chief concern
as important as the chief complaint would enlarge the physician’s attention
and serve the physician’s own “goal” in taking the patient’s history. The for-
mal requirement of its explicit articulation in the chart, in the same way that
the chief complaint is an explicit category in the chart, would go a long way
toward accomplishing this.
A second thing that is necessary in order for the intern and resident to
understand their patient’s story, including her concern, is to understand the
structure and elements—­that is, the schema—­of narrative in general. The
possibility of apprehending what is unsaid in a patient’s story (later in this
book, we cite Dr. Rita Charon’s discussion of the unsaid in narrative) re-
quires a conscious understanding of what is necessary for narrative whole-
ness. We say “conscious” because even young children recognize ill-­formed
narratives without understanding why; to achieve an explicit articulation of a

12  /  the chief concern of medicine

story’s concern, one needs to have a sense of what might be missing, what
cognitive psychology calls the “variable slots” in the overall structures or
“schemas” of apprehension. In this story, Dr. Vannatta notices that a signifi-
cant character is missing from his patient’s narrative and discovers her con-
cern when he helps to make her narrative whole. It is to achieve the goal of
such conscious understanding of narrative that we pursue the development
of narrative schemas.
Finally, for the intern and the resident to understand their patient, they
must be taught—­or have their colleagues and profession explicitly acknowl-
edge through protocols and routine procedures—­that the definition of health
should begin with the patient rather than with the seeming self-­evident facts
of physiology. In Boyd’s terms, they must see illness to be as important as
disease. To discern a patient’s concern is to situate the patient as a significant
collaborator in the pursuit of medicine’s outcome. Sometimes, of course, pa-
tients choose to put themselves completely in their physician’s hands, and
this is fine as long as it is clearly a choice. But when physicians imagine them-
selves as the only responsible party in the patient-­physician relationship, not
only do they miss important information, but their work becomes burden-
some (often powerfully) to them personally. The “practical reasoning” of ph-
ronesis is precisely the search for and negotiation of what counts as impor-
tant in ethical and other enterprises (as opposed to the dicta of normative
ethics or the calculations of utilitarian ethics, as we note in chapter 2), and
such a sense of medicine, with its goal of health as a shared enterprise, cre-
ates space in the work of the physician for different kinds of interest, engage-
ment, and fulfillment besides the burden of seeming total responsibility.
All of the matters we have touched on here—­the concern of the pa-
tient, the ethics of action embedded in the active pursuit of Aristotle’s eu-
daimonia by means of “practical reasoning” (phronesis), the definitions of
health in terms of the action of katharsis that Aristotle describes in the
Poetics, the vicarious experience afforded by literary and other narratives
(e.g., Bastard Out of Carolina), and the very engagement with and facilita-
tion of the patient’s story by the physician—­are essentially entwined with
the actions and forms of narrative and the narrative knowledge they give
rise to, and we will return to these topics and further elaborate them in the
chapters that follow. Teaching such forms and knowledge—­in a word, such
narrative schemas—­and using them within the practices of medicine will,
we believe, allow physicians, much earlier in their careers, to do the job to
which they have committed themselves—­namely, as we have said, bring
greater care to those who come to them ailing or in fear or faced with ter-

Introduction  /  13
rible suffering—­more efficiently, more effectively, and with greater profes-
sional fulfillment.

Schema-­Based Medicine

Throughout this introduction, we have mentioned a new concept in the prac-

tice of medicine, “schema-­based medicine,” which will loom large through-
out this book in its practical aim of discovering strategies for developing the
practical reasoning of phronesis earlier in the careers of physicians and
health care workers.3 We formulate schema-­based medicine—­and princi-
pally, as we argue in chapter 3, the particular schemas of narrative knowl-
edge—­to parallel the widely accepted and widely used procedures of what
has come to be called “evidence-­based medicine.” Evidence-­based medicine
has come to assume two forms. The strictest of these forms is what Atul Ga-
wande describes as “the idea that nothing ought to be introduced into prac-
tice unless it has been properly tested and proved effective by research cen-
ters, preferably through a double blind, randomized controlled trial” (2007:
188). Another sense of evidence-­based medicine, however, pursues a less
restrictive approach, where “evidence” consists of matters of fact that are
gathered through more general observation of what happens in less-­rigid
controlled situations (i.e., situations less strictly controlled than laboratory
testing). The Apgar score (which Gawande is describing when he articulates
the “strong” model of evidence-­based medicine we have just quoted) is one
example of using evidence based on general observations rather than evi-
dence derived from controlled and—­most important—­repeatable situations
of testing. These two forms of evidence correspond to what we describe later
as two “modalities” of scientific understanding. The first modality, best exem-
plified by physics, seeks more or less mathematically formulated laws that
can be rigorously tested by carefully controlled experiments. Such laws seek
more or less timeless formulas in that they are, at best, articulated in com-
mutable formulas that read equally true forward and backward (e.g., F = ma
is not different from ma = F). The second modality is less rigidly formulaic:
newborns with rosy cheeks, strong pulse, regular breathing, responsive mus-
cles, and so on survive more readily than newborns with deficits in some or
all of these categories. The kind of evidence on which hypotheses of this
second kind are based is often exemplified by statistical epidemiological
studies. One defining form of this second evidence-­based science, as we sug-
gest later, is evolutionary biology insofar as it pursues not the formulas of

14  /  the chief concern of medicine

physics but retrospective explanation of the “natural selection” of particular
biological adaptations. In this model, the existence of biological forms, such
as the mammalian eye, can be understood as the product (“end”) of a long
history of advantageous adaptations.
Besides these two forms of scientific explanation, we are suggesting that
there is a third broad sense of understanding, one not based on timeless for-
mulas that are (or can be) rigorously established by carefully controlled ex-
periments or on retrospective explanations based on evidence of a less con-
trolled kind (as comes from some epidemiological studies or from the fossil
record of evolutionary change), but one that can still be considered as sys-
tematic and methodically legitimate as physical and evolutionary sciences. As
we note in chapter 1, Charles Sanders Peirce describes the “symbols” of
language and semiotics—­that is, the “symbols” of humanistic understanding
as opposed to formulaic or explanatory scientific accountings of evidence—­as
constituting the “law that will govern the future.” Such “law”—­despite its
scientific-­sounding language—­is the law of provisional truth. Whereas phys-
ics offers, at its most precise, seeming timeless truth, and whereas evolution
offers retrospective truth, humanistic understanding offers the truth of pro-
visional endings of unfolding sequences of events that seemingly have a be-
ginning and a middle but no definite “end.” Because of the search for provi-
sional truth in the humanities, we use the term speculation throughout this
book, rather than Francis Steen’s term construal. Speculation, we believe,
more fully captures the sense that the search for the “law” governing the fu-
ture is a procedure that weighs and chooses among systematically plausible
alternatives rather than articulating certain necessary and sufficient condi-
tions governing a particular choice. (As we see in Part 1, this systematic
search for a plausible end of action is the work of Aristotle’s phronesis as
well.) In the preceding narrative of the young mother, for instance, while the
dramatic role of “father”—­more technically, as we see in chapters 3 and 8,
the actantial role of “opponent”—­is a necessary feature of the narrative, that
a person’s father should play this role is not necessary but is only, in a par-
ticular instance, a possible sufficient instantiation of that role. In other words,
the young mother could have had other reasons for not mentioning her fa-
ther: perhaps he was rarely at home, his chief concern was his career, her
parents were divorced, and so on. In this example, the cognizance of specific
possible narrative roles functions in the same way that the “Review of Sys-
tems” in the History and Physical Exam quickly touches on possible but not
necessary conditions a patient might present (e.g., no headache, no blurred
vision, no sore throat, etc.). The possible, or provisional elements of a schema

Introduction  /  15
offer the systematic consideration of possible elements that could add up to
a particular understanding and experience, but the acceptance of a particular
schema is always provisional in that further evidence can lead to its abandon-
ment or revision. Thus our felt sense that a room is a classroom as we appre-
hend such salient features as a blackboard, bookshelves, and chairs—­that is,
through the apprehension of features that conditions our experience as well
as our understanding as we enter that room—­can evolve, upon encountering
further evidence, into the understanding that it is a stage set or a nursery.4
In Part 1 of this book, we describe the necessary but not sufficient condi-
tions that schemas set forth. Mathematical physics describes necessary and
sufficient conditions; evolutionary biology describes sufficient but not neces-
sary conditions. Evolutionary biology starts with the “end” as given (e.g., the
existing mammalian eye), which it seeks to understand as the result of a se-
ries of adaptations. Mathematical physics starts with what seems to be a state
of affairs manifest in repeatable events (e.g., objects falling from a height),
which it attempts to understand as governed by a general law that can be
articulated through rigorous mathematical formulation. Humanistic under-
standing, however, starts with neither a particular “end” nor a “state of [more
or less regular] affairs.” Rather, it begins with a situation where there are
facts but no “end” or no self-­evident regular state of affairs (e.g., the seeming
unique “facts” of Mozart’s music, of a particular set of historical events, or of
a person with a particular set of somatic or psychological disturbances),
which it attempts to understand as governed by a schematic interpretative
structure that can account for these facts, Peirce’s “law that will govern the
future.” Such a humanistic “law” is, we are arguing, thoroughly provisional: it
is neither the once-­and-­for-­all accounts of physics nor the more or less thor-
ough plausibilities of evolutionary explanations (based on natural selection or
what might be called “the law that has governed the past”). Whereas physics
pursues the mathematical certainties that were Descartes’s dream of
“method,” and whereas evolution pursues the plausible retrospective expla-
nations that account for biological formations in the context of the theory of
natural selection, the humanities pursue systematic contending accounts of
phenomena—­which might be described as “paradigms” or, as we describe
them here, as “schemas”—­whose aim is to give understandable schematic
structure to a particular situation (the “law that will govern the future”) in
order to resolve it in a provisional (and, indeed, a pragmatic) manner.5
We are taking the term schema from cognitive science. Todd Gureckis
and Robert Goldstone recently defined this term in the Cambridge Encyclo-
pedia of the Language Sciences.

16  /  the chief concern of medicine

 A schema is a high-­level conceptual structure or framework that organizes
prior experience and helps us to interpret new situations. The key function of
a schema is to provide a summary of our past experiences by abstracting out
their important and stable components. For example, we might have a
schema for a classroom that includes the fact that it typically contains a chalk-
board, bookshelves, and chairs. Schemas provide a framework for rapidly
processing information in our environment. For example, each time we enter
a classroom, we do not have to consider each element in the room individu-
ally (e.g., chair, table, chalkboard). Instead, our schemas “fill in” what we
naturally expect to be present, helping to reduce cognitive load. Similarly,
schemas also allow us to predict or infer unknown information in completely
new situations. If we read about a third grade classroom in a book, we can use
our established classroom schema to predict aspects of its appearance, in-
cluding the presence of a coatroom and the types of posters that might deco-
rate the walls. (2011: 725)

The schemas we are particularly interested in describing are those that can
govern the most productive aspects of the patient-­physician relationship as
they manifest themselves in encounters between patients and their physi-
cians. In The Chief Concern of Medicine, we pursue the description of what
we mean by the “most productive” aspects of doctoring under Aristotle’s
term phronesis; and in chapters 2 and 3 and throughout Part 1 of this book
most generally, we argue that the “practical reasoning” of Aristotle’s phrone-
sis characterizes medicine as it achieves most fully—­that is, most produc-
tively and most efficiently—­its ends of the health of the patient. In part 1, we
use Martha Nussbaum’s term salient features to describe what Gureckis and
Goldstone describe as “important and stable components.” The term stable
should suggest the provisional rather than absolute nature of the schemas we
discuss.
What makes schema such a useful concept in the context of practices of
medicine is the widespread assumption that phronesis is a skill or set of skills
that can only be derived from “experience”; Martha Nussbaum is particularly
emphatic about this, but even Rita Charon (who rarely uses the term phro-
nesis) sometimes seems to insist that the thorough experience of “intensive
narrative training” (2006a: viii) is necessary for good doctoring. In this con-
text, what is striking about the concept of a schema is that it attempts to ac-
count for “experience,” which can then be understood as mediated rather
than always uniquely immediate. One such form of mediation is what Thomas
Nickles describes as “case-­based reasoning.” “Case-­based (CB) systems,” he

Introduction  /  17
says—­and he is thinking of the “reasoning” of artificial intelligence as it is
manifest in computer programming—­“work by storing cases in a case base or
case library. When a problem is presented, the system does not attempt to
solve it from scratch, as an RB [rule-­based] system would. Instead, it em-
ploys some sort of similarity metric to find one or more cases similar to the
presented case. . . . Routine (identical) problems can be solved immediately,
simply by calling up the old solution. Less routine problems may require
some combination and/or deformation of the previous cases, and perhaps of
the new problem as well, in order to obtain a suitable fit. CB systems learn
from experience. Successful new cases but also important failures are added
to the case library” (1998: 70–­71). As such, the concept of a schema allows
“experience”—­ including the vicarious experiences that narratives afford
us—­to be anticipated (or “inferred,” as Gureckis and Goldstone note) and
thereby to be taught.6
This aspect of the notion of schema we are describing, as we have already
proposed, is closely related to Thomas Kuhn’s conception of a “paradigm”; in
fact, Nickles has vigorously argued that “we may think of Kuhn’s paradigms
as very large schemas” (1998: 78).7 But schema is a better term for our pur-
poses, because, as we will note shortly, it is much more focused on experi-
ence than is paradigm as Kuhn conceives it; indeed, Kuhn’s conception is
much more closely tied to intellectual understanding, even when such un-
derstanding manifests itself in unconscious assumptions. In any case, Nick-
les’s definition of schema nicely complements that of Gureckis and Gold-
stone insofar as he describes schemas in relation to their practical application
in psychology and artificial intelligence.

Briefly, a schema is a sort of chunking matrix—­that is, a device for structuring

a complex situation or set of inputs into an organized whole (and in this re-
spect it is vaguely reminiscent of Gestalt theory). Schema theory in psychol-
ogy is an attempt to solve the old Greek and Kantian problems of relating
universals or abstract concepts to particulars in humanly accessible ways.
Schema theory denies that human perceptions and judgments consist in
atomic events such as the passive ideas of the British associationists. Rather,
our experiential inputs, and our output behaviors as well, are integrated into
larger, active structures. Schemas are molar structures postulated to underlie
both declarative knowledge and procedural knowledge or skills. They are
abstractly represented as frameworks of connected nodes, expressing the
overall structure, with variable slots in which specific information can be in-
serted and stored. Typically, the more important slots are supplied with de-

18  /  the chief concern of medicine

 fault values that function as “first guesses,” subject to revision with experi-
ence. (1998: 78)8

The implications of this definition of a schema are most exciting in relation

to the practices of medicine and in relation to our development of strategies,
skills, and procedures for physicians engaging in the patient-­physician rela-
tionship. These implications include (1) its description of the problem of
relating abstract concepts to particulars, which we describe in chapter 4 in
relation to the “logic of diagnosis”; (2) its description of variable (and some-
times invariable) “slots,” which we have already seen function in the clinical
narrative of the young mother and which we will describe shortly in relation
to Atul Gawande’s proposal of the importance of “checklists” in the face of
overwhelmingly complex situations and problems and the necessarily com-
plex procedures they necessitate; and (3) the possibility it offers us, as we
argue throughout The Chief Concern of Medicine, for the creation of proce-
dures, routines, and signals that will allow medical students and physicians to
integrate the knowledges of the humanities and of narrative into their prac-
tice with the same efficiency and care that they bring the knowledges of the
biomedical sciences to the care of their patients.
Whatever the sense of “schemas” in psychology, cognitive science, neu-
rology, and philosophy—­and there is a good deal of controversy about the
ontological and functional status of schemas in these fields—­they provide the
practice of medicine with a provisional framework of understanding that “ac-
counts” for facts and, more important, for situations and categories,9 but not
once and for all, as in physics, and not based on a single large framework of
understanding, as in the natural selection of evolution. In this way, as Nickles
suggests, the term schema is closely aligned with Kuhn’s conception that a
paradigm is always provisional, even when it feels, for those who subscribe
to it (or simply assume it), to possess the force of (infallible) law. Thus the
scientific paradigms Kuhn examines gives rise both to the “nomological” sci-
ence of physics (“nomological” being a Greek-­derived term meaning “law-­
like” and thus “timeless”) and the “retrospective” science of evolution, based
as it is on the “law” of natural selection. But paradigm has two other mean-
ings that are particularly useful in grasping an operational sense of schema
for practicing physicians: (1) paradigm describes an “example” or “model” of
understanding such as physic’s mathematics or evolution’s natural selection;
and (2), most specifically, paradigm describes the “grammar” of language
that allows speakers to predict regularities, such as the regular form of verbs
based on the “paradigm” of verb formations in a particular language.10 This

Introduction  /  19
last is important because it is a clear and simple example of Peirce’s sense of
the “law that will govern the future”: the “paradigm” of a regular verb we
know (e.g., “I care”) suggests the forms of verbs (e.g., “I touch”) that we do
not know (just as, Gureckis and Goldstone note, “schemas also allow us to
predict or infer unknown information in completely new situations” [2011:
725]). Of course, such predictions remain provisional insofar as our lan-
guages also offer irregular verbs (e.g., “I think”). That young children conju-
gate irregular verbs regularly (e.g., “I thinked”) demonstrates both the power
and the provisional nature of paradigms11 and, more strikingly for our pur-
poses, of schemas as well. Grammatical paradigms are a clear subset of the
larger term schema, as is, as we suggest later, the periodic table.
Schemas—­ and even paradigms, though they are somewhat more
narrow—­are the basic building blocks of humanistic understanding (see ap-
pendix 1) and, as such, define what the medical humanities can contribute to
the practical tasks of doctoring. When someone wants to “account for” Mo-
zart’s music, she pursues the “schemas” of musical form that would allow her
to “predict” that a certain piece of music is, in fact, written by Mozart, to
grasp, in Gureckis’s and Goldstone’s terms, “a summary of our past experi-
ences [of Mozart] by abstracting out their important and stable components”
(2011: 725), what we call in chapter 3, following Nussbaum, the “salient fea-
tures” of his music. (Schemas are precisely lists or structures of salient fea-
tures.) When someone wants to “account for” a particular set of historical
events, he provisionally chooses a schema of understanding—­a framework
whose salient features constitute economic forces or political power or per-
sonal initiative comparable to the framework of salient features of “class-
room” that conditions understanding and experience upon entering a room.
When someone wants to “account for” a person complaining of fever, red-­
spotted skin, and tiredness, she pursues the “schemas” or “paradigms” of
human conditions we call “diseases.” Such an account seeks both salient fea-
tures and salient frameworks. The three models of systematic understanding
we are presenting—­the “strict” science of physics, the “explanatory” science
of evolutionary biology, and the provisional “speculations” of the humanities—­
correspond to the (timeless) deduction, (empirical) induction, and (specula-
tive) abduction that we describe in chapter 4 in Peirce’s account of the “logic
of diagnosis.”
Throughout The Chief Concern of Medicine, we argue that these sche-
matic or paradigmatic forms of humanistic understanding lend themselves
to—­and, in fact, can help to habituate—­pragmatic skills that can be taught

20  /  the chief concern of medicine

and can inform the everyday practices of physicians. We describe three sets
of skills in this book:

Skills in listening to patients entail the articulation of the “salient fea-

tures” of narrative in order to develop systematic strategies that allow
physicians to recognize efficiently and, hopefully, automatically the
information patients bring to the patient-­ physician relationship.
These are “skills” based on a practical schema of narrative under-
standing in relation to a grammar that predict forms of understand-
ing. We present speculative evidence that suggests that a pragmatic
“grammar” of narrative that we develop would aid physicians in lis-
tening to their patients.
Skills in interviewing entail systematic strategies for obtaining such
information. These are “skills” based on examples and models, such as
listening for particular “hot words” from patients that indicate paths
to follow to discover the “law” of a particular patient’s future. We
present empirical evidence—­Kuhn’s “exemplars” or schema models—­
that enlarge the information physicians can obtain from patients. This
empiricism is based on evident schemas of relationship in our par-
ticular society, such as marriage relationships, economic relation-
ships, and power relationships that are typical of American society. It
is of the utmost importance to remember that such “hot words” em-
body, often not quite self-­consciously, the patient’s chief concern.
Skills in actions (or virtues) in behavior with patients entail system-
atic strategies for behaviors appropriate to the patient-­physician in-
teraction. These are “skills” based on (provisionally) timeless under-
standing of morally “good” values, the “good life” (or eudaimonia)
Aristotle describes, which, we believe, in the context of medicine,
should be translated as “good health.” Such goodness of behavior,
based on the “timeless” understanding that the patient’s health is the
chief end of medicine, presents schemas that speculatively construe
the “ends” of medicine, what we are calling its “chief concern.”

The description and value of such “schematic” skills are based on humanistic
understanding that warrants as much authority in the education and practice
of medicine as do strict evidence-­based medicine and empirical evidence-­
based medicine. The presentation of the value of such skills—­ and the
schema-­based checklists in appendix 2, which will allow the use and, per-

Introduction  /  21
haps, habituation of such skills early in a medical career—­is a primary goal of
The Chief Concern of Medicine, in its philosophical examination of “evi-
dence” itself in relation to the pragmatism of Peirce and John Dewey (Part
1), its empirical examination in relation to schemas (or models) of patient-­
physician relationships in fact and narrative (Part 2), and its examination in
relation to pragmatic skills and checklists (grammatical, empirical, and spec-
ulative models) of doctoring (Part 3). Throughout this book, we argue that
such skills can be taught and that, following (in part) Gawande’s model of
checklists, they can become part of the everyday routines of medicine, man-
ifest strictly in the patient’s chart, empirically in the questions and attention
of the medical interview, and habitually in schemas or “touchstones” of be-
havior for physicians to attend to in their actions with and toward patients.

The Practical Uses of Schema-­Based Medicine

The practical uses of schema-­based medicine can follow the practical uses of
evidence-­based medicine. The practicality of evidence-­based medicine is
manifest in the evidence-­based guidelines that we describe in chapter 3 and,
more generally, in concise reviews of “clinical evidence” we describe here,
both of which serve physicians in their daily work. In regard to this second
systematic use of evidence-­based medicine, we note, for instance, that the
British Medical Journal regularly publishes updates of clinical evidence de-
scribing useful therapies for various diseases. Thus, in one example, Clinical
Evidence Concise—­which is regularly published annually with monthly up-
dates online—­lists both two “beneficial” treatments of people with type 1
diabetes based on one or another “systematic review . . . compared with pla-
cebo or controls” (including a “review that found no significant difference
between intensive glycaemic control and conventional control in the inci-
dence of severe hypoglycaemia, but found higher incidence of diabetic keto-
acidosis in people treated with continuous subcutaneous insulin infusion
compared with conventional multiple injection treatment”) and four treat-
ments with “unknown effectiveness” since “no systematic review or RCTs
[random control trials]” could be found among clinical testing (Schlipak 2005:
149–­50). In effect, this presents a concise compendium (not quite a checklist)
of treatments (usually pharmaceutical) based on laboratory or epidemiologi-
cal evidence. In a parallel discussion in chapter 9, we present a vignette of a
patient suffering from diabetic ketoacidosis, in which she presents her chief

22  /  the chief concern of medicine

concern (explicitly that “her stomach is ‘dead,’” implicitly that she was very
poor and suffers from marital stress) as well as her chief complaint (diabetic
ketoacidosis, and she might also suffer from borderline personality disorder).
Just as Clinical Evidence Concise offers a list of beneficial treatments physi-
cians should be aware of, we offer a list of three Aristotelian “virtues” that a
physician should also be aware of in treating such a complicated and difficult
patient (namely, conscientiousness, discernment, and compassion).
While such “attitudes” toward a patient and her complaint and concerns
might seem self-­evident—­certainly more self-­evident than whether or not
certain treatments have been subjected to systematic scientific review—­it is
precisely the self-­evidence of proper procedures, as Atul Gawande argues in
The Checklist Manifesto, that sometimes (and disastrously) gets lost in the
face of the enormous abundance of options for “making the right treatment
choice” (2010: loc. 175). Thus he notes, “I have been trying for some time to
understand the source of our greatest difficulties and stresses in medicine. It
is not money or government or the threat of malpractice lawsuits or insur-
ance company hassles—­although they all play their role. It is the complexity
that science has dropped upon us and the enormous strains we are encoun-
tering in making good on its promise” (2010: loc. 187). In the face of this
problem, he concludes,

Here, then, is our situation at the start of the twenty-­first century: We have
accumulated stupendous know-­how. We have put it in the hands of some of
the most highly trained, highly skilled, and hardworking people in our soci-
ety. And, with it, they have indeed accomplished extraordinary things. None-
theless, that know-­how is often unmanageable. Avoidable failures are com-
mon and frustrating, across many fields—­from medicine to finance, business
to government. And the reason is increasingly evident: the volume and com-
plexity of what we know has exceeded our individual ability to deliver its
benefits correctly, safely, or reliably. Knowledge has both saved us and bur-
dened us.
That means we need a different strategy for overcoming failure, one that
builds on experience and takes advantage of the knowledge people have but
somehow also makes up for our inevitable human inadequacies. And there is
such a strategy—­though it will seem almost ridiculous in its simplicity, maybe
even crazy to those of us who have spent years carefully developing ever
more advanced skills and technologies.
It is a checklist. (2010: loc. 217)12

Introduction  /  23
The checklists Gawande describes are, in fact, similar to the lists of “proven”
treatments found in Clinical Evidence Concise and to the evidence-­based
guidelines we discuss in chapter 3.
Evidence-­based guidelines usually take the form of algorithms of care,
while Gawande’s “checklists” only occasionally do. In The Checklist Mani-
festo, Gawande offers three different kinds of checklist. He calls the first a
“do-­confirm” checklist, exemplified by the procedures to be done by a pilot
before takeoff. He calls the second a “read-­do” checklist, exemplified by the
printed list of procedures to be followed in the case of an emergency, such
as the loss of a door on an airplane in flight or the “Guidelines on Periop-
erative Cardiovascular Evaluation and Care for Noncardiac Surgery” we
discuss in chapter 3. Such read-­do checklists are, in fact, algorithms of
behavior—­ if-­
then instructions—­for particular situations. The evidence-­
based guidelines we discuss in chapter 3 are such checklists. Finally, Gawa-
nde presents what he calls “communication” checklists, which require
members of a working team—­two extended examples he offers are medical
teams in surgery and construction teams in building a complicated high-­rise
edifice—­to discuss various aspects of a complex undertaking and, through
discussion, to potentially prevent future problems and failures. A fourth
kind of checklist, which Gawande does not offer, is the self-­inventory check-
list we present in appendix 2, in which a particular agent in an active pro-
gram inventories her own readiness for the task at hand. This is analogous
to the do-­confirm checklist, but on the level of the agent rather than the
activity.13
The purpose of checklists, as Gawande says, is “to provide protection
against . . . failures. They remind us of the minimum necessary steps and
make them explicit. They not only offer the possibility of verification but also
instill a kind of discipline of higher performance” (2010: loc. 515). In his
book, he is chiefly concerned with developing checklists that take into ac-
count more or less technical procedures in medicine, air flight, construction,
even restaurants, just as Clinical Evidence Concise provides pharmaceutical
and, sometimes, physical treatments of hundreds of diseases and conditions.
Still, one significant difference between Gawande’s checklists and the
evidence-­based treatments of Clinical Evidence Concise—­and, to a lesser
extent, between checklists and evidence-­based guidelines—­is that checklists
have built into them a sense of teamwork and cooperation (most notable in
Gawande’s “communication” checklists). Describing the checklists airplane
pilots go through, Gawande notes that

24  /  the chief concern of medicine

 before the pilots started the plane’s engines at the gate, however, they ad-
hered to a strict discipline—­the kind most other professions avoid. They ran
through their checklists. They made sure they’d introduce themselves to
each other and the cabin crew. They did a short briefing, discussing the plan
for the flight, potential concerns, and how they’d handle troubles if they ran
into them. And by adhering to this discipline—­by taking just those few short
minutes—­they not only made sure the plane was fit to travel but also trans-
formed themselves from individuals into a team, one systematically prepared
to handle whatever came their way. (2010: loc. 2427)

In other parts of his book, he describes the teamwork necessary for surgery
and other medical situations.
Nevertheless, the concept of “the discipline in following prudent proce-
dure and in functioning with others,” Gawande notes, is “outside the lexicon”
of medicine, in which the “professional lodestar” is “autonomy . . . , a prin-
ciple that stands in a direct opposition to discipline” (2010: loc. 2535). Thus
he concludes, “we’re obsessed in medicine with having great components—­
the best drugs, the best devices, the best specialists—­but pay little attention
to how to make them fit together well” (2010: loc. 2563). The teamwork
Gawande is describing—­and that requires and creates a group of people
working together, literally reading off checklists to one another—­takes place
among health care workers in relation to clinical and therapeutic interven-
tions, best exemplified by the team of surgeons, anesthesiologists, nurses,
and others in the operating room. In The Chief Concern of Medicine, we fo-
cus on a different kind of “teamwork,” that between the physician and the
patient, where, we argue, the skills and behaviors that grow out of schema-­
based understanding will make medicine more accurate, more efficient, and
more fulfilling. One of our checklists in appendix 2 literally puts in the pa-
tient’s hand a checklist concerning whether or not the physician understood
the patient’s chief concern (see checklist 5, “Patient Engagement”). This pro-
cedure authorizes the patient to engage and question the physician, and in so
doing, it seeks to facilitate teamwork, just as Gawande’s communication
checklists do.
We are arguing here that schemas for patient-­physician interactions—­
including the diagnosis of the patient’s chief complaint, the discernment of
her concern as well as her complaint, the negotiation of the category of
“health” that applies in her situation, and the development, again through
negotiation, of the treatment or plan of action to achieve that goal of

Introduction  /  25
“health”—­ can be based on the “high-­ level conceptual structure[s] or
framework[s]” of schemas (Gureckis and Goldstone 2011: 725) that is the
work of the humanities. Such schemas and checklists can be abstracted from
the philosophical, narrative, and semantic analyses we provide in The Chief
Concern of Medicine, just as the procedures of Gawande’s checklists and the
“treatments” of Clinical Evidence Concise are based on the evidence of epi-
demiological surveys and clinical trials. As such, schema-­based medicine will
allow physicians and other health care workers to attend to their patients
with greater focus, care, and attention.
In fact, in our appendixes, we present such abstractions that follow, to
some degree, the “checklist for checklists” that Gawande provides in The
Checklist Manifesto. There he notes that the elements on a functional check-
list must include “concise objectives,” a concise number of listed items, and
criteria for choosing items of the list. In appendix 2, we offer such shorthand
schemas for the skills and procedures that grow out of engagement with nar-
rative in the practices of medicine. Appendix 3 is a compilation of schemas,
similarly abstracted, for memory, understanding, and attention. The simplest
and most concise is the practice of adding the patient’s chief concern to the
History and Physical Exam—­as with our checklist 5 already mentioned,
barely a “checklist” at all, but certainly a procedural guide for practice and
for the History of Present Illness altogether. But others, engaging with sche-
mas of interpersonal interaction, narrative understanding, and professional
or “virtuous” behavior, should help to allow the analyses and arguments of
our book to affect the work of health care in practical ways.

The Organization of The Chief Concern of Medicine

The organization of The Chief Concern of Medicine follows the nonexhaus-

tive catalog of elements of the “better physician” we enumerated at the be-
ginning of this introduction. Part 1, “Phronetic Skills: The Technē of Medi-
cine,” examines general aspects of medicine in relation to both science and
the humanities—­what we are calling the “intellectual practice” of medicine—­
from the points of view of philosophy, evolution, and professional medical
practices. In chapter 1, “The Functional Realism of Medicine,” in describing
the pragmatic reality of biomedicine, we set forth the philosophical argu-
ment that the humanities—­particularly with its focus on narrative discourse—­
provides a knowledge (“narrative knowledge”) that is as real as the knowl-
edge science pursues. In this chapter, the examination of the relationship

26  /  the chief concern of medicine

between the humanities and the nomological sciences serves to introduce
the intellectual practices of medicine discussed in Part 1 and our more gen-
eral focus on the chief concern of medicine throughout this book. Chapter 2,
“Modalities of Science: Narrative, Phronesis, and the Skills (Technē) of Med-
icine,” develops a more specific—­and wider—­sense of science, in its focus
on Aristotle’s notion of phronesis in relation to narrative. It is our hope that
expanding the conception of science developed in chapter1 to one more
closely practicable in medicine will appeal to medical students and physi-
cians, trained as they are in the scientific method. Chapter 3, “The Chief
Concern of Medicine: Narrative Knowledge and Schema-­Based Practice,”
articulates our overarching purpose of developing a practical framework for
the everyday practices of medicine, particularly in relation to the concept of
the chief concern of a patient, the patient’s awareness of what his ailment
means in relation to the ongoing story of his life.
In chapter 3, we also develop the concept of schema-­based medicine in
relation to evidence-­based medicine. To this end, we focus on schemas of the
salient features of narrative, of narrative roles, and of narrative genres, all of
which constitute narrative knowledge. In later chapters, we also focus on
verbal schemas for provoking empathy, conceptual schemas (Aristotelian
virtues-­in-­action) for making us mindful of the necessary skills narrative un-
derstanding requires and for what we call “narrative virtues,” and schemas or
structures that allow us to see the necessary features of speech communica-
tion and narrative forms that are powerfully useful in achieving phronesis in
medicine. Later, in chapter 9, we also cite the American Medical Associa-
tion’s description of the rights of patients, which itself forms a schema and,
indeed, a kind of checklist, like the beneficial treatments of Clinical Evi-
dence Concise in practices of medicine. Throughout The Chief Concern of
Medicine, we suggest that such schemas can offer “teachable” strategies to
help develop the physician into the phronimos. In chapter 4, “The Logic of
Diagnosis: Peirce, Literary Narrative, and the History of Present Illness,” we
focus on the “logic of discovery” as it was formalized by Charles Sanders
Peirce—­he called it the logic of “abduction” complementing deduction and
induction—­in relation both to Aristotle’s “practical syllogism” and to the
functioning of narrative knowledge, in order to discuss a further schematic
understanding of the diagnostic practices of medicine.
The four chapters of Part 1 offer a general intellectual examination of the
practices of medicine that are explored in greater detail in Part 2, “The Work
of Narrative in Practices of Medicine.” The chapters of Part 2 examine more
closely the ways that particular narratives—­notably literary narratives—­can

Introduction  /  27
help physicians and medical students more fully understand and achieve ef-
ficient, accurate, and fulfilling practices in medicine. Chapter 5, “The
Patient-­Physician Relationship: The Scene of Narration,” focuses on the re-
lationship between patient and doctor that is at the heart of the privileged
encounter between a healer or caretaker and someone in distress; chapter 6,
“The Patient’s Story: The Apprehension of Narration,” and chapter 7, “Doc-
tors Listening and Attending to Patients: Response and Engagement with
Acts of Narration,” examine this relationship in terms of the storytelling and
diagnostic listening that embody, most fully, this relationship.
Part 3, “Schema-­Based Medicine,” re-­traverses—­or, as Kathryn Mont-
gomery Hunter has argued, “re-­stories” (1991: 141ff.)—­these practices by
understanding them in relation to schematic apprehensions of narrative for-
mation, practical encounters, and ethical behaviors that can help shape and
sharpen medical practice. Chapter 8, “Narrative and Medicine: Schemas of
Narration,” returns to Aristotle’s conception of pity and terror in tragedy in
relation to medical practices we touched on here and develops a schematic-­
structural understanding of narrative formations that can offer physicians and
students frameworks for understanding patient narratives. Chapter 9, “Narra-
tive and Everyday Medical Ethics: Schemas of Action,” focuses on everyday
responsibilities of doctoring that grow out of this relationship, organizing
those responsibilities into an Aristotelian schema of virtues-­in-­action. In the
part titled “Conclusion,” chapter 10, “Reading The Death of Ivan Ilych,”
makes more explicit the knowledge, skills, and practices examined through-
out The Chief Concern of Medicine, by focusing on the technē of medicine
realizable in relation to a particular literary text; and our afterword sums up
the nexus of literature and medicine as we present it throughout The Chief
Concern of Medicine. Together, these two conclusions, presenting a sense of
the overall work of our book through narrative and through a schematic ac-
counting of its themes and purposes, recapitulate the methods and work—­
the technē—­of narrative knowledge. Finally, as we noted, the appendixes—­
particularly appendixes 2 and 3—­provide particular checklists for behavior
and understanding in the patient-­physician relationship that concisely set
forth the schemas that govern our analyses throughout this book.

Practices of Medicine

Perhaps the use of the plural word practices in Part 2 of this book will startle
physicians and other health care workers, who have always heard and used

28  /  the chief concern of medicine

the term medical practice. The use of the plural helps emphasize the connec-
tion between medicine, literature, and narrative. On the level of literature
and literary techniques, the phenomenon of being startled can be described
in terms of the technical literary description of the “defamiliarization” or
“making strange” of experience discussed in the chapter 10. This term—­
developed in Russia early in the twentieth century and often used in discus-
sions of Leo Tolstoy—­describes one of the ways that literature works to
sharpen listening, attention, and even care, by working against habit and un-
reflective assumptions about the world. Such defamiliarization can be under-
stood precisely in terms of the schemas we pursue in this book. Schemas, as
we noted, help “predict” and normalize experience, and precisely the viola-
tion of the expectations that schemas provide leads to the discomfort of defa-
miliarization and the reflective understanding such feelings give rise to. Here
as much as any place else, the provisional nature of schemas is apparent.
But perhaps more important, the use of the plural in referring to “prac-
tices of medicine” aims at suggesting that the whole of medicine can benefit
from attending to and comprehending relationships between the parts and
the whole, the process of “adding up” itself: “the old Greek and Kantian
problems of relating universals or abstract concepts to particulars in humanly
accessible ways” that Nickles notes is the work of schemas. Such comprehen-
sion always takes place in successful narrative—­successful, as we noted, both
in its execution and its reception in the relationship between teller and
listener—­and in achieved ethical action in the world. By beginning with the
particular practices of medicine with the aim of understanding their power-
ful place within human affairs, medicine can learn from narrative and can
learn the important place of storytelling, the patient-­physician relationship,
and the narrative drama of medical practices in its work of relieving suffer-
ing, healing, and caretaking.
In these chapters, then, we hope to demonstrate the ways in which vari-
ous “practices” of medicine help create a whole greater than the sum of its
parts. This is most notable in chapter 9, focused on the more or less discrete
ethical “virtues,” as Aristotle described them, as a way of demonstrating how
ethics is woven into every aspect of everyday medicine and how the ethics of
compassion and trustworthiness, discernment, and conscientiousness allow
caretakers to fully enter into a patient-­physician relationship and to compre-
hend and attend to the patient’s story and, most of all, the patient’s concern in
the face of illness. These everyday virtues “add up” to the virtue of phronesis
Aristotle describes, “practical reasoning” or “practical wisdom” that might
well be translated as “clinical judgment”; and together, these local and global

Introduction  /  29
virtues in medical practices allow health care workers to pursue their voca-
tion and jobs with a final virtue of “common decency.” With this last chapter
of Part 3, we are suggesting that knowledge of and skills in narrative—­the
very “humanistic understanding” that The Chief Concern of Medicine seeks
to describe and enact (see appendix 1 for a concise account)—­are crucial to
medical practice in a manner that is at least analogous to the importance of
the knowledge and skills of “logico-­scientific” biomedicine that are rigorously
taught in medical schools. Moreover, we are suggesting that possessing such
humanistic knowledge and skill, along with biomedical knowledge and skill,
is part of the ethical responsibility of good doctoring. But the discussions in
the chapters in Part 2—­on the ways of discovering balances between patient
and physician (chapter 5), the need to comprehend the patient’s story (chap-
ter 6), and practices of conscientiously attending to patients (chapter 7)—­all
touch on the responsibilities that accompany the privileged vocations that
encounter suffering, grief, and pain in our fellow human beings.
Throughout all the chapters of The Chief Concern of Medicine, we are
also suggesting that there is a special relationship between narrative and
medicine insofar as each can produce the recognition of and response to
those things that are grave and constant in human affairs. For this reason, we
believe that our book should be useful to others besides medical students,
physicians, and health care workers. After all, other professions—­the law,
education, the arts, students of literature, even politics—­regularly encounter
narrative and whatsoever is grave and constant in human affairs. All of us, in
the lives we live, know pity and terror at what doctors deal with profession-
ally and on a daily basis: suffering, death, grief, pain. We also know those
other things that the practice and practices of medicine give rise to: the joys
of well-­being, of good news, of friendship, of teamwork, and of good health.

The Privilege of Doctoring

The work of a physician is not simply an example of human life, simply a

closely delineated example of “humanities.” Rather, the practices of physi-
cians and health care workers take place within a profession that is attained
through a particular program of hard work and rigorous training. Like many
other professions, health care professions have the potential for great social,
intellectual, and—­for want of a better term—­spiritual rewards. Yet, in many
ways, medicine is a defining profession because it entails enormous profes-
sional competence brought to bear at the great crises—­of health and illness,

30  /  the chief concern of medicine

well-­being and suffering, life and death—­of particular human beings and
communities of people. As a profession, it is characterized by a remarkable,
growing body of knowledge about illness and health, particular standards of
truth and behavior, and organized practices and methods of understanding.
But in its encounters with ailing human beings, it is privileged in that it en-
tails interactions with people—­within the context of its professional stan-
dards and responsibilities—­that touch on the vital centers of human life in
general. There are few professions that call on the intimacies, the emotions,
the potentiality of honest and heartfelt interchange that characterize the best
part of our private lives as does a profession in medicine. Because of this,
throughout The Chief Concern of Medicine, we repeatedly describe—­as do
the physicians we cite—­what we are calling the “humanistic” aspect of the
medical profession, frequently in seemingly vague terms, including “honor,”
the “sacred,” the “mystery of suffering,” “decency,” “grace,” and the sense
that “something important happens” in patient-­ physician relationships.
These are vague, though real, terms that are difficult to define precisely yet
whose meaning most everybody knows or feels. Just as frequently through-
out this book, we seek to articulate terms and concepts that are teachable,
precise, and work toward explanation—­this is our hope for the schemas we
present—­that will make men and women, striving to do the best by the peo-
ple in their care, more mindful and more careful in their everyday practices
and routines. Both Aristotle and Charles Sanders Peirce, two towering fig-
ures we depend on in these pages, understood that habit and habitual, rou-
tine behavior best express our values and our beliefs, and one of our chief
aims in this book is to discover, by means of certain exercises of mindfulness
and purpose (by means of schema-­based checklists), ways in which people
can develop the habitual practical reason and practical wisdom of phronesis
that otherwise often develop over a lifetime of experience.

A Note for Physicians and Health Care Workers

We expect that appendix 1, “Humanities as a Discipline,” will address read-

ers interested in the human as well as the medical sciences, so here we ad-
dress physicians and health care workers. We hope this book will accomplish
two primary goals. The first is to provide a philosophical or “intellectual”
defense of the nexus of literature and medicine, which demonstrates that
narrative knowledge is a useful tool in the education and the professional
practices of doctors. The second is to suggest pragmatic programs for teach-

Introduction  /  31
ing and practicing medicine based on that defense. These suggestions not
only exist in the explicit arguments and checklists we present about the
teaching and practicing of medicine. They are also implicit in the examples
or “models”—­versions of case-­based reasoning—­in the literary narratives we
set forth and analyze. Both toward the philosophical defense of widening our
conception of medicine and medical practice and toward the pragmatic pro-
gram of developing teachable practices that will embody that widened con-
ception of medicine, we provide multiple examples of how literary and other
narratives “work” to aid in the understanding of narrative knowledge that is
so important in practicing the highest quality medicine.
In its discussions, arguments, and advocacies, this book pursues these
goals by focusing on two important aspects of medical practice in relation to
narrative knowledge and actions that stem from it. The first is patient-­
physician communication, especially concentrating on the medical
interview—­the most important diagnostic narrative. We hope that thorough
understanding of the ways narratives function will lead to better apprehen-
sion of the patient’s chief concern and a more accurate diagnosis. The second
is how to make such understanding habitual. Throughout The Chief Concern
of Medicine, we argue that narrative knowledge is teachable and that some
fairly simple behaviors—­if habituated—­can aid in its more efficient use. As
we mentioned, these behaviors are concisely delineated in appendixes 2 and
3, presented as checklists and heuristic compilations, but they are abstracted
from the larger arguments of the book as a whole (particularly Parts 2 and 3).
We anticipate that discerning and experienced clinicians will recognize in
these appendixes actions that they have habituated through experience and
have come to see as enormously helpful in the care of patients. For physi-
cians who are inexperienced or student doctors, we hope this book and its
appendixes will aid in more efficiently learning these helpful behaviors inso-
far as it presents both “vicarious” examples of such experience and the sche-
mas that experience produces.
Finally, we hope that health care providers other than physicians will find
the contents of this book helpful. Nurses, pharmacists, physical therapists,
dentists, and allied health providers develop the same therapeutic relation-
ships with patients as do physicians. The contents of this book can facilitate
richer relationships, more accurate communication, and more humanistic
understanding of their patients’ experience of illness.

32  /  the chief concern of medicine

 part 1
Phronetic Skills: The Technē of Medicine
1
the functional realism of medicine

The Problem of “Narrative Medicine”

While efficacy of training for and utilizing “narrative knowledge” within the
practices of medicine—­something that Rita Charon has aptly called “narra-
tive medicine”—­has grown and continues to grow in medical education and
professional practice (see Charon 2006a for a thorough account), defending
its method and aims to the medical establishment remains a difficult task. It
seems that the burden of proof of its efficacy and scientific reliability still
resides on the shoulders of the practitioners of narrative medicine. Those
teaching physiology to first-­year medical students seem relatively free of the
similar onus of demonstrating in a decisive way that their course leads to bet-
ter medical results, even though, it should be added, no such evidence exists
to support that it does. Underlying the suspicion of the “softness” of narrative
medicine is an often tacit metaphysical presupposition that the language of
the positive sciences is a description of the nature of reality. Science ad-
vanced, in the work of Galileo, Descartes, and Newton, with an understand-
ing of nature as mathematicizable and quantifiable. (In chapter 2, we exam-
ine this conception of science under the term mathematical physics to
distinguish it from the more historically oriented science of evolutionary bi-
ology.) Biomedical science followed suit, and the benefits of this advance are
not to be underestimated. Nevertheless, this assumption of the primacy of
“hard” quantifiable truth leads to three important responses. First, in the
teaching and practices of medicine, it has led to the most notable and explicit
expression of this assumption in the pursuit of “evidence-­based medicine,” a

/  35  /
categorization, coined in the early 1990s and growing out of the work of the
Scottish epidemiologist Archie Cochran, that advocates that systematic, em-
pirical, and quantifiable research—­as opposed to “traditional,” more or less
untested medical practices—­form the basis of medical practice. Needless to
say, the pursuit of evidence-­based medicine was and remains a salutary re-
sponse to often unexamined assumptions about what is effective medical
practice, but it also participates in the tacit metaphysical presupposition
about what “counts” as knowledge, explored in this chapter. In a second re-
sponse, more generally—­and perhaps less self-­reflectively than evidence-­
based medicine—­the assumption of the primacy of quantifiable truth has led
the medical establishment to seek evidence of the efficacy of narrative med-
icine in quantified results. If the effects of narrative medicine in medical
education can only be justified in reflective (case-­based) descriptions of its
power and efficacy—­or even in the schema-­based understanding we present
in this book—­rather than in the evidence-­based facts and formulas of sys-
tematic scientific testing and research, those holding this assumption will
count such reflective descriptions against, not for, their use in the curriculum
and practices of medicine.1
But there is a third response to this assumption, which we follow here
(without discarding evidence-­based medicine). One premise of our defense
of narrative medicine is that while natural phenomena, including physiologi-
cal ailments, can be described in mathematical and quantifiable vocabular-
ies, that language can be said to correspond to a reality only insofar as the
biomedical results of biomedical science are treated as just that—­results,
achievements, and outcomes of scientific inquiry. This reminder prevents
two fallacies. The results of biomedical scientific inquiry should not be
thought of as existing antecedent to the inquiry that produced them, and we
should be prudent in our tendency to import those results to other clinical
situations. Treating biomedical knowledge as the outcome of inquiry, whose
reality inheres in the functional ability to resolve the problems that give rise
to inquiry, infuses medical practice with both fallibilism—­that is, the philo-
sophical doctrine that all claims to knowledge can, in fact, be mistaken—­and
the possibility for growth and improvement. Further, reminding the medical
community of this insight prevents the clinical physician from failing to con-
front the individual patient as an individual (rather than a “case” of a
disease)—­with all her particularity, richness, affective experience, and what
we describe as her concern—­by viewing her narrative in the clinic as a shroud
to the real biomedical knowledge sought after. As we suggested in the intro-
duction, we believe that education in and mindfulness about narrative can

36  /  the chief concern of medicine

avoid both of these mistakes.2 Our hope and contention is that a medical
community that treats biomedical knowledge as an outcome of scientific in-
quiry retains the fallibilism necessary for the correction of errors and the
production of new knowledge and becomes more open to the inclusion of
narrative medicine within both medical education and medical practices.
In other words, describing the functional realism of medicine, as we do
here, creates a pragmatic defense of the most effective clinical practices of
medicine precisely because of our focus on the actions and results in health
care. We argue that the languages of science (both evidence-­based and de-
scriptive) and the languages of what we are calling the human sciences (nar-
rative knowledge, semiotics, abduction, schemas) offer parallel ways to help
solve medical problems, all of which can improve medical practice. We argue
that the ideas, concepts, and laws produced by the instrumental vocabularies
of natural science and by the cognitive apprehensions of narrative are real.
Thinking with Charles Sanders Peirce, we treat these concepts not as onto-
logical truths antecedent to the inquiries that produced them—­truths that
exist once and for all—­but as real in their function and in the consequences
of their appropriate enactment in the clinic. While the concepts of both bio-
medical science and narrative knowledge are conventional and contingent on
a history of social interaction, communal use, and scientific inquiry—­in the
case of narrative knowledge, contingent on the “long” history of evolution
(see chapter 2 and Gould 1989)—­they are real insofar as they serve as fallible
(which is to say provisional) laws governing future activity. Relying on Peirce’s
theory of meaning, we maintain that the meaning of these concepts resides
in the consequences of their employment. To understand the meaning of the
concepts proffered by the language of either biomedical science or narrative
is to understand the whole of their effects in medical practice.3
Thus, to create an “intellectual” foundation for the subsequent chapters
in Part 1 and, indeed, in The Chief Concern of Medicine as a whole, we use
the rest of this chapter to describe in general terms the use of narrative
within practices of medicine that we explore more fully throughout this
book. We do so by presenting Peircean pragmatic realism as the proper con-
ceptual model for our argument that the practices of medicine should em-
ploy both scientific and narrative knowledge, giving each its proper space.
We set forth, in chapter 3, a concept of “schema-­based medicine” (parallel to
“evidence-­based medicine,” which reflects the assumptions inherent in the
mathematical and quantifiable vocabularies of the natural sciences)4 and, in
chapter 4, a concept of the “logic of diagnosis” (parallel to Aristotle’s “prag-
matic syllogism”). In this initial chapter, our reflections on the instrumental

The Functional Realism of Medicine  /  37

vocabularies of literary narrative and science and the reality of their concepts
give rise to a description of the ideal aims—­the “ends”—­of the enterprise of
medicine, something we discuss more fully in chapters 2 and 3 and work out
in subsequent chapters of the book. That medicine ultimately serves the
ideal of restoring well-­being or at least alleviating or coping with human suf-
fering, including coping with death—­definitions of health we set forth in the
introduction—­speaks to the humanity of the practice of medicine. Pursuing
such ends and goals begins in and ends in the feeling and apprehension of
our common humanity, and such sense and experience of humanity draw no
strict border between narrative and science. The medical community should
not either.

What Is Narrative Medicine?

The term narrative medicine was invented by Rita Charon, professor of both
medicine and literature at Columbia University. Dr. Charon is a general in-
ternist and has a PhD in English literature, having written a dissertation on
the writings of Henry James. She is the director of the Narrative Medicine
Program at the College of Physicians and Surgeons at Columbia University.
She defines narrative medicine as “medicine practiced with the narrative
competence to recognize, absorb, interpret, and be moved by the stories of
illness” (2006a: vii). With the term narrative medicine, she emphasizes what
we asserted in the introduction: that much of what is done in the practice of
medicine is narrative in nature and that a physician can practice better med-
icine by becoming narratively competent. As we have seen, examples of nar-
rative activities in medicine are the initial History of Present Illness, the phy-
sician’s retelling of that story to the patient in a medicalized form, the
negotiation of a diagnosis, the negotiation of a treatment plan, and, as we
argue more fully in chapter 3, some sense of the patient’s “chief concern” (on
which the negotiations are based). For the majority of physicians who prac-
tice medicine, at least in the Western world, the practice can be said to be
primarily narrative in nature. This is because the most common task of the
physician is eliciting stories—­interviewing, negotiating with, or teaching—­a
patient. It has been estimated that most physicians will perform this task
around two hundred thousand times in a career (Lipkin 1995: vii). Interview-
ing, discussing, listening, and teaching all involve narratives. The patient tells
the physician a story, one that represents why he made the appointment or
the essence of how he is suffering, his “chief complaint.” Medicine has come

38  /  the chief concern of medicine

to formally describe this story as the History of Present Illness, or HPI. In
addition, the patient and the physician may discuss a diagnosis or treatment
through narratives concerning why the patient should participate in a certain
therapy or why the patient is skeptical about that therapy. The physician may
be attempting to teach the patient or her family enough about her particular
illness to get informed consent to treat or perform diagnostic tests. A final
story that is implicit in the HPI—­we argue throughout this book that it ought
to be a formal explicit element of the History and Physical Exam—­is that of
the patient’s “chief concern”: what worries or concerns her most about the
situation of illness that brings her to the physician. This book examines how
such a narrative should form part of the therapeutic action that the patient
and physician undertake together.
These stories function the same way all stories do: as we argue in the fol-
lowing chapters, their functioning is based on a small number of salient fea-
tures of narrative—­the schema of narrative—­that human beings seem to
possess and use “naturally” in making cognitive sense of their personal and
shared experiences. Stories or narratives, then, are designed to communicate
plot (sequences of events, including time frames), characters (including mo-
tives for action), and often an “unsaid” message or point as well as the one
clearly verbally articulated. They also always have a teller and a listener, a fact
that is so obvious it is hardly noticed but that is of crucial importance to the
patient-­physician relationship (in which these roles often reverse themselves
as one or the other becomes the teller). Finally, as we mentioned in chapter
3, narrative always has a witness who learns from the story, which is another
crucial factor in the patient-­physician relationship. By definition, patient nar-
ratives are singular, as Charon notes (they refer to the experience of one
singular patient’s suffering), but their structures are shared and universal and
give rise to a category of knowledge about the patient’s illness that we define
as “narrative knowledge.” We examine the nature and structure of that
knowledge—­its teachability—­in general terms in the following two chapters
and in terms particular to practices of medicine in Parts 2 and 3 of this book,
particularly in chapter 8. This knowledge is understood using a vocabulary
different from the vocabularies used to describe the science underlying the
illness as it is finally diagnosed, whether it be the mathematical and quantifi-
able vocabulary based on the model of mathematical physics or the more or
less historical vocabulary of evolutionary biology, concerned with means and
ends. The vocabularies used to express the physician’s understanding of the
final diagnosis can be categorized as a biomedical vocabulary reflecting a
“biomedical knowledge.” Biomedical knowledge is general and is usually un-

The Functional Realism of Medicine  /  39

derstood to be, at least in its ideal form, objective and value-­neutral, that is,
not affected by the time and place of its apprehension or the “knower” who
grasps its “truth.” In this, it employs a vocabulary of necessary and sufficient
truths, while narrative knowledge organizes itself in terms of necessary but
not sufficient truths. The necessary but not sufficient nature of narrative
knowledge means, as Francis Steen has argued, that while such knowledge
has necessary structures and abstract features, the sufficient details of a nar-
rative “vary from individual to individual” (2005: 89).5
Two additional ways of understanding the difference in these two vo-
cabularies is that narrative vocabulary describes a phenomenon—­ the
story—­in which the whole is greater than the sum of its parts, while bio-
medical vocabulary is used to tell a story where the whole is equal to the sum
of its parts. Lastly, biomedical knowledge, being general in nature—­that is,
“commensurable” across different particular cases—­can be used to quanti-
tate characteristics of diseases. Gall bladder disease due to stones can be
counted as “commensurable” with other cases of gall bladder disease caused
by stones. This can occur, of course, only after the diagnosis has been con-
firmed. The stories that comprise narrative knowledge are difficult to relate
to one another in the same quantitative and commensurable manner, be-
cause they reflect a “subjective” or individual experience—­by definition, an
experience not “commensurable” with other experiences—­and are prelimi-
nary to the final diagnosis. Even so, the roles of the limited number of agents
or characters or narrative genres can be related to one another and grasped
as necessary but not sufficient—­and thus not quantifiable—­schemas that aid
in self-­consciously recognizing narrative knowledge. The stories that patients
tell, like all narratives, contain—­and are based on—­“general” as well as spe-
cific knowledges. Most important, these stories are the most valuable infor-
mation used in the abductive process of making a diagnosis in the first place.
It is our position that the vocabularies of both categories of knowledge—­the
nomological knowledge of evidence-­ based medicine and the narrative
knowledge of schema-­based medicine—­reflect a functional reality and that
both are essential to the making of a final medical diagnosis. (The historical
knowledge of evolutionary biology, which we are hardly considering here,
plays a lesser role in medical practice, though it is sometimes a model for the
etiological understanding of a particular condition and functions within the
working of the logic of diagnosis.) They are also both essential to effective
communication between the professional who possesses biomedical vocabu-
lary and knowledge and the patient who does not.
The term narrative medicine is also meant, by Charon and others who

40  /  the chief concern of medicine

use it (including ourselves), to encompass an endeavor whereby the formal
narrative discourses of literature, poems, short stories, novels, and
ethnography—­what we are calling “art” narratives—­are used to explore and
understand what takes place in doctoring in the clinical sense. Behind this
use, often not explicitly considered, is the fact, which we already mentioned,
that all narratives, from the naive and sometimes seemingly incoherent state-
ments of frightened patients to the elaborate structures of much-­
contemplated art narratives, share schematic structures and that students
and physicians can come to more fully understand the order of narrative
knowledge by studying the more sophisticated narrative forms of art. More-
over, literary narratives, as we note in chapter 9, more fully realize and em-
phasize the vicarious experience to which narrative in general gives rise. Is-
sues narrative medicine emphasizes include the patient-­ physician
relationship, understanding the patient’s story, development of empathy, and
creating solidarity between patient and physician. All of these issues are
taken up in Part 2 of The Chief Concern of Medicine, in the context of the
aspects of the functional realism of narrative knowledge described in Part 1:
the systematic technē (or “methodical skill”) of Aristotle’s conception of ph-
ronesis as the practical reasoning of clinical medicine (chapter 2), the narra-
tive structure of medical phronesis (chapter 3), and the logic of diagnosis
(chapter 4).

The Crisis of the Sciences and Overcoming the Mirror of Nature

Of central importance in our presentation of practical, functional realism in

medicine is the relationship between the natural sciences and the humani-
ties. (We touch on this in appendix 1.) While the progress of the former has
advanced medicine by leaps and bounds since the seventeenth century, med-
ical practice belongs to the latter. Medicine is an interpersonal, humane, and
moral enterprise at its core. (The morality of medicine leads us to Aristotle’s
contemplation of the “practical reason” of moral action that we examine in
the next chapter.) K. M. Hunter expressed this when she wrote that medi-
cine is better characterized as a “moral knowing, a narrative, interpretive,
practical reasoning” (cited in Greenhalgh and Hurwitz 1999: 49). However,
the medical establishment as a whole is not self-­conscious in its need of a
theory of narrative interpretation. In fact, that the proposition that medicine
is, first of all, “moral knowing” might sound exceptional is itself an extraordi-
nary example of what Edmund Husserl called “the crisis of the sciences” in

The Functional Realism of Medicine  /  41

the early twentieth century (1970). The phenomenon Husserl bemoaned
was an inversion of the order of our experience in science. The purpose in
advancing natural science emerged from human needs and concerns, much
as the purpose of advancing medical science emerged from the need of al-
leviating human suffering. However, if we allow the results of science to
harden into free-­floating propositions taken as first-­order “truths” about the
world, we, at the least, run the risk of misplacing concreteness on the ab-
stractions of scientific investigation (Whitehead 1967: 51)—­to replace the
particularity of phenomenal (everyday) experiences with the commensura-
bility necessary to nomological science.6 Moreover, at worst, we run the risk
of serving science while forgetting that science should serve humanity. This
inverted relationship between human concerns and scientific results can lead
us to diminish the importance of qualitative and affective human experience.
When this takes place in the clinic, the patients’ individual experience and
concern can be discounted or even ignored. Ignoring patient narratives, such
as a narrative of abuse (as we noted in the narrative of the young mother in
the introduction), can border on the inhumane and also hinder proper diag-
noses, where the narratively competent clinician attends to patient narratives
in service of the diagnostic process.
The aspiration of narrative medicine reflects Husserl’s goal to illuminate,
animate, and integrate the sciences into the spiritual “nexus” of humanity
(2001: 5–6)—­by which he also hopes to reveal the failure of the pretension
of the sciences—­so that we become better and wiser through them. (The
very learning from mistakes—­truly a form of experiential “particularity” that
gives rise to checklists, as Atul Gawande has argued [2010]—­is part and par-
cel of narrative medicine.) Narrative medicine holds dear the purpose of the
practice of medicine, the solving of human problems and the alleviation of
human suffering, though it does not abandon (or wish to abandon) the bio-
medical knowledge of the natural sciences. Trisha Greenhalgh notes the
“dissonance” between the “science” of objective measurement and the “art”
of clinical proficiency and judgment. She tells us, quite rightly, that “science
is concerned with the formulation and attempted falsification of hypotheses
using reproducible methods that allow the construction of generalizable
statements about how the universe behaves” (such generalization, as we have
already noted, is the “commensurability” of science). However, as Green-
halgh adds, the training of a doctor in science relies on the “tenuous assump-
tion” that the diagnostic process follows the protocol of scientific inquiry
(1999: 323). In the course of our discussion of the reality of scientific con-
cepts in this chapter, we will illustrate why this assumption is misguided. The

42  /  the chief concern of medicine

assumption treats abstract conclusions of genuine scientific inquiry as con-
crete and commonly dismisses the affective dimensions of concrete
experience—­the very concern of patients we are emphasizing—­as peripheral
or inessential to the diagnosis. (Even when the affective is not dismissed, it is
often so devalued as useless or peripheral that possible skills in absorbing
and interpreting it are not developed in school or in practice.) Calling the
conclusions of scientific investigation “abstract,” however, does not dismiss
them as somehow misguided. These conclusions are powerful, necessary in-
struments used in the successful practice of medicine. But we should not
forget the order of the experience of the patient, which begins in concrete
experience, even if it may, through a medically scientific inquiry, result in an
abstract instrument that is helpful to the doctor negotiating a final diagnosis
and treatment plan. Greenhalgh, too, reminds us of the fallacy of misplaced
concreteness, the mistake of taking summary statistics (the abstract conclu-
sions of scientific inquiry) as hard realities (1999: 324). The hard reality is the
affective experiences of the patient given in her history in the form of narra-
tive, as in the case study we presented in the introduction. How did it come
about that such affective concern could be dismissed as unimportant (a
“crock”), and how have we failed to inquire into the need for interpretive
strategies whose narrative analysis attends to such realities and broadens
both research and practice in clinical medicine? Could it be that the resis-
tance to narrative medicine by the profession—­medical school curriculum
committees, practicing physicians, and professional institutions designing
standardized practices and protocols, among others—­evokes an inversion of
the relationship of the sciences to the humanities? Explaining the emergence
of such an inversion will enable us to disclose the proper conceptual model
we offer as its antidote.
Since Descartes and Newton—­the inventors of mathematical physics—­
the aspiration of philosophy was to establish knowledge claims with such
certainty as to ground the new science on a firm foundation. The most thor-
ough and uncompromising extension of this pursuit and quest for certainty
came with the Vienna Circle’s logical positivists in the 1920s. Inspired by
Bertrand Russell and G. E. Moore, these philosophers, including Rudolph
Carnap, preoccupied with theoretical physics and symbolic logic, concerned
themselves primarily with analysis and clarification of meaning, with the pri-
mary goal of unifying the sciences and providing an account of their opera-
tion (see West 1989: 183). The enterprise of logical positivism assumed a
form of sentential atomism, which correlated isolated sentences with their
empirical confirmation by science or with their logical necessity.7 This is of

The Functional Realism of Medicine  /  43

the utmost importance for our discussion of narrative knowledge, here and
in the following pages, because narrative can be described as meaningful
discourse beyond the confines of the sentence. For the logical positivists,
however, truth-­value was situated within isolated sentences, so that the truth-­
value of synthetic propositions (propositions about “facts” in the world) was
judged by the court of empirical observation and the scientific method of
mathematical physics, while the truth-­value of analytic statements (the self-­
consistent meaning of general concepts) was judged by the court of logic.
Sentences regarding ethics, art, or religion—­and especially series of sen-
tences that gathered up the meaning or “point” insofar as their collective
whole was greater than the sum of their parts—­corresponded to what looked
like the fictional trash heap of emotion. Medicine had already been co-­opted
by quantitative natural science; the more or less “scientific” structures of
present-­day medical education were developed in the generation before the
logical positivists. Now philosophy, the discipline that seeks to generalize the
various modes of inquiry and, particularly, the various “vocabularies” used to
comprehend experience and reality, was also co-­opted by quantitative sci-
ence. The logical positivists conceived of ordinary experience as shot through
with affectivity and “messiness,” since they believed that the only “real” pre-
cision was the correspondence of element to element in sense experience
and vocabularies of understanding. For this reason, they attempted to re-
duce experience to sense-­data pure and simple, without considering the pos-
sibility that sense-­data might be conditioned by evolutionarily inherited cog-
nitive formations, including cognitive formations of “narrative knowledge.”8
Such reduction translated sentences about physical objects into sentences
about actual and possible sensations.
The reductionism and the dichotomous thinking of the positivists have
had a pervasive and often detrimental legacy. We suspect that the bias against
the putative “softness” of narrative medicine tacitly relies on some of the di-
chotomies erected by the positivists’ project of grounding the natural sci-
ences. An implicit separation of scientifically verifiable claims from qualita-
tive and affective narratives—­ the very concern embedded in patient
narratives—­enables a medical clinician to discount patient experience and
enables committees determining medical school curriculum and institutional
procedures and protocols to discount narrative medicine as imprecise and
haphazard. But by defending narrative medicine, we argue that medical
practice should become more empirical, rather than less; that is, clinical
medical practice should attend to patient experience and concern in a thor-
oughgoing and systematic way, not a reductive way. Inquiry, including diag-

44  /  the chief concern of medicine

nostic practice in the clinic, should begin in the lived experience of the pa-
tient, his “chief concern” as well as his “chief complaint.” A thoroughgoing
empiricism attends to experience as it is experienced, in which case “things—­
anything and everything—­ . . . are what they are experienced as” (Dewey
1900b: 158). Concrete experience as experienced contains the basis for and
clues to its own intellectual refinement, and the understanding and engage-
ment of that experience, as we argue in the following chapters, can be aided
by the self-­conscious understanding of the necessary but not sufficient forms
of its expression beyond the confines of particular sentences in narrative. As
schema theory suggests, “experience” is not immediately given—­ simple
“data”—­but mediated through structures and categories of knowledge that
facilitate understanding and engagement.
The nonreductive empirical method appropriate to the medical clinic
was best articulated by John Dewey’s instrumentalism, naturalism, and prag-
matism and, significantly, by his evolutionary thinking. Dewey articulated the
same crisis of the sciences as Husserl, in different terms. (In the ancient
world, Aristotle did so as well, but again, as we see in the next chapter, in very
different terms that particularly call on the practices of medicine.) According
to Dewey, inquiry begins with the felt immediacy of experience and includes
the qualities of experience as constituent parts of the world. But he differen-
tiates immediate apprehension of qualitative experience from knowledge of
the world. For Dewey, knowledge is always the end of inquiry, not the begin-
ning. Mistaking warranted assertions about the world (his fallible substitute
for the purported “absolute” true knowledge claims the positivists pursued)
for immediate experience was the “philosopher’s fallacy.” Thus the warranted
assertion of the existence of gravity does not explain—­or explain away—­our
felt sense of rootedness in the world.
At this point, we might remind ourselves that narrative medicine begins
with the narrative experience of the patient. Such descriptive accounts are
qualitative, affective, and particular (even while they share salient features).
They are not atomized units reducible to truth-­values by scientific observa-
tion or logic, nor are they veils covering their scientific explanation (e.g., the
“veil” of rootedness covering the “fact” of gravity). Rather, they are narrative
accounts, statements about the world that exceed the limits of a sentence;
their form, as A. J. Greimas has argued, is “neither pure contiguity nor a
logical implication” (1983: 244). Taking these qualitative accounts of experi-
ence as primary, not secondary, reorders the relationship between the hu-
man and natural sciences with which we began this section. That these ac-
counts might lead to scientific inquiries, which terminate in warranted

The Functional Realism of Medicine  /  45

assertions about the relationship of pathophysiology to the experience of the
patient, speaks to the virtue of narrative medicine. The use of schemas of
narrative—­often most clearly discernible in literary texts—­is another tool
that can bridge the gap between patients’ stories and scientific inquiry. Nar-
rative medicine, therefore, draws a pragmatic continuity among inquiries,
refusing to sever facts from values needlessly.
However, the integration of facts and values in the fields of medicine
poses a challenge to the medical establishment if such an integration is seen
to infringe on medicine’s positive scientific ideals. George Khushf describes
such ideals in what is a strong articulation of the assumptions of evidence-­
based medicine: “in modern medicine it is assumed that clinical practice
should be established on medical science, largely regarded as a value neutral
base of knowledge that is independent of individual and social commit-
ments” (1998: 99). Yet narrative medicine and the schema-­based medicine
we describe here strive to maintain the integrity of medical science’s ideals
without distorting the order of our experience. The nonreductionism of the
empirical method we are defending still retains—­indeed, initiates and builds
on—­the integrity of the scientific method. However, we want to ensure that
such a method is thoroughgoing and pervasive, eschewing any dogmatism
that would forestall other modes of inquiry, such as the inclusion of narrative
education within medical training and of the schemas of the human sciences
within the practices and protocols of medical care.
A return to Dewey’s philosophy of language will allow us to explain the
emergence of the reductionism and dichotomous thinking (e.g., “hard” vs.
“soft” science) that, we believe, often create obstacles to optimal medical
care. Dewey wrote that the “inescapable trait of every human concern” is our
interaction with our biological and cultural environments (1900a: 1.324).
Language, thinking, knowledge, and reason are not exempt from this trait.
Dewey explained that our use of language and our reasoning is a process, a
method, and that our thinking and knowledge are modes of interaction with
nature, of whose energy systems we compose a part (1900a: 1.324–­25). How-
ever, certain dominant trends in the history of Western thinking have con-
verted the product of our successful interaction with our environment, espe-
cially our linguistic interaction, into a supposed ontological ground of the
structure of that environment (this is the philosopher’s fallacy previously
described). According to Dewey, this process began with the Greek tendency
to take the structure of discourse to be the structure of things, instead of the
form that things assume under the pressure and opportunity of social coop-
eration, interaction, and exchange (1.135). That fallacious tendency culmi-

46  /  the chief concern of medicine

nated in the logical positivism that we have described and that, in some de-
gree, grounds “scientific” medicine. Dewey argues that this entire tradition
failed to see that meanings, as objects of thought, are the outcome of a com-
plex history of inquiry, social interaction, and purposeful use (1.135).
Perhaps the most revolutionary and seductive critique of this failure in
academic philosophy in the twentieth century—­an academic philosophy that
often conditioned or justified the shortsightedness of practicing scientists—­
was Richard Rorty’s Philosophy and the Mirror of Nature (1979). In this
book, Rorty employs Dewey’s pragmatism, among other tools, to topple the
presumption that nature speaks the language of science, calling for an end to
philosophy’s task of mirroring nature in mental representation and language.
He showed that observation was so theory-­laden (i.e., laden with unexam-
ined assumptions) that truth claims about the world by appeal to the world
itself were bound to be circular. Rorty is a thoroughgoing antirealist—­he
opposes the philosophical conception that particular ideas and concepts de-
scribe the “real” world and are “real” themselves—­and understanding his
antirealism allows us to present a different conceptual mode, a “Peircean
realism,” that defends narrative medicine and the “practical reasoning” of
the schema-­based medicine we describe. Rorty, as well as the pragmatists for
whom he thought he spoke, viewed language, including narrative and scien-
tific vocabularies, as thoroughly instrumental. These vocabularies are tools
we use to solve problems and make the world as we hope it will be. This
pragmatic theory of language is fully evolutionary and temporal. This is of
the utmost importance, because if our languages are fully instrumental and
evolutionary products of our interaction with our environment, then the test
for which language a doctor should (in a particular case) employ in diagnos-
ing a patient is consequential, rather than theoretical: it is, as we argue in the
following chapters, best conceived in terms of action rather than concepts.
Precisely this sense of consequential action ties the behavior of physicians to
Aristotle’s notion of phronesis; it is why he chose physicians as a chief exam-
ple of his “practical reasoning.” We should measure the use of a given sche-
matic language, whether fictional narrative or natural science, by its effects.
In fact, the preference for biomedical knowledge over narrative competence
by the medical profession in its schools, practices, and protocols is a tacit
(i.e., not philosophically articulated) demonstration that the medical estab-
lishment itself is already pragmatic (i.e., consequentialist) in its test for
meaning and truth. Evidence-­based medicine has won the day in medicine
simply because it works better at achieving many of medicine’s goals; that is,
the effects of science, the production of technologies and medical

The Functional Realism of Medicine  /  47

treatments—­ not the theoretical conceptions about science—­ exhibit the
meaning and reality of science. This is absolutely true of the “science” of
medicine on a daily basis. Therefore, for a moment here, we will look at the
effects of narrative medicine. Later, in discussing the “practical reason” of
narrative in chapters 2 and 3, in addressing the logic of diagnosis in chapter
4, and in detailed examinations of the relationship between literature and
medicine in Part 2 of this book, we will continue the pragmatic, practical
focus on narrative within medical practices, culminating in the presentation
of schema-­based medicine in Part 3.

Science and Literature in the Practice of Medicine

In traditional medical education, the student is presented with the biomedi-

cal information needed to understand diseases as we currently understand
them. This is knowledge obtained by using the scientific method of valida-
tion through experiment, or evidence-­based medicine. It uses a specific vo-
cabulary to describe universals we understand as diseases. There is much
uncertainty in the way we understand these universals. Nonetheless, we
must have a way of discussing and categorizing them, so that we can act on
them. The student will also be taught to elicit the patient’s story and to use
the information from the story to decide which anatomical site to examine
closely and which tests to perform. The way in which students are taught to
elicit the story varies among medical schools, but all schools provide students
with a uniform manner of categorizing the information. As mentioned earlier
in this chapter, how well the patient’s story is elicited and apprehended by
the doctor determines, to a remarkable extent, the efficiency and accuracy of
the diagnosis and, therefore, of the treatment. It follows that medical stu-
dents and their patients will be well served by physicians becoming compe-
tent at apprehending stories—­a skill that takes its place in overall medical
competence. This skill in narrative knowledge confronts a vocabulary that is
particular and unique—­the patient’s story—­yet describes something that is
real. It is the reality as experienced by the subject—­the patient—­who is re-
lating the story. In chapter 3, we explore more fully the important aspect of
this experienced reality, the patient’s “chief concern” (that includes, as it
must, the patient’s “chief complaint”). It is our contention that training stu-
dents with the engagement of narrative in various forms (short stories, nov-
els, poetry, drama, and film, among others) will provide the medical learner
with appropriate schemas through which he can more fully understand pa-

48  /  the chief concern of medicine

tient stories. (By “more fully,” we mean in greater detail and precision, in-
cluding implicit as well as explicit detail.) This process is not unlike the pro-
cess in literary courses—­close reading, reflective writing, and discussion.
These practices, like practicing sports or performing music—­or, for that mat-
ter, performing surgery—­allow the formation of more or less habitual behav-
ior and cognitive patterns, which reveal the schema of performance patterns
that can be discerned and understood on their own and which also lend
themselves to algorithms of recognition and behavior. Narrative compe-
tence, as we argue in the next chapters, is a technē—­what we are translating
as a “methodical skill”—­that is teachable, precise, and concerned with expla-
nation. The acquisition of this competence, like the acquisition of biomedical
knowledge, will aid the physician in most areas of her practice—­including
making the diagnosis, communicating with patient and family, and under-
standing and habitually enacting the ethics of everyday practice.
The chapters of Part 2 of The Chief Concern of Medicine present numer-
ous examples of how the study of literary narratives—­and the schemas of
narrative more generally—­can be used in the service of educating the doctor.
As we shall see, these texts are exemplary in their provocation of “vicarious”
experience, in their presentation of the salient features of narrative, and in
the ways they lend themselves to the development of the usefulness of sche-
mas in the practice of medicine. Texts that focus on practices of medicine
also instantiate and demonstrate how narrative competence leads to effective
outcomes in situations where simply applying the doctor’s biomedical vo-
cabulary would most likely have failed. Most important, these narratives—­
like the scientific narratives of evolutionary biology—­do not lend themselves
to quantification or quantitative evaluation. Neither does the narrative skill
the physician must use to effectively practice medicine—­to achieve the
“practical wisdom” of a phronimos—­lend itself to mathematical analysis.

Peircean Realism in Medical Practice

As we suggested earlier, not every pragmatist is as radical as Rorty, and some

are thoroughgoing realists, arguing at length against the antirealism that
Rorty unabashedly exhibits. While Rorty holds that ideas, concepts, and laws
are merely fleeting products of convention, each only an arbitrary and con-
tingent name for a particular fact or event, pragmatic realists hold that ideas,
concepts, and laws are real. Rorty was a self-­titled nominalist. Nominalism
holds that ideas, concepts, and laws are merely fleeting products of conven-

The Functional Realism of Medicine  /  49

tion, each only an arbitrary and contingent name for a particular fact or event
that could, in fact, be named or configured in a different manner. Realism
holds that ideas, concepts, and laws are real. Our argument is that the con-
cepts and law-­like scientific relations of biomedical knowledge as well as the
concepts and relational norms (schemas) found in narrative are both conven-
tional and real. The combination of conventionality and reality produces the
“fallibilism”—­the provisionality—­of schemas, which we described in the
introduction. Our recourse to the classical pragmatists, Charles Sanders
Peirce and John Dewey, will enable us to defend the functional reality of
these concepts. For Peirce—­the focus of chapter 4 and the self-­proclaimed
initiator of philosophical pragmatism—­the concept of the real is internally
related to his theory of inquiry. Inquiry begins with a living doubt, and as a
response to such a doubt, we inquire. Our inquiry begins in hypothesis and
arrives at belief by way of inference. For Pierce, once we acquire a belief, we
are no longer in doubt, because beliefs are habits of action.9 Because the
whole of the meaning of a concept is found in its effects or, in Aristotle, its
“ends,” the meaning of a belief is found in our habits of acting on it. Peirce
even argues that belief is simply habit made conscious. In this way, belief or
the habitual acting (often unconsciously or at least unreflectingly) on a belief
does not involve doubt.
For Peirce, humans are inquiring animals who, at any given moment, are
in possession of information or cognitions that have been logically derived by
induction and hypothesis from previous cognitions (experience), and the
process of inference proceeds from the less general and the less lively to the
more distinct, vivid, and general. Pierce identifies two sorts of these cogni-
tions in us, the true and the untrue, whose objects correspond to the real and
the unreal (1992: 52). The real is a conception that we find upon our discov-
ery of error and illusion, and the real presents itself when we correct our-
selves. According to Pierce, this difference calls for a distinction between
those things relative to “private, inward determinations” and those things
independent of individual idiosyncrasies (52). The test for such indepen-
dence is the progress of the community of inquiry, whose indefinite increase
in knowledge will reaffirm the concept of the real. As Pierce explains, that
which we think in a given cognition, whose falsity cannot be discovered, con-
tains no error, and thus the object of that thought is the real (52). Nothing
prevents our inquiry from knowing outward things as they really are. How-
ever, although we do know things as they really are in many cases, we cannot
be absolutely certain of knowing things as they really are in any particular
case. The concept of the real, then, is a regulative ideal, which presents to us

50  /  the chief concern of medicine

truth that is necessary but never absolutely “sufficient.”10 Still, such a con-
cept of the real governs our community of inquiry, and our community af-
firms and finds it by the self-­correcting method of scientific inquiry. As this
suggests, such scientific inquiry does not necessarily entail only quantifiable
(or “formulaic”) vocabularies.
The quest for certainty—­that is, for necessary and sufficient truth—­led
Descartes, as well as the scientific tradition he helped to establish, to privi-
lege the vocabulary of mathematics and mathematic physics. That we can-
not, with absolute certainty, determine our knowledge of the real in any par-
ticular case speaks to the fallibilism of science conceived in the pragmatic
tradition. In that tradition, as Peirce asserts, “fallibilism” denies intuitive or
certain knowledge, even of common-­sense propositions. The myth of mod-
ern philosophy from Descartes through Kant was the quest for certainty. But
the pragmatists conceived science as capable both of making mistakes and of
self-­correction. Moreover, fallibilism leads to further consequences, which
turn the nominalists’ attack on the realists on its head. The nominalists held
that the scholastic realism of the Middle Ages was a belief in true “real” exis-
tence of metaphysical fictions. But realism, according to Peirce, lays claim to
more knowledge than knowledge of true representations; it entails the
knowledge embodied in pragmatic results. Nominalists hold that our general
concepts, such as human, do represent and apply to some human object, but
they hold that general concepts rely on their particular objects for their
merely nominal, historical, and conventional being and that there is thus no
existent (“real”) concept as such. Rorty is an antiessentialist in this manner.
His project is to illustrate the failure of any attempts to cut nature “at the
joints” (see Rorty 1985) by positing to nature what Peirce calls an “incog-
nizable” substructure—­something that fallibilism suggests cannot be named
accurately and once and for all—­from “God” to “substance,” “matter,” and
“atoms.” However, since the nominalist holds that there is no human without
a particular human, she takes the generality out of generals and, by turning
general concepts into particulars, both needlessly isolates them and utterly
enfeebles their ability to govern the future. (As we noted earlier, Peirce
claims that the function of meaningful symbols is to establish “the being of
law that will govern the future” [1931–­58: 1.23].)11 Because science does
produce effects that resolve our doubts, we infer that those laws it hypothe-
sizes and discovers are both real and real in their generality, even though we
cannot be absolutely certain that such laws explain things as they really are in
any particular case. In other words, these effects describe conditions that are
necessary but not absolutely sufficient.

The Functional Realism of Medicine  /  51

 Scientists—­and, in this regard, the quintessential “scientists” of medical
care—­are always in the middle of inquiry and its inferences, and they want
to know the effects that general conceptions, such as scientific laws, will have
on the future. A recognizable biomedical example is the measurement of
oxygen content of arterial blood. Following experiment and observation, it
has been determined that when the oxygen content of arterial blood falls
below 40–­50 percent, catastrophic outcomes can be expected in the brain
(stroke) or the heart (myocardial infarction). Thus these biomedical observa-
tions accurately predict the future. In this way, then, science does produce
effects that resolve our doubts, and, in fact, those laws it hypothesizes and
discovers—­which, in the vocabulary we develop in chapter 4, it abduces and
induces—­are both real and, most important, real in their generality. But
science—­whether it be the formulas of mathematical physics, the explana-
tions of historical evolutionary biology, or the speculations of hypothesizing
semiotics—­always is negotiating the relationship between the particular and
the general, the present moment and the future. Medicine—­as we have said,
perhaps more fully than other sciences insofar as its formulations, explana-
tions, and speculations imbue every aspect of its practices—­might well be, in
this sense, the most pragmatic of the sciences.
For pragmatic realists, such as Peirce, ideas, concepts, and laws, from
justice to the law of gravity, are real; they are not particulars, nor are they
static and fixed, nor do they have strict edges. (In this, again, they are neces-
sary but not fully sufficient.) Categories, from male and Caucasian to hypo-
glycemic, are not merely names of sets of particulars, not merely nominal
designations. But neither are they atemporal Platonic realities in which male
excludes female, Caucasian excludes Latino, unprovoked hypoglycemic ex-
cludes diabetic. These categories evolve, have vague and fuzzy borders, and
participate in what we describe in the next chapters, following Aristotle, as
“general accountings.” (As we see in the next chapter, Aristotle, like the
pragmatists—­and like the accomplished medical practitioner—­is anxious to
discover or negotiate the precise functional meanings of “vague” concepts.)
The reality of these categories—­ideas, concepts, and laws, from justice to the
law of gravity—­inheres in the consequences of their function. Although male
includes the elements of its social construction, male is a real category, be-
cause it governs the future as a general law, partly determining the function
of the object described, for instance, socially privileged with certain biologi-
cal features and functions.
What is at stake in these general philosophical observations is the efficacy
of a given mode of inquiry in resolving doubt. More specifically, we want to

52  /  the chief concern of medicine

determine and validate the use of narrative—­narrative phronesis in under-
standing and acting on the plight and concern of patients, the narrative im-
pulse in the logic of diagnosis, and narrative knowledge in the everyday prac-
tices of medicine—­in helping provide the conditions that enable a clinician
to help solve a patient’s problem. Thus we must conceive of the problems
described, in their qualitative thickness of concern, to be in relation to a par-
ticular general physiological description of the factors contributing to those
problems. Second, we must conceive of the doctor’s process of inquiry as a
form of interaction with his environment and thus in relation to it. The tools
of relating to the environment include language and the cognitive power of
narrative understanding, and environment includes both the qualities of the
suffering patient and the description of that suffering to the doctor in the
clinic. If the use of narrative schemas improves the ability of the doctor to
empathize with the patient’s discursive context and opens that doctor up to
possibilities whose realization—­ whose “abduction”—­ would otherwise be
forestalled, not only are the tools of comprehending narrative schemas valid
pragmatically, but the ideas therein are robustly real, governing future rela-
tions. If the use of narrative analysis enables a doctor to hypothesize a viable
diagnosis by relating the qualitative description of the ailment to the general
malady governing it, the schemas of narrative analysis are real as well, also
governing the future. Dismissing the use of narrative schemas and narrative
analysis in medical education or practice enacts the nominalist fallacy. Such
a dismissal asks the question, why would reading this particular (“singular”)
novel with these particular characters be of help in diagnosing a particular
disease? Such dismissal rejects a set of tools available to the doctor to turn
general lessons and analytic strategies into particular useful diagnoses and
therapies. If such lessons were mere particulars, they would not have any
strategies to teach or any relation to the reader—­they would not embody and
present the technē of science, craft, and art. They would be fleeting, fictional,
and idiosyncratic vagaries in the mind of the author and thus would be ut-
terly impotent. However, such lessons, as we argue in the next two chapters,
are the lessons of experience, the lessons of phronesis, the lessons of narra-
tive; and they are everywhere demonstrated in the accomplished work of
seasoned physicians.
Is the possibility of learning from experience—­including the “vicarious”
experience provoked by narrative—­simply a function of the nature of lan-
guage, whether literary or scientific, or is there a reality to the concepts rep-
resented in the languages of science and literature? Answering this question
means not only thinking of the general as the “law that will govern the future,”

The Functional Realism of Medicine  /  53

as Peirce does, but thinking relationally and transactionally, with Dewey: this
is what we mean, in chapter 3, by thinking with deliberation. Separating the
individual from his environment distorts the relationship between the lan-
guage he uses and the natural interaction with the environment that both
gives rise to the need of that language and illustrates the effects of its use.
Ignoring the interaction between the individual and her environment treats
the world of inner experience as independent of social products and opera-
tions of language (including the narrative operations of language). But Dewey,
like later students of cognitive evolution we cite in the following chapter,
treats language as a natural function of human association; and the conse-
quences of language react on other events, physical and human, giving them
meaning or significance (1967–­90: 1.137). Dewey treats inquiry of all sorts as
an interaction between elements of human nature and the social and natural
environments. For Dewey, moral and scientific concepts are both conven-
tional and real. Our moral and scientific concepts and solutions emerge natu-
rally in our social settings and in our interactions with problematic situations.
However, that these moral and scientific concepts and solutions are con-
ventional does not mean that they are only nominal. Nominalism, as we have
seen, views the name as an expression of a ready-­made, exclusively individ-
ual, mental state, sensation, image, or feeling, which, simply by existing, is
necessarily particular. But for Peirce and Dewey, concepts are modes of so-
cial interaction, means to achieve the ends of association and interaction.
Meaning arises from use in a community of action. Nominalism—­like the
logical positivism we mentioned earlier—­ignores the organization, the prod-
uct of natural interaction, which gives character to language. For pragmatists
like Peirce and Dewey, language is relational, not particular (Dewey 1967–­
90: 1.145). The reality of the moral concepts of trustworthiness, discern-
ment, or conscientiousness, for instance—­all virtues, we argue in chapter 9,
that inhabit the practices of the “practically wise” physician—­is not under-
mined by the fact that these concepts have their origins in social convention.
(That some of these virtues, such as trustworthiness, decency, and compas-
sion, might have their origin in evolutionary adaptation for our highly social
species only underlines the pragmatics and, as Rorty says, the “contingency”
of their reality.) Rather, the consequences that ensue from the social prac-
tices of trustworthiness, discernment, and conscientiousness exhibit their
reality. Similarly, the reality of the law of gravity is not undermined by the
fact that its origins lie in Newton’s attempt to overcome Aristotelian and me-
dieval teleology, nor is the reality of natural selection undermined by the fact
that its origins lie in Malthusian economics, nor is the reality of semiotics and

54  /  the chief concern of medicine

information theory undermined by their appearance at the moment that in-
dustrial capitalism transformed itself into finance capitalism. Rather, think-
ing with Peirce, we consider their effects and shall know the whole of the
meaning of these concepts. Because of the continuity among inquiries, from
scientific to practical to moral, the tools we use should tend toward an ami-
able latitude and openness, not an insolent constraint and limitation. The
very progress of inquiry—­in general, but also for a particular patient talking
with her physician—­depends on such a liberality.
Further, since all inquiry begins in a feeling of irritation, often communi-
cated by the patient to her doctor in narrative form, the order of the norms
that govern our inquiry must be made explicit. For Peirce, logic provides the
norms, which guide our thinking. Our inquiries begin in a living doubt, which
motivates our search for a resolution to the irritation of that doubt.12 If our
inquiry is successful, it culminates in a belief. Our beliefs, such as successful
diagnoses, serve as resolutions to antecedent doubts, and they generate hab-
its of action. To the extent that they do not, we are still in doubt. But because
we assess the beliefs by their practical effects, the norms of logic are subor-
dinate to the norms of ethics, which provides the norms guiding our conduct.
This is because thinking, theorizing, scientifically experimenting, and diag-
nosing illnesses in the clinic are all kinds of practice, the very “action” that we
follow in Aristotle in subsequent chapters. Further, because our conduct al-
ways seeks a goal and serves a purpose (an “end”), the norms of ethics are
relative to the ideals we serve. Borrowing Peirce’s language, aesthetics is the
normative science of how we ought to feel.13 It is the science that guides our
feeling of admiration toward our ideals. Since the beginning and end of all
inquiry is a feeling, the inquiry of the medical community is and has always
been a human enterprise and a spiritual science. As we suggested in the in-
troduction, medicine ultimately serves the ideals of alleviating human suffer-
ing, coping with it, or, perhaps at best, promoting human well-­being. That we
forget these various definitions of health is our fallacy and our crisis. Being
mindful of them—­and, as we argue here, creating self-­conscious schemas
and protocols that promote habitual mindfulness—­are conditions for the
possibility of growth and progress in medical education and practice.

Conclusion

In this chapter, we have presented a pragmatic philosophical argument that

the human sciences in general and specifically the narrative organization of

The Functional Realism of Medicine  /  55

literary fiction represent real categories of knowledge—­as real as those of
evidence-­based medicine—­that are particularly useful in the practices of
medicine. Their reality inheres from the consequences they produce, which,
in medicine, provide a more profound and attuned relationship between a
physician and a patient, with a deeper engagement with the patient’s suffer-
ing on the part of both the physician and the patient, leading to the allevia-
tion of suffering, the restoration of well-­being, or simply ongoing care. Here,
we have argued, in the context of the philosophy of science and of the intel-
lectual practice of medicine, the vocabularies—­the knowledges—­in both the
human and natural sciences are necessary for the education and everyday
practices of the physician. In the next chapter, we more specifically argue for
the inclusion of the human sciences within a range of pragmatic understand-
ings of science and describe an evolutionary-­scientific argument—­based on
the combination of evidence and speculation—­for the adaptive reality of
narrative cognition in relation to Aristotle’s category of phronesis, or practical
reason, that can be discerned in the successful practices of medicine. In
chapter 3, we continue our Aristotelian inquiry in attempting a “general ac-
counting” of narrative and narrative knowledge, with the pragmatic end of
articulating narrative schemas and developing protocols and habits to con-
tribute to physicians’ successful engagement with patients. In the final chap-
ter of Part 1, we explore the practical functioning of such practical reasoning
in Peirce’s logic of hypothesis formation, a diagnostic technē. Like evolution-
ary biology, narrative medicine does not lend itself to quantitative analysis,
but it does situate itself among the science, craft, and art of medicine, the
very technē of what has been the most practical science from ancient times.
For that reason, we offer histories and narratives of medical practices in Part
2, and in Part 3 we articulate schemas growing out of them to make the prac-
tical consequences of those practices more effective.14

56  /  the chief concern of medicine

2
modalities of science
Narrative, Phronesis, and the Skills (Technē)
of Medicine

Near the beginning of the Nicomachean Ethics, Aristotle describes the na-
ture of practical reason, or phronesis, particularly in relation to action rather
than theoretical thought. “Since, then,” he writes,

the present inquiry does not aim at theoretical knowledge like the others (for
we are inquiring not in order to know what virtue is, but in order to become
good, since otherwise our inquiry would have been of no use), we must ex-
amine the nature of actions, namely how we ought to do them. . . . Now, that
we must act according to the right rule is a common principle and must be
assumed—­it will be discussed later, i.e. both what the right rule is, and how
it is related to the other virtues. But this must be agreed upon beforehand,
that the whole account of matters of conduct must be given in outline and
not precisely, as we said at the very beginning that the accounts we demand
must be in accordance with the subject-­matter; matters concerned with con-
duct and questions of what is good for us have no fixity, any more than mat-
ters of health. The general account [of practical reasoning] being of this na-
ture, the account of particular cases is yet more lacking in exactness; for they
do not fall under any art or precept but the agents themselves must in each
case consider what is appropriate to the occasion, as happens also in the art
of medicine or of navigation. (NE 2.2.1104a; trans. Ross)

Of crucial importance in this account is the fact it is focused on action rather

than knowledge, actions that make its agents achieve goodness in particular
behavior and in life more generally. Phronesis, or practical reasoning, is,

/  57  /
then, understanding that manifests itself in action, and it is no accident that
what Aristotle calls the “practical syllogism” of ethics—­which we examine
more closely in chapter 4—­concludes not with an abstract understanding but
with particular actions in the world.
Such an understanding, as Aristotle suggests in this passage, is closely
connected to practices of medicine, whose aims, after all, are not so much
the achievement of knowledge as action that realizes a certain pragmatic
result, namely, an imprecise or unfixed sense of “health” that can only be
grasped in “outline and not precisely,” simply because there can be no “fix-
ity” in understanding what good health always and only is. But even if there
is no fixity in understanding health, there is, as we noted in the introduction,
a range of pragmatic agreed-­on understandings of what we might mean by
health, whether it be the restoration of an earlier state of affairs before af-
fliction or illness, the achievement of an ideal of human physical and psycho-
logical potential, or simply the accomplishment of functioning in day-­to-­day
living in the face of affliction or illness. This range, as we see it (see also
Boyd 2000), exhausts (or all but exhausts) any reasonable working under-
standing of health. Moreover, while the particular actions of a physician—­in
concert with her patient—­might well not, in Aristotle’s terms, “fall under
any art [technē] or precept,” the range or scope of possible actions in relation
to illness and to the commitment to ill people seeking some useful and salu-
tary sense of health should, nevertheless, create more or less fixed criteria
for choice and engagement and, indeed, for a general account of practical
reasoning.
Toward the end of After Virtue, Alasdair MacIntyre describes Aristotle’s
conception of phronesis (practical reason) in relation to tradition that is re-
lated to several things that can help us understand the work of health care.
First of all, phronesis is concerned with the “ends” of action (something we
will return to), and for MacIntyre, tradition is the basis for the ethical ends
that morality in Aristotle both perceives (grasps) and pursues (Wall 2003:
321). Moreover, within medicine, the ends of action constitute a well-­defined
tradition that, as Edmund Pellegrino has argued, offers agreement on a
telos—­that is, “an end and a good”—­namely, “a healing relationship between
a health care professional and a patient, [in which] most would agree that the
primary end must be the good of the patient” (1995: 266). Such agreement
about medicine is more readily accepted than other ends and values in more
general considerations of morality.
In a second theme inherent in relation to tradition, phronesis is related to
any working definition of narrative. What practical reason most shares with

58  /  the chief concern of medicine

narrative is, of course, experience. Aristotle insists, Martha Nussbaum ar-
gues, “that practical wisdom . . . [achieves] insight through experience”
(1990: 68). Moreover, since the “end” of action is a central aspect both of
Aristotle’s conception of phronesis and of the structure of narrative as we
describe it here, it is altogether reasonable that they should be closely re-
lated. Thus, here and in the following chapter we particularly emphasize the
end that both narrative and phronesis develop. The “logic” of narrative is also
closely related to the logic of diagnosis, particularly in relation to the concep-
tion of abduction that Charles Sanders Peirce developed in the early twenti-
eth century, insofar as abduction offers a working-­out, often resulting in a
narrative, of Aristotle’s “practical syllogism.”
Finally, we hope to illustrate comprehensions of what we are describing
in The Chief Concern of Medicine as “humanistic understanding,” both in
terms of practical reason and, in this chapter, in relation to the systematic
understandings of science. In Nussbaum’s description, Aristotle contrasts
practical reason (phronesis) and theoretical or scientific reason (epistēmē),
rather than understanding that both can be systematically understood and
taught; and most commentators suggest that he also contrasts practical rea-
son and systematic reasoning skills (phronesis and technē).1 The science Ar-
istotle examines is “the theoretical study of nature,” with mathematics as his
defining example (Nussbaum 2001: 292), but if we also consider our modern
sense of evolutionary biology as well as mathematical physics, we can situate
the practical reasoning and humanistic understanding of both phronesis and
narrative knowledge as modalities of technē that systematically examine and
organize phenomena. This last theme, the humanistic understanding of
practical reason as systematic understanding, craft, or art, should, we hope,
tie together phronesis, medical practice, and narrative under the category of
technē (“science,” “craft,” and “art” are all translations of technē [see Nuss-
baum 2001: 94]).
Now let us return to MacIntyre’s description of the place of tradition in
any working concept of phronesis (see Wall 2003: 320–­22 for a fine descrip-
tion of the place of tradition within MacIntyre’s ethics). In After Virtue, he
argues that

an adequate sense of tradition manifests itself in a grasp of those future pos-

sibilities which the past has made available to the present. Living traditions,
just because they continue a not-­yet-­completed narrative, confront a future
whose determinate and determinable character, so far as it possesses any,
derives from the past.

Modalities of Science  /  59
 In practical reasoning [phronesis] the possession of this virtue is not mani-
fested so much in the knowledge of a set of generalizations or maxims which
may provide our practice inference with major premises; its presence or ab-
sence rather appears in the kind of capacity for judgment which the agent
possesses in knowing how to select among the relevant stack of maxims and
how to apply them in particular situations. (1984: 223)

The not-­yet-­completed narrative mentioned by MacIntyre describes, nicely,

the very narratives that patients bring to physicians. After all, a patient brings
to a physician, almost of necessity, a story without an “end”—­a story with a
beginning, a middle, and, at best, only a hoped-­for conclusion. Moreover, the
capacity for judgment that MacIntyre describes is the capacity to recognize
or imagine the “end” or “ends” that are called for by particular situations.
In this passage, then, MacIntyre is articulating the elements of Part 1 of
our book: the pragmatic realism and practical reason of phronesis; the man-
ner in which narrative—­particularly the “not-­yet-­completed narrative” that
MacIntyre describes, the provisional open-­endedness of which, we argue, is
always a constitutive element of narrative itself—­informs both phronesis and
abduction; the further possibility of understanding the concept of phronesis
within a tripartite comprehension of the work of the sciences, physics, biol-
ogy, and semiotics; and, finally, the work of this human science within the
traditions and innovations of clinical medicine. This last point is, in reality,
our first: after all, clinical medicine is the oldest and, perhaps, the most
“practical” practice of practical science. As David Wiggins has noted in an
important and influential essay examining practical reason as it is articulated
in the Nicomachean Ethics, “Aristotle’s account,” like medicine itself, which
we have already seen was one of Aristotle’s chief examples of the phronesis,
“is informed by a consciousness of the lived actuality of practical reasoning
and its backgrounds” (1980: 220).
Still, our chief concern in this chapter is to demonstrate the relationship
between phronesis and narrative, with the end of suggesting that phronesis
can and should be counted among the systematic knowledges (technē) taught
to medical students. Narrative and narrative knowledge, we contend, are
part of our human inheritances as social animals. They are closely linked to
what philosophers and psychologists call “theory of mind.” “Having a Theory
of Mind,” Robin Dunbar has argued, “means being able to understand what
another individual is thinking, to ascribe beliefs, desires, fears, and hopes to
someone else, and to believe that they really do experience these feelings as
mental states. We can conceive of a kind of natural hierarchy: you can have a

60  /  the chief concern of medicine

mental state (a belief about something) and I can have a mental state about
your mental state (a belief about a belief). If your mental state is a belief
about my mental state, then we can say that ‘I believe that you believe that I
believe something to be the case’” (1996: 83). Dunbar even suggests that “no
living species will ever aspire to producing literature as we have it. This is not
simply because no other species has a language capacity that would enable it
to do this, but because no other species has a sufficiently well-­developed
theory of mind to be able to explore the mental worlds of others” (1996:
102).2 In his book What Science Offers the Humanities, Edward Slingerland
describes theory of mind as “the ability to extract humanly relevant action
and intention schemas from the buzzing, blooming confusion of the world
and accurately reproduce them” (2008: loc. 3446). Slingerland is silently cit-
ing William James’s characterization of the world of the infant as “one great
blooming, buzzing confusion,” which Francis Steen explicitly quotes in his
study of the evolutionary development of narrative knowledge in our species
(2005: 95). Steen argues that rather than naive confusion, “our conscious
perceptual experience [and he says that this “is already true for very young
infants”] is the fine-­tuned product of hundreds of millions of years of mam-
malian evolution, presenting an orderly world of objects, agents, and events”
(2005: 95). One such “fine-­tuned product,” Steen argues, is narrative cogni-
tion itself, what we are calling “narrative knowledge.”
Such cognitive ability is crucial to articulating and comprehending narra-
tive, an ability to speculate about the endings of not-­yet-­completed narrative.
Throughout his study of narrative in the context of evolutionary cognition,
Brian Boyd argues that theory of mind is adaptive for an intensely social spe-
cies such as Homo sapiens (this is Dunbar’s and Slingerland’s contention as
well); that “children between one and two start to entertain multiple models
of reality, to recall the past and recognize it as no-­longer, to anticipate the
future and recognize it as not-­yet, and enjoy pretense as not-­really”; and that
by age four, children “understand readily past, present, and future; real, pre-
tend, supposed, or counterfactual” (2009: 269). In a very different idiom
from that of Boyd, Walter Benjamin argues that the essence of the story—­he
contrasts the story with the novel, whose “birthplace,” he says, “is the solitary
individual” (1969: 87)—­is that the story, rather than inviting “the reader to a
divinatory realization of the meaning of life by writing ‘Finis’” (1969: 100),
instead offers counsel. In a wonderful description that should help define the
power of narrative and the practical reason (or “practical wisdom,” as it is
sometimes translated) of phronesis in the patient-­physician relationship,
Benjamin notes that

Modalities of Science  /  61
 counsel is less an answer to a question than a proposal concerning the con-
tinuation of a story which is just unfolding. To seek this counsel one would
first have to be able to tell the story. (Quite apart from the fact that a man is
receptive to counsel only to the extent that he allows his situation to speak.)
Counsel woven into the fabric of real life is wisdom. (1969: 86)

Whether it be the basis of intergenerational sociality (as Benjamin contends)

or the larger work of species formation (as Dunbar, Slingerland, and Steen
contend), the wisdom Benjamin describes is the end of the practical reason-
ing of narrative—­its “point” and “concern”—­and it flowers forth both in the
well-­lived life Aristotle describes and, more locally, in the successful prac-
tices of medicine pursuing the health of patients.

Eudaimonia as the Well-­Being of Health

Brian Boyd’s notion of counterfactual—­or, at least, not-­yet-­completed—­

narrative and Benjamin’s assumption that storytelling gives rise to wisdom
both lie at the heart of Aristotle’s conception of phronesis. Perhaps the rich-
est “flowering forth” of a meditation on the nature and functioning of practi-
cal reasoning can be found in the literary-­philosophical work of Martha
Nussbaum. We use the figure of “flowering forth” because this is, in fact, a
legitimate translation of Aristotle’s central term eudaimonia, the “end” or
“goal” of a well-­lived life. Eudaimonia is usually translated as “happiness” but
can, as Ian Johnson argues, plausibly be translated as the flowering forth or
“realization” of human potential, of human “well being” as he calls it.

This English rendering [“happiness”] causes some difficulties if we do not

remind ourselves that by the term Aristotle means something much wider
than the word happiness might suggest to us. Eudaimonia carries the notion
of objective success, the proper conditions of a person’s life, what we might
more properly call “well being” or “living well.” Thus, eudaimonia includes a
sense of material, psychological, and physical well being over time, for the
fully happy life will include success for oneself, for one’s immediate family,
and for one’s descendants. This notion links the Ethics directly with the
Greek traditions, especially the Iliad, in which the happiness of life includes
a sense of posthumous fame and the success of one’s children as vital compo-
nents. We may better get a sense of what Aristotle means by the term if we
take the advice of one interpreter and see eudaimonia as the answer to the

62  /  the chief concern of medicine

 question “What sort of a life would we most wish for our children?” (I. John-
son 1997)3

This unpacking of the meaning of eudaimonia is of great importance, be-

cause, as we will note throughout The Chief Concern of Medicine, definitions
of “health” include “well-­being” as well as “absence of disease” and “care,”
the last being accomplished, along lines Nussbaum suggests, by means of the
flowering forth of “improvisation” (see 1990: esp. 94–­97). This last definition
is described nicely, as we noted in the introduction, by Dr. John Stone in his
famous poem “He Makes a House Call,” where he describes the improvisa-
tion of health as “whatever works / and for as long” (1980:5). Nussbaum takes
great pains to describe the improvisatory nature of phronesis, though she
does not warrant strongly enough how people can be trained or train them-
selves in improvisation.4

Practical Reason and Science

For Aristotle, Nussbaum argues, it is of the utmost importance that the

“practical reason” of phronesis necessarily be distinguished from the reason-
ing of science. According to Nussbaum, such rational “science” encompassed
“a family of characteristics that were usually associated with the claim that a
body of knowledge had the status of an epistēmē” (1990: 55)—­a term con-
temporaneous with Aristotle and Plato—­what she later calls “systematic sci-
entific understanding” and “a system of universal principles” (1990: 68).
Richard Bernstein describes a sense of science “in the modern world” that,
as we suggested in chapter 1, characterizes much of the way that contempo-
rary American medical education conceives of science: “in the modern
world,” he writes, “the only concept of reason that seems to make sense is
one in which we think of reason as an instrument for determining the most
efficient or effective means to a determinate end, and why the only concept
of activity that seems viable is one of technical application, manipulation, and
control” (1983: 46). The conception of truth and science that Bernstein de-
scribes follows from the “logical positivist” theory of truth we examined in
chapter 1.5 As we shall see, the issue of “a determinate end” is of crucial im-
portance to Aristotle’s conception of phronesis.
Although Aristotle—­ and, indeed, the classical science Nussbaum is
describing—­does not distinguish, as we do here, between the mechanistic/
mathematical science of physics and the explanatory/historical science of

Modalities of Science  /  63
evolutionary biology, Nussbaum does describe the conception of science (as
does Bernstein, in his modern definition) against which Aristotle is positing
the practical reason of phronesis. The scientific reasoning against which Ar-
istotle reacts, Nussbaum argues, possesses three “closely interwoven” di-
mensions, based on three assumptions (1990: 55):

The assumption that objects of scientific reason are “commensurable,”

that is, susceptible to generalization and universalization across dif-
ferent phenomena. Such commensurability characterizes the neces-
sary and sufficient reasoning of mathematical physics.
The assumption that universal or generalizing judgments are more im-
portant than particular judgments—­which includes “the insistence
that rational choice can be captured in a system of general rules or
principles which can then simply be applied to each new case” (1990:
66). This can be seen in the sufficient but not necessary reasoning of
evolutionary biology.6
The more general assumption that rational behavior, by definition, is the
opposite to and should banish both emotion and imagination (1990:
55).

These assumptions also participate in the tacit metaphysical presupposition

that the language of the positive sciences is a description of the nature of
reality.7 Later, Nussbaum argues that “a general account may give us neces-
sary conditions for choosing well; it cannot by itself give sufficient condi-
tions” (1990: 93). “Choosing well” is, of course, the work of practical reason
(phronesis), and, as we argue later in this chapter, phronesis does its work by
means of necessary but not sufficient reasoning in relation to what Nussbaum
later calls “the structure of general terms” (1990: 95) and what we would call
the schemas of semiotic and humanistic science. (“Necessary and not suffi-
cient” describes the provisional nature of humanistic understanding that we
discussed in the introduction.) When, in the Nicomachean Ethics, Aristotle
argues that “the whole account of matters of conduct must be given in out-
line and not precisely” (NE 2.2.1104a; trans. Ross), he is describing necessary
but insufficient reasoning. In this way, necessary but not sufficient reasoning
informs phronesis—­in fact, the action of practical reason is to comprehend
this situation and pursue a “sufficient” response to it—­and, as such, it ties
phronesis to narrative. A chart outlining these relationships follows. (As we
noted in the introduction, one definition of schema is “diagram.”)

64  /  the chief concern of medicine

Classical Scientific (Modern) Sciences Description
 Criteria
commensurable mathematical physics universal and generalizable:
  necessary and sufficient
apply general rules evolutionary biology general over particular
  judgments: sufficient
  but not necessary
scientific reason epistēmē (and technē) avoid emotion and
  imagination
*****
choosing well semiotic (human) general (narrative) schemas:
 (phronesis)   sciences   necessary but not sufficient

The Ends of Practical Reason

An additional aspect of the distinction between practical reason and scien-

tific reason that Nussbaum describes has to do with the conception of means
and ends in Aristotle’s thinking that is explicit in Bernstein’s description of
the “determinate end” of any particular scientific endeavor (1983: 46). Such
a determinate end might be necessary and sufficient for the nomological sci-
ence of mathematical physics, and it certainly offers sufficient functional cri-
teria for evolutionary biology. But it is necessary but not sufficient for semi-
otic science, particularly when it focuses on not-­yet-­completed narrative
structures. In her analysis of what is at stake in the confrontation of Aristotle
and Plato in ancient philosophy (and also in ancient tragedy), Nussbaum
notes that there are difficulties in a widespread mistranslation in an impor-
tant claim of the Nicomachean Ethics, Aristotle’s contention in the standard
translation that “we deliberate not about the end, but about the means to the
end” (cited in Nussbaum 1990: 61 n. 15). The correct translation, Nussbaum
contends, is “we deliberate about what pertains to the end,” which “includes,
as well, the further specification of what is to count as the end” (1990: 61 n.
15); elsewhere, she says it is “‘we deliberate not about ends, but about what
is towards the end’—­or, ‘what pertains to the end’” (2001: 297).8 In other
words, practical reason—­unlike the “scientific” reasoning assumed by the
logical positivists—­does not assume that its ends are determinately self-­
evident in the manner of the deontological ethics of Kant or of the utilitarian
ethics of Bentham: it is precisely the work of practical reason to deliberate on
the constituent features of the end or goal of action altogether.

Modalities of Science  /  65
 For this reason, Nussbaum argues that “Aristotle does not make the
sharp distinction between means and ends that is taken for granted in much
of social science literature, in economics, perhaps, above all. Nor does he
hold that ultimate ends cannot be objects of rational deliberation. We can ask
concerning each ultimate end not only what the instrumental means to its
realization are, but also what counts as realizing this end” (1990: 62). Medi-
cine possesses what Nussbaum describes as “a vague end, health,” and the
issue in medicine, as she says, “will be to get a more precise specification of
the end itself” (2001: 98). Ends or goals, conceived in this way, are more or
less provisional; as Nussbaum argues (1990: 56ff.), they are subject to the
uniqueness of phenomena (as opposed to the “commensurability” assumed
by scientific reason) and to the priority of the particular over the general (as
opposed to the “generalizations” of normal science), and they become more
clearly discernible with the aid of the interested feelings of emotion and the
contrary-­to-­fact considerations of the imagination. In these ways, they entail
“choosing well.” Rather than the formulas of means and ends in deontologi-
cal ethics (and in mathematical physics and “evidence-­based medicine”) and
the explanations of costs and benefits in utilitarian ethics (and in evolutionary
biology and epidemiological surveys), practical reason pursues deliberation
about “what pertains to the end” and the ways that ends and benefits can be
perceived and understood. Phronesis entails what has been called specula-
tion9 (rather than “formulation” or “explanation”) in Aristotle’s virtue ethics
(and in semiotics and information theory) that attempts to discern and de-
limit ends and benefits—­Charles Sanders Peirce might well call this “to
hypothesize”—­rather than assuming them. This schematic list summarizes
the relationships among these systematic modes of accounting for phenom-
ena and value.

Formulas of means and ends (necessary and sufficient truth): deonto-

logical ethics; mathematical physics10; evidence-­based medicine
Explanation of costs and benefits (sufficient but not necessary truth):
utilitarian ethics; evolutionary biology; epidemiological surveys
Speculations discerning (construing) ends and benefits (necessary
but not sufficient truth): ethics as phronesis; scientific semiotics,
Charles Sanders Peirce’s abduction; schema-­based medicine

In this way, phronesis shares this quality or pursuit with narrative, which
seeks, above all, what Kermode described many years ago as the “sense of an

66  /  the chief concern of medicine

ending,” “fictive”—­or we might say “putative, speculative”—­“concords with
origins and ends, such as give meaning to lives and to poems” (1967: 7).

Experience, Perception, and Narrative in Practical Reason

What practical reason most shares with narrative is, as we already mentioned,
experience. Aristotle insists, Nussbaum argues, “that practical wisdom is not
epistēmē . . . but must be grasped with insight through experience” (1990:
68). Wittgenstein nicely describes “experience” as “variable experiences”—­
and in Philosophical Investigations, he also pursues practical reasoning in
attempting to choose well and catalog the “constituent features” of any work-
ing definition of experience (Wittgenstein 2001: II.xi).11 Throughout her
various discussions of Aristotle’s conception of phronesis, Nussbaum makes
clear that the “experience” of practical reason is experience of actual cases—­
particulars—­and also generalizations that can be drawn from earlier (or
“prior”) particular experiences. In this, phronesis is connected to schema
theory in psychology, which, as we have seen, “is an attempt to solve the old
Greek and Kantian problems of relating universals or abstract concepts to
particulars in humanly accessible ways” (Nickles 1998: 78). (In his emphasis
on tradition, MacIntyre focuses on the collective nature of prior experience.
We might say that traditions are schemas made visible.) For this reason,
Nussbaum argues, “the content of rational choice must be supplied by noth-
ing less messy than experience and stories of experience.” “Among the sto-
ries of conduct,” she continues,

the most true and informative will be works of literature, biography, and his-
tory; the more abstract the story gets, the less rational it is to use it as one’s
only guide. Good deliberation is like theatrical or musical improvisation,
where what counts is flexibility, responsiveness, and openness to the external.
(1990: 74)

In this account, phronesis functions like perception itself—­just as schema

theory attempts to discover the elements that help constitute what feels like
the immediate experience of perception—­and it is no accident that Nuss-
baum entitles this chapter of Love’s Knowledge dealing with Aristotle’s con-
ception of practical reason “The Discernment of Perception” and later de-
scribes “an Aristotelian perception-­based morality” (1990: 165): “practical

Modalities of Science  /  67
insight,” she argues, “is like perceiving in the sense that it is noninferential,
nondeductive; it is an ability to recognize the salient features of a complex
situation” (1990: 74). The aim of perception—­aided in Aristotle’s under-
standing, Nussbaum argues, by “imagination” or phantasia (1990: 77)—­is
“that of focusing on some concrete particular, either present or absent, in
such a way as to see (or otherwise perceive) it as something, picking out its
salient features, discerning its content” (1990: 77).12 In her analysis of Aristo-
tle, Nussbaum is following the lead of David Wiggins, who notes that in
moral deliberation—­as, we might add, in medical deliberations—­

the relevant features of the situation may not all jump to the eye. To see what
they are, to prompt the imagination to play upon the question and let it acti-
vate in reflection and thought-­experiment whatever concerns and passions it
should activate, may require a higher order of situational appreciation or, as
Aristotle would say, perception (aesthēsis). (1980: 233; see also 237 for the
explicit equation of aesthēsis and “situational appreciation”)

Perception, then, is the perception—­and the “experience”—­of the “the sa-

lient features” of a situation (Nussbaum 1990: 74), and as such, it is medi-
ated or conditioned by perceptual schemas. Thus, as Wiggins notes, “it is the
mark of the man of practical wisdom . . . to be able to select from the infinite
number of features of a situation those features that bear upon the notion or
ideal of existence which it is his standing aim to make real” (1980: 236).
Nussbaum also notes that “it is no surprise to find [Aristotle] invoking [phan-
tasia or “imagination”] in connection with the minor premise of the ‘practi-
cal syllogism,’ that is, the creature’s perception of an item in the world as
something that answers to one of his or her practical interests or concerns”
(1990: 77). This becomes important in relation to Peirce’s formulation of
abduction that we describe in chapter 4 in pursuing the narrative logic of
diagnosis.
Nussbaum argues that “experience is concrete and not exhaustively sum-
marizable in a system of rules” (1990: 75), but another way that practical
reason is like narrative is that it attends to rules even while it is not wholly
governed by them—­such rules are provisional, necessary but not sufficient—­
just as narrative organizes itself in relation to narrative genres and, some ar-
gue, narrative grammars that are necessary but not sufficient so that narra-
tives are not wholly governed by them.13 Narrative, we should add, is
particularly not wholly governed by systems of rules insofar as it remains

68  /  the chief concern of medicine

“not-­yet-­completed.” In The Sense of an Ending (1967), Kermode argues
that the “end” of narrative creates its power, even when endings necessarily
remain provisional. The precise nature of the stories that patients bring to
physicians is that their “end” is not clear—­either as a diagnosis or as an epi-
sode in the patient’s life. And the not-­yet-­completed narrative of patients
requires precisely the practical reason of phronesis. Moreover, while she ar-
gues that phronesis is neither epistēmē nor technē—­neither a systematic sci-
ence nor a methodical skill—­Nussbaum nevertheless contends that a rule
“does offer [practical reason] guidance, and it does urge on us the recogni-
tion of repeated as well as unique features [of experience]” (1990: 75). In this
way, we are arguing, rules for practical reason, like rules and structures that
aid us in analyzing and, indeed, apprehending, narrative, are necessary but
not sufficient. As we have already noted, Nussbaum argues that “a general
account of the techniques and procedures of good deliberation, . . . may give
us necessary conditions for choosing well; it cannot by itself give sufficient
conditions” (1990: 93).
Such “a general account” is particularly useful in understanding narra-
tive, particularly accounts of narrative action and narrative meaning. As we
note in later chapters, A. J. Greimas provides general accounts for both in
relation to what he calls the “actants” of narrative (his name for particular
narrative agent/actors, which do not have to be animate) and particularly in
his category of the receiver-­actant in narrative, the agent/actor who receives
the sought-­for good at the end of a narrative. What makes actantial analysis
apposite to Aristotle’s notion of practical reason is that practical reasoning—­
explicitly in his “practical syllogism”—­completes itself in action. In chapter 3,
we examine the end of narrative, defined in terms of this reception of the
sought-­for good, which also realizes the narrative meaning. Of particular
interest to the combination of action and meaning in Greimas’s structural
narratology is Nussbaum’s description of “theatrical improvisation,” which
she describes as “a favorite . . . Aristotelian image for the activity of practical
wisdom” (1990: 94). This is also a fine figure for the physician’s need to self-­
consciously assume one or another dramatic narrative role in relation to her
patient: “an improvising actress,” Nussbaum notes, “if she is improvising
well, does not feel that she can say just anything at all. She must suit her
choice to the evolving story, which has its own form and continuity. Above all,
she must preserve the commitments of her character to the other charac-
ters. . . . More, not less, attentive fidelity is required” (1990: 94). (In his at-
tentiveness to his patient in the vignette presented in our introduction, Dr.

Modalities of Science  /  69
Vannatta assumed the role of counselor rather than allopathic physician.)
This metaphor, she goes on, indicates

to us, then, that the perceiver who improvises morally is doubly responsible:
responsible to the history of commitment and to the ongoing structures that
go to constitute her contexts; and especially responsible to these, in that her
commitments are forged freshly on each occasion, in an active and intelligent
confrontation between her own history and the requirements of the occa-
sion. (1990: 94)

Nussbaum calls these commitments and ongoing structures “a host of past

obligations and affiliations (some general, some particular),” and precisely
these “general items . . . such as ‘father’ and ‘friend’” (1990: 94) link practical
reason to narrative structures. (They also link practical reason to MacIntyre’s
“tradition.”)
Nussbaum offers a fine description of perception in relation to phronesis
that suggests its connection with narrative. She concludes that “perception”—­
but we might say “perception or narrative”—­

is a process of loving conversation between rules and concrete responses,

general conceptions and unique cases, in which the general articulates the
particular and is in turn further articulated by it. The particular is constituted
out of features both repeatable and nonrepeatable; it is outlined by the struc-
ture in general terms, and it also contains the unique images of those we love.
The general is dark, uncommunicative, if it is not realized in a concrete im-
age; but a concrete image or description would be inarticulate, in fact mad, if
it contained no general terms. (1990: 95)14

For Nussbaum, however, such a “conversation”—­which, we note, is aptly

analogous to or even instantiated by the conversations that constitute the
patient-­physician relationship—­is a form of “non-­scientific deliberation” that
encompasses what she calls the “‘stochastic’ arts—­e.g. medicine, navigation,”
as opposed to the sciences that pursue “a deductive system concerned
throughout with universals” (2001: 290). In this, she is arguing that Aristotle
is refusing “the Platonic aspiration to make ethics [and “practical reason”
more generally] into a technē” (2001: 291). Throughout her work, Nussbaum
likewise refuses to make either phronesis or, by implication, comprehensions
of narrative and experience into the systematic methodical skill of technē.

70  /  the chief concern of medicine

Technē and Medicine

Despite the fact that medicine may be, in significant part, “stochastic”—­that
is, a science that deals not in certainties but in conjectures or, at best, in the
“warranted assertions” we discussed in chapter 1—­it still can be understood
as technē, even though Nussbaum argues that phronesis, one of the most
important features of good medicine, does not lend itself to technē. (In fact,
in her description of the meaning of the term technē, she notes that “in set-
ting out criteria for technē in the fifth and early fourth centuries, we can turn
above all to the earlier treatises of the Hippocratic corpus, especially the
treatises On Medicine in the Old Days and On Science” [2001: 95].) We sus-
pect, as we have already mentioned, that she would argue that narrative
similarly does not lend itself to systematic technē, though we want to argue
that it does, even if it is a stochastic art (parallel to medicine as a stochastic
science). In fact, her description of the “perception” of phronesis as “a loving
conversation between rules and concrete responses” encompasses, we are
arguing, both the science of medicine and the art of narrative, even as it ad-
dresses, as schemas do, relationships between universals and particulars in
humanly accessible ways. To make this argument, we should set forth Nuss-
baum’s powerful definition of technē in The Fragility of Goodness. “The word
‘technē,’” she argues,

is translated in several ways: “craft,” “art,” and “science” are the most fre-
quent. Examples of recognized technai include items that we would call by
each of these three names. There are housebuilding, shoemaking, and weav-
ing; horsemanship, flute-­playing, dancing, acting, and poetry-­writing; medi-
cine, mathematics, and meteorology. The Greek word is more inclusive than
“epistēmē,” usually translated “knowledge,” “understanding”; or “science,”
“body of knowledge” (depending on whether it is being used of the known or
of the cognitive condition of the knower). In fact, to judge from my own work
and in the consensus of philologists, there is, at least through Plato’s time, no
systematic or general distinction between epistēmē and technē. (2001: 94)

Thus, when she argues that phronesis is “non-­scientific,” she is also suggest-
ing that it does not fall under the category of technē.
Both the early Greek medical texts and Aristotle’s own reflection on
technē in Metaphysics argue that medicine “really deserves the title technē,”
and “four features of technē” are stressed in Aristotle’s discussion—­which

Modalities of Science  /  71
Nussbaum suggests is informed by “Aristotle’s own medical background”
(2001: 95; she is referring to the fact that Aristotle’s father was a prominent
physician). “Aristotle’s reflection on technē (especially the medical technē),”
she writes,

agrees remarkably well with the [ancient, Hippocratic] medical texts; they
may display Aristotle’s own medical background. We find, in these sources,
four features of technē stressed above all: (1) universality; (2) teachability; (3)
precision; (4) concern with explanation. (2001: 95)15

Technē is formed by means of the abstraction of universals from experience;

it is teachable in that it “can be communicated in advance of the experience”;
it offers the precisions of “measures” and “standards” so that “the doctor (on
the defensive here, as we might expect) apologizes for the lack of akribeia
[precision] in his art by pointing out that the measure to which he must, faute
de mieux, refer is something far more elusive than number or weight—­
namely, the perceptions of each patient’s body”; and it explains by asking
“‘why’ questions about its procedures,” so that “a doctor who has learned the
medical technē differs from his more ad hoc counterpart not just in his ability
to predict what will happen if a certain treatment is applied, but also in his
ability to explain precisely why and how the treatment works” (2001: 95–­96).
All these features, Nussbaum argues, resist chance and disorder with “sys-
tematization and unification of practice that will yield accounts and some sort
of orderly grasp” (2001:97).
Moreover, Nussbaum notes that “there are, then, several varieties of
technē”: shoemaking, for instance, “abstracting it from its aesthetic side,”
provides an “external” end that lends itself to “a clear measure of the activi-
ties’ success”; “flute-­playing is much more elusive, since part of what is at
stake is what we shall count as the end” (2001: 98, 99). Medicine is somewhat
odd here, because its “end,” “health,” is what Nussbaum explicitly describes
as “a vague end”: “when a doctor prides himself on his technē, he includes his
work on the end as well as the investigation of productive means” (2001: 98).
Thus Aristotle asserts that “matters concerned with conduct and questions of
what is good for us have no fixity, any more than matters of health” (NE 2.2;
trans. Ross; cited in Wiggins 1980: 231 and also at the beginning of this chap-
ter). In her emphasis that phronesis deliberates about the ends of action,
Nussbaum (as she acknowledges) is following Wiggins, particularly his dis-
cussion of “nontechnical deliberation.” Wiggins notes that in technical delib-

72  /  the chief concern of medicine

eration, it is “absolutely plain what counts” as the goals or end of the delib-
eration, and one thus deliberates about

what means or measures will work or work best or most easily to those ends.
But the standard problem in a nontechnical deliberation is quite different. In
the nontechnical case I shall characteristically have an extremely vague de-
scription of something I want—­a good life, a satisfying profession, an inter-
esting holiday, an amusing evening—­and the problem is not to see what will
be causally efficacious in bringing this about but to see what really qualifies
as an adequate and practically realizable specification of what would satisfy
this want. (1980: 228)

Aristotle “is convinced,” Wiggins says later in his essay, “that the discovery
and specification of the end is an intellectual problem, among other things,
and belongs to practical wisdom” (230). In this way, then, phronesis, as we
have seen, is better understood outside the opposition of means and ends; it
“pertains” to the end, as the pursuit (as we noted, following Nussbaum) of a
fuller understanding of the ends that are pursued. For this reason, Nuss-
baum argues, Aristotle refuses “the Platonic aspiration to make ethics into a
technē,” since “our notion of goodness falls short of the unity required from
the establishment of a single science, since ‘good’ has application to items
belonging in different logical categories” (2001: 291, 292).

A Science (Technē) of Experience and Perception

We argue that Nussbaum’s emphasis on the unsystematic nature of practical

reason does not allow for a conception of understanding that includes the
possibility of a science of perception, conceived not as an immediate appre-
hension of what is but, rather, as a mediated act of discovering or inferring
the “salient” aspects of experience that bear on a particular situation. Such a
systematic understanding of the seeming immediacy of experience is pre-
cisely the aim of schema theory. Moreover, such a systematic understanding
of the salient features of experience—­as disciplined an understanding as that
found in the sciences—­should legitimately command a place in the educa-
tion of physicians. (That our species is adapted to perceive salient features of
the environment is a basic assumption of the study of evolutionary cogni-
tion.) The key term here is mediated—­the fact that the “appearance” or

Modalities of Science  /  73
“feel” of immediate experience can, in fact, be understood as mediated
through systems, structures, or schemas of apprehension that lend them-
selves to refined procedures of discernment and to analysis. Some such
structures may be universal (in the sense of being necessary and sufficient),
but they are all general (and again necessary but only provisionally suffi-
cient); moreover, they are teachable, precise, and concerned with explana-
tion—­in a word, they lend themselves to the methodical skills of technē. Oli-
ver Sacks describes what we are suggesting in his discussion of the seeming
“immediacy” of language and thought that can, we believe, be applied to
experience and narrative. “Language and thought, for us,” he writes,

are always personal—­our utterances express ourselves, as does our inner

speech. Language often feels to us, therefore, like an effusion, a sort of spon-
taneous transmission of self. It does not occur to us at first that it must have
a structure, a structure of an immensely intricate and formal kind. We are
unconscious of this structure; we do not see it, any more than we see the tis-
sues, the organs, the architectural make-­up of our own bodies. But the enor-
mous, unique freedom of language would not be possible without the most
extreme grammatical constraints. (1989: 74–­75)

Just as language and thought and their felt immediacy, in Sacks’s argument,
possess “a structure of an immensely intricate and formal kind,” so the felt
immediacy of experience—­at least beyond the immediacy of brute sensate
experience before it is apprehended in relation to memory, reference, and
experiential or narrative categories—­also has such a structure, even if we are
“unconscious” of it. Evolutionary cognition describes the ways that narrative
structures organizing “experience” are, in fact, adaptive for our species, and
we examine them more closely later in this chapter. Cognitive science, as we
noted in the introduction, recognizes schemas “that [organize] prior experi-
ence and helps us to interpret new situations” (Gureckis and Goldstone
2011: 725).
Here, though, we can describe such “experiential categories” more gen-
erally. Charles Sanders Peirce describes such categories in his catalog of
three kinds of signs that mediate our “experience” of the world: icon, index,
and symbol. Peirce’s icon, he notes, is a sign that depends on and “calls up”
the kind of “brute sensate experience” we mentioned (e.g., the sensation of
redness). Such experience, he argues, is isolatable in analysis but, in fact, is
never—­or rarely, to the point of triviality—­simply “pure” experience; it is
always tied up with the referential experience of indexes, engaging preexist-

74  /  the chief concern of medicine

ing things in the world (e.g., the redness of an apple), and with the meaning-
ful experience of symbols, promising the meaning or “purport” of experience
itself (e.g., the meaning or purport of Adam’s apple). As we saw in chapter 1,
Peirce describes the symbolic function of signs as embodying the “law that
will govern the future.” Purport is the term that the linguist Louis Hjelmslev
argues should be substituted for the term meaning, which, he claims, carries
far too much metaphysical baggage (see Schleifer 2009a: esp. 26–­ 27).
Hjelmslev’s definition of meaning is striking in the context of Aristotle insofar
as it describes the end or goal of communication just as practical reason is
understood in terms of the ends and goals of action in the world. We should
also note that schemas are also tied up with referential experience (e.g., the
“prior experience” of classrooms) and symbolic purport (e.g., the inferred
experience of posters we might encounter in a classroom we read about).
Sacks also addresses the combination of modalities of experience that
Peirce describes, in neurological rather than semiotic terms. In Musico-
philia, Sacks describes the neurological breakdown of the simultaneous par-
ticipation of these modalities in experience and perception. The technical
term of this breakdown is simultagnosia, and he chronicles this dysfunction
in relation to a composer-­patient who, after brain injury, could not integrate
the sounds of musical pieces. In a note, Sacks says that “something analogous
to a transient simultagnosia may occur with intoxication from cannabis or
hallucinogens. One may find oneself in a kaleidoscope of intense sensations,
with isolated colors, shapes, smells, sounds, textures, and tastes standing out
with startling distinctness, their connections with each other diminished or
lost” (2007: 115). Sacks’s neurological discussion thus comports with Peirce’s
contention that the experiences and perceptions of consciousness—­ “of
whatever is at any time before the mind in any way” (1931–­58: 1.23)—­are
mediated by the simultaneous apprehension of differing experiential modali-
ties, namely, the simultaneous experience of sensation, material referential
fact, and a sense of the meaning or purport of these experiences themselves.16
Another way to think about experience is in relation to the broader neu-
rological suggestions that we can distinguish between “core consciousness”
and “extended consciousness” (Damasio 1999: esp. 16–­17). Gerald Edelman
makes the same distinction under the categories of “primary consciousness”
and “higher-­order consciousness.” “Primary consciousness,” Edelman writes,

is the state of being mentally aware of things in the world, of having mental
images in the present. It is possessed not only by humans but also by animals
lacking semantic or linguistic capabilities whose brain organization is never-

Modalities of Science  /  75
 theless similar to ours. Primary consciousness is not accompanied by any
sense of a socially defined self with a concept of a past or a future. It exists
primarily in the remembered present. In contrast, higher-­order conscious-
ness involves the ability to be conscious of being conscious, and it allows the
recognition by a thinking subject of his or her own acts and affections. . . . At
a minimal level, it requires semantic ability, that is, the assignment of mean-
ing to a symbol. In its most developed form, it requires linguistic ability, that
is, the mastery of a whole system of symbols and a grammar. (2005: 8–­9)

In Peirce’s catalog, “things in the world” (e.g., a red apple) are signified by
indexes, while “awarenesses” (e.g., the sensation of redness) are signified by
icons. “Higher-­order consciousness” (e.g., perceiving an apple as signifying
temptation) is signified by symbols. Moreover, as we are arguing—­following
not only Pierce but also Sacks’s neurological description of simultagnosia—­
the human experience that Aristotle calls on in explaining practical reason
combines these modalities of experience.
A final way to think about the systematic understandings and procedures
(technē) of experience is in relation to the suggestion of evolutionary cogni-
tion that humans (Homo sapiens) inherit a small number of preexperiential
cognitive modalities that govern or at least constrain the ways we experience
the world. These modalities are themselves also subject to analysis. Edward
Slingerland describes many of these universal, precise, and explanatory cog-
nitive “categories” in What Science Offers the Humanities. In The Origins of
Stories, Brian Boyd also argues—­much less adequately, because he never
clearly defines what he means by “stories”—­that one such inherited cognitive
ability is our ability to perceive and recognize narrative within what otherwise
might seem simply unformed “experiential” phenomena. (Francis Steen
[2005] makes this argument much more adequately.) In a moment, we will
look at the evolutionary adaptation of narrative cognition more closely. In any
case, these three ways of analyzing “experience”—­in terms of Peircean semi-
otics, neurological physiology, and evolutionary cognition—­repeat the three
levels of systematic understanding that we have mentioned in the examples of
semiotics, mathematical physics, and evolutionary biology. What is important
here, particularly in relation to Nussbaum’s distinction between phronesis
and epistēmē, is the fact that, as we have argued, the “human science” of se-
miotics, like the human activity of practical reason, can be understood as ho-
mologous to the sciences of physics and biology—­that all three can be appre-
hended as forms of technē. This is particularly important because, as we noted
in chapter 1, many who pursue a scientific-­based medicine (and particularly

76  /  the chief concern of medicine

evidence-­based medicine) dismiss phronesis (including the vicarious experi-
ence afforded by narrative that Nussbaum mentions) or the narrative medi-
cine that Rita Charon advocates, simply because it seems to them to be based
on idiosyncratic experience that does not allow for systematic description and
analysis. In fact, the schema-­based medicine we are advocating presents a
systematic—­ and therefore teachable, precise, and explanatory—­
understanding of the “experiences” conditioning phronesis and narrative
knowledge. By situating phronesis and narrative understanding on this con-
tinuum of physics, biology, and semiotics,17 we are hopeful that such people
might reconsider the “warranted assertion” of the usefulness of narrative
knowledge in medical practices and its teachability in medical education.

An Evolutionary Account of Narrative

In chapter 3, we give a general account of narrative, arguing that it is as rea-

sonable as a general account of grammar—­or a general account of gravity—­
and that such an account can offer us an understanding of experience beyond
ultimate particulars and can define the category of narrative knowledge. Be-
fore we explore the salient features of narrative, though, we would like to
offer a systematic account of narrative in the context of evolutionary cogni-
tion, including arguments and evidence based on experimental data.18 An
important feature of narrative—­one that is often overlooked because of its
sheer self-­evidence—­is that it is recognizable as narrative, so that we simply
“know” when a discourse is a story. This is true even for young children. This
feature of the self-­evident recognizability of narrative suggests, we believe,
that narrative apprehension and understanding might well be a cognitive in-
heritance that human beings share, a particular human, “natural” way of ap-
prehending experience that nicely aligns itself with Aristotle’s practical rea-
son. In chapter 10, we touch on one more feature of narrative (which might
be a corollary to its recognizability), namely, that narratives are subject to
retelling and summary. This is an important aspect of Benjamin’s distinction
between a story and a novel when he suggests that stories call for retelling far
more readily than novels do. In any case, we are suggesting that the probably
inherited cognitive power of narrative is what we (and Charon) call “narra-
tive knowledge.” Steen describes such inherited cognitive power as “a ge-
neric and universally understood narrative structure” that is “made possible
by a complex suite of well-­established and tested adaptations with a deep
biological history.” “In a nutshell,” he goes on, “narrative in its elementary

Modalities of Science  /  77
form is an evolved mode of construal, a systematic method for predicting
what agents will do” (2005: 88–­89).19 In fact, the self-­evident recognizability
of narrative might well explain why Boyd feels no need to describe narrative
form in any detail in his extensive study of the adaptive basis of narrative
storytelling that resulted in inherited cognitive processes.
But even without such a description, Boyd outlines the evolutionary
adaptiveness of the narrative processing of information (or “experience”) in
nice detail, claiming (like Steen) that storytelling “makes us more expert in
social situations, speeding up our capacity to process patterns of social infor-
mation, to make inferences from other minds and from situations fraught
with difficult or subtle choices to run complex scenarios” (2009: 49). In his
argument, he follows the usual procedure in philosophy and cognitive sci-
ence of calling “neural systems,” which he describes as “self-­enclosed, im-
pervious to introspection,” “modular” (2009: 43; he is following Jerry Fodor’s
“classical” use of the term modular [1983]); and throughout his discussion,
he suggests that storytelling and story comprehension comprise a “modular”
neural system of this kind. Later, in discussing what some psychologists call
“a cheater-­detection module,” he notes—­wisely, we think—­that he “would
prefer to call it a sub-­routine and to define its role as emotional highlighting
rather than detection” (2009: 60). Steen also describes modularity nicely
when he notes that “a key argument in evolutionary psychology is that natu-
ral selection will tend to produce highly specialized cognitive subsystems,
each of which is optimized for solving recurring problems within a narrow
domain” (2005: 94). Such descriptions of neural modules as subroutines and
subsystems emphasize inherited functions and human predispositions with-
out positing a sense of the inheritance of strict “faculties” of mind. In other
words, the term modular—­insofar as it suggests a “concrete” entity rather
than an operational subsystem—­participates in the fallacy of “misplaced con-
creteness” we described in chapter 1. We certainly would agree with both
Boyd and Steen that the ubiquity of perceiving or experiencing phenomena
in terms of the features of narrative we outline in chapter 3 suggests that it is
part of our shared cognitive inheritance, but we think that its description in
terms of function and capability—­rather than in terms of self-­enclosed
modules—­more fully emphasizes the ways that humans can take up these
capabilities for larger ends.20 Moreover, such terminology allows the possibil-
ity that practical reason is such a function, insofar as it presents a logic of
narrative, and that, in its aim at deliberating possibilities, it would still be
considered a methodological skill (technē) if the science and craft of technē

78  /  the chief concern of medicine

were conceived in terms of organizing possible actions as well as describing
existing phenomena.
Now and then, Boyd does suggest definitions of narrative, in ways that
offer the evidence of cognitive scientific research as support of our descrip-
tion of the salient features of narrative, but he does so without discussing
narrative as such.21 For instance, in a catalog of citations of work in cognitive
science on memory (in a chapter titled “Understanding and Recalling
Events”), he notes studies and data that substantiate the account of narrative
we present in the following chapter. “We tend to remember deep rather than
the surface factors,” he writes,

the “gist” rather than the detail, just as in stories we remember not words but
our inferences about sequences, causes, and goals. [endnote citing a child study, contra-
dicted by a lexical study
] We recall not surface impressions but implications for ac-
tion. We remember information across rather than within sentence boundar-
ies. [endnote citing a 1932 study of remembering] We sort events so rapidly into sequence
and causal sense that both children and adults recall events in chronological
order even if they have been told them out of order and instructed to recall
the information as presented. [endnote citing a study of preschool children] At three years,
children cannot mentally reassemble an out-­of-­order sequence of pictures.
At four, they can, but inflexibly. By six, they can construct the events forward
and backward and sort them into hierarchical categories. [endnote citing a book on
intelligence, the preceding preschooler study, and a study on narrating
]
We form general expectations of individuals (“traits”) or situations
(“scripts”), and do not need to retain what conforms to those expectations,
since we can simply access the general pattern in semantic memory [memory
of concepts rather than episodes of action]. But we retain episodic memories
partly so that we can reevaluate past incidents if we encounter new informa-
tion that challenges our evaluations, and perhaps revise our understanding of
this part of the past. [endnote on the study of the evolution of memory] We search in memory
for explanations beyond the immediate context according to the salience of
the event we wish to understand, its causal connections with outer events,
and the time we have to search. (2009: 154)

We cite this passage at some length because this description of memory,

based on empirical research in cognitive science, encompasses, without ex-
plicitly noting, six features of narrative that we describe more fully in the next
chapter. This account presents (1) the sequence and (2) the intelligible con-

Modalities of Science  /  79
clusion or “end” of narrative in its “gist,” “sequence,” “chronology,” and
“script”; (3) the agents of narrative in its “implications for action” and “indi-
viduals”; and (4) the learning narrative provokes in its “evaluation” and “un-
derstanding.” While Boyd explicitly asserts that narration is different from
“experience” (2009: 159), his account of memory—­an account that is not
explicitly (or, as far as we can infer, implicitly) about narrative at all—­
nevertheless describes (5) the sense of the way that narrative organizes and
even perhaps shapes experience. This is implicit in the facts he describes of
the overpowering sense of chronology that preschool children (he describes
their experience under the pronoun “we”) recover in memory, as well as in
his description of “understanding this part of the past.”22 Elsewhere, he also
subscribes to another salient feature of narrative we describe, (6) that it also
suggests a teller and a listener (2009: 382).
Although Boyd distinguishes here between “semantic memory” and “ep-
isodic memory,” other studies in cognitive science distinguish between “epi-
sodic memory” and “procedural memory,” that is, remembered events (e.g.,
where a worm can be found) and remembered procedures (e.g., how to sing)
(for further discussion, see chap. 6, n. 2). People with brain damage destroy-
ing episodic memory (as portrayed in the famous case of H. M. [see Hilts
1989] or in the film Momento) still retain the ability to walk or drive a car.
The focus on “semantic memory” rather than “procedural memory” in Boyd’s
larger argument that storytelling is an inherited cognitive adaptation is con-
sistent with his attention to cognition rather than to action. But it also allows
him to avoid explicitly analyzing the elements that constitute narrative
knowledge—­the salient features of narrative we describe in chapter 3—­in
part because it is easier to conceive of semantic cognition as “modular” while
procedures (i.e., actions) might be better described in relation to subroutines
or subsystems. In fact, in a discussion of his experimental work in discovering
the physiological basis of memory in neural cells (which won him the Nobel
Prize), Eric Kandel argues that procedural memory (he calls it “implicit
memory”) is “not a single memory system but a collection of processes” that
are akin to the implicit memory of simple animals, including invertebrates
(2006: 132; see Schleifer 2009a: 136–­38 for a discussion of physiological and
narrative memory). If both semantic and episodic memory are “modular,”
the lack of any systematic (or even paratactic) discussion of the constituent
parts of narrative (or an argued taxonomy of modular semantic categories)—­
the very schema of salient features of narrative knowledge we describe in the
next chapter—­does not seem necessary.23 Instead, Boyd argues that the “bio-
cultural approach to fiction” that his study pursues

80  /  the chief concern of medicine

 will focus especially on the shared understandings that make us able and ea-
ger to tell and listen to stories. It therefore operates upon premises different
from other approaches current in literary studies. It suggests that the most
fruitful research program will consist not in looking for codes in the language
of narrative, in the structuralist mode, or in analyzing how ideology or the
contestation of ideologies determines narrative, in the poststructuralist
mode, or in erecting a taxonomy of possibilities (of communicative positions,
temporal relations, or character roles), in narratology. (2009: 130)

It is not clear to us how the premises of empirical studies of cognitive psy-

chology differ to the point of exclusion from those that govern the examina-
tions of the taxonomies and codes of the systematic analyses of narrative
forms. In fact, it is our contention that understanding “the unique human
capacity for narrative” (Boyd 2009: 16) as a cognitive response to the world
that is evolutionarily adaptive rather than beginning from a “blank slate”24 is
hardly incompatible with research programs examining the particular ele-
ments of narrative, what we describe in chapter 3 as a “schema-­based” un-
derstanding that is particularly useful to the practices of medicine. Yet, by
opposing “episodic memory” to “semantic memory” of concepts rather than
to “procedural memory” of behavior, Boyd retreats from the action of narra-
tive to the states of mind of cognition.
In The Right Mind, Robert Ornstein examines the division of the brain
into left and right hemispheres, with a notable division of cognitive function
that, as he argues, creates “a system whereby one side of the brain performs
step-­by-­step thinking, which we associate with the highest form of human
achievements, and the other makes quick judgments of other animals’ ex-
pressions and perhaps their intentions” (Ornstein 1997: 28). This bicameral
system, we are suggesting, is “isomorphic with procedural and episodic
memory” (see Schleifer 2009a: 143 for the development of this argument).
These two abilities—­corresponding to the “general structure” of rules and
procedures and the “ultimate particulars” of experience that Aristotle
describes—­also inhabit narrative understanding and, most important, the
understanding of phronesis. Practical reason, as Nussbaum and others have
demonstrated, attempts to relate the particular instance to a general rule. As
we have seen, Wiggins argues for the possibility of “nontechnical delibera-
tion” that cannot be certain of the “end” or “rule” in question. Charles Sand-
ers Peirce has formalized this in terms of the logic of abduction, which has
also been called “inference to the best explanation” and which we describe in
chapter 4 as “the logic of diagnosis.” Such a logic—­ in Peirce and in

Modalities of Science  /  81
diagnosis—­needs to discover the “rule” (or ailment) rather than already pos-
sessing it, and insofar as this is true, it is formally analogous with both narra-
tive, which (as we argue more fully in the following chapter) always needs to
discover its “end,” and with phronesis, which likewise needs to discover the
“ends” of action. In other words, the organization of the elements of narra-
tive we describe in the next chapter form a “general structure” that does not
“sufficiently” specify the particularities of individual narratives, even as those
particularities help realize and shape the structure. Narratives have ends, but
how they end is not particularly described in a general account; they have
agents performing actions, but how they act and interact, while allowing for
a “general” account, are not completely prescribed; and they present lessons
that can be abstracted from “experience,” but the content of those lessons
and the shape of that experience is also not necessarily predictable. In other
words, narrative conditions the relationship between general and particular
understanding, and that conditioning can be understood as universal (par-
ticularly in the face of the evidence of studies in cognition and evolutionary
cognition), teachable, precise, and concerned with explanation, a procedure
of technē in itself.
In this chapter, we have attempted to conceive of Aristotle’s conception
of phronesis as a form of systematic knowledge—­as a modality of “science”—­
and we have attempted to relate its functioning to the general functioning of
narrative. Moreover, we have argued that both narrative and phronesis are
themselves susceptible to scientific study and, in turn, allow their own sys-
tematic development in understanding and practice. We have suggested that
both possess a technē that is universal, teachable, precise, and concerned
with explanation. Phronesis, both Aristotle and Nussbaum suggest, grows
with experience and, most particularly, the concern that experience gives rise
to. Insofar as it gives rise to what we describe in the next chapter as narrative
knowledge, its growth can be nurtured, taught, and developed with “rules”
that encourage its practice within the everyday work of medicine.

82  /  the chief concern of medicine

3
the chief concern of medicine
Narrative Knowledge and Schema-­Based Practice

Literature is hardly of interest to medicine only because great books have been written
about illness and death. More fundamental by far than the content of Bleak House or
King Lear is the modeling, by literary acts, of deeply transformative intersubjective
connections among relative strangers fused and nourished by words. Recognizing that
my responsibility toward my patient includes my being a dutiful and skillful reader helps
me to understand what skills to develop within my doctorly self.
—­rita charon, Narrative Medicine (2006a: 54)

In this chapter, we examine the concept and function of “narrative knowl-

edge,” both in general and in the practice of medicine. We focus on narrative
knowledge in terms of not only the knowledge that a physician-­listener can
glean from narrative—­knowledge that Rita Charon richly describes in her
presentation of part of medical practice she calls narrative medicine—­but
also the knowledge of narrative itself and how a working understanding of
the shape and features of narrative can contribute to successful medical
practices (which Charon also describes). There is great controversy concern-
ing the nature of narrative, its “salient” features, its cognitive functioning, its
role in cognition and (indeed) in relation to possible neurological organiza-
tions of the human brain, and its place in interpersonal relationships and
larger social formations. In her response to David Rudrum’s pragmatic anal-
ysis of narrative, Marie-­Laure Ryan nicely summarizes “a tentative formula-
tion of . . . nested conditions” by which narrativity could be progressively
defined or circumscribed (2006: 193–­94). She lists nine criteria by which
people might decide if a particular text is a narrative, beginning most gener-
ally, with the contention that “(1) narrative must be about a world populated
by individuated existents,” and ending with “(9) The story must have a point”

/  83  /
(2006: 194). When people are asked if a particular text is a narrative, she
writes, some will be satisfied it is if the text is about individuated existents in
a world that undergoes historical change caused by external events, “while
others . . . will insist that narrative must be about human experience”; still
others, she writes, will insist that a narrative demonstrates a “sequence of
[nonhabitual] events [that] must form a unified causal chain and lead to clo-
sure”; and finally, there are some who see that “the story must have a point,”
even “while others . . . think that a pointless utterance can still be a narrative”
(2006: 194).
While such controversy inhabits scholarly debates about the nature of
narrative and the qualities that allow us to recognize a particular text as a
narrative, no such controversy inhabits the situation when a patient tells her
doctor the narrative of her illness. These stories, like Ryan’s final criterion,
must have a point, an overriding “concern”: the stories patients bring to
physicians are necessarily goal-­oriented even when—­or perhaps particularly
when—­they present themselves in the form of a not-­yet-­completed narra-
tive, as we described in the preceding chapter. In fact, we believe that it is
engagement with just such not-­yet-­completed narratives that led Aristotle to
develop his ethical notion of phronesis, his sense of “practical reason,” one
of whose chief examples, as we saw in his discussion in the Nicomachean
Ethics, is the work of medicine. As we have argued in chapter 2, we contend
that phronesis warrants being considered as a systematic skill so that it can
be taught and learned as both epistēmē and technē; and we further contend
that the narrative knowledge it both instantiates and produces is an impor-
tant part of the practice of medicine. As we saw, phronesis is focused on
action rather than knowledge, actions that make its agents achieve goodness
in particular behavior and in life more generally. Such an understanding is
closely connected to practices of medicine, whose aim, after all, is not so
much the achievement of knowledge as it is action that realizes a certain
result, namely, achieving the “health” of the patient in a particular case (un-
fortunately including, in some cases, a “healthy” death), even if the abstract
meaning of “health” is imprecise or unfixed and can only be grasped, as Ar-
istotle says, in “outline and not precisely” (NE 2.2.1104a; trans. Ross). De-
spite the “singularity” of particular cases and the vagueness of a general
definition of health, as we have suggested, the range or scope of possible
definitions of health—­and, therefore, possible actions taken by a physician
in concert with her patient—­is small enough to lend itself to the methodical
skill of technē.

84  /  the chief concern of medicine

The Chief Concern

Before we turn to the salient features of narrative and a working sense of

narrative knowledge, we should state more fully what is at stake for medical
practices in our understanding of narrative knowledge in relation to phrone-
sis. The understandings of both phronesis and technē call for a simple yet
profound change in the procedure of the History of Present Illness (HPI),
the narrative history patients tell in describing why they have sought out a
physician. The HPI is almost always the starting point in the patient-­physician
encounter (even when a third party offers the history for a patient not able to
do so). As we noted in the introduction, physicians should not only begin
with the “chief complaint” in their description (and engagement) with a pa-
tient’s ailment, as is the standard procedure; they should also include in the
History and Physical Exam a description and engagement with a patient’s
“chief concern.”1 This concern pertains to the ends of health care, the “vague”
definition of the end or goal of medicine, however the patient conceives of
“health” under the circumstances (including a “healthy” way to die). That the
patient should participate in the deliberation of what constitutes health alto-
gether goes a long way toward realizing the physician as a phronimos (“a man
of practical wisdom” [Aristotle, NE 6.5.1140a; trans. Ross]). The chief com-
plaint of the History and Physical Exam in the American practice of medi-
cine lends itself to technē in terms of its working definition that Nussbaum
describes: its (1) universality, (2) teachability, (3) precision, and (4) concern
with explanation (2001: 95). Physicians encounter patients who, almost by
definition, universally come with a complaint; both physicians and patients
are concerned with explanation; and through the rigorous training of medical
school, physicians learn precise responses to this situation. But the chief con-
cern, focused as it is on discovering a practical sense of health (or at least the
desired outcome) in the particular case at hand, also participates in the
teachability, precision, and explanatory power of technē: physicians can be
taught precise strategies or protocols for speculating on or construing2 the
meaning of their patient’s narratives, including strategies for understanding
the “unsaid” as well as the said in the narrative histories they encounter.
In other words, the formal inclusion of the “chief concern” in the His-
tory and Physical Exam will necessitate, within the everyday practice of
medicine, deliberation about the necessary but insufficiently defined ends
and goals of each and every particular treatment of a patient. While it is
universally acknowledged that the physician is the expert in relation to her

The Chief Concern of Medicine  /  85

patient’s complaint, the patient is expert in relation to his concern, and the
scene of interaction of expertise is the site of deliberation. Such delibera-
tion is at the heart of James Phelan’s articulation of “narrative as rhetoric.”3
The action of narrative as rhetoric, he argues, is the “telling [of a] particular
story to a particular audience in a particular situation for, presumably, a
particular purpose” (1996: 4; see also 8). In this, he is paraphrasing Barbara
Herrstein Smith’s profoundly simple definition of narrative, which we cite
later. More important, he is precisely describing—­and perhaps explaining—­
the action of the HPI. Almost of necessity, a patient brings a not-­yet-­
completed narrative to a physician—­a story with a beginning, a middle,
and, at best, only a hoped-­for end. Such an end, we believe—­particularly in
the United States, where patient “autonomy” has become one of the guid-
ing principles in clinical medicine—­ought to be negotiated between patient
and physician. As we noted in the introduction, the chief concern is ulti-
mately practical: the patient’s fear that this ailment will keep him from per-
forming his job, her concern that her medication will deprive her family of
other necessities (again, a particular problem in the United States), a fear of
losing close relationships, an overwhelming need to hold on to life whatever
the cost, or the contrary sense that quality end-­of-­life experience is more
important than doing everything possible to extend life. In a book with a
title that is wonderfully apt for this discussion of phronesis, The Nature of
Suffering and the Goals of Medicine, Eric Cassell catalogs a thorough, but
not exhaustive, list—­a provisional schema—­of the characteristics of “per-
sonhood” that are threatened, uprooted, and destroyed in suffering and
that condition the deliberation of patients faced with suffering. “Persons,”
he says,

have personality and character, a lived past, a family, a family’s lived past,
culture and society, roles, associations with others, a political dimension, ac-
tivities, day-­to-­day behaviors, and existence below awareness, a body, a secret
life, a believed-­in future, and a transcendent dimension. (1991: 160; see also
Schleifer 2009a: 145–­50)

What is remarkable about these characteristics is that most, if not all, of them
can be defined or described only through “episodic memory” (discussed in
chapter 2) that is embodied in and experienced by means of narrative: a lived
past, social and political associations, subconscious or unconscious behavior,
a sense of the future, even a transcendent dimension—­all these phenomena

86  /  the chief concern of medicine

possess a progressive and graspable existence in time. Suffering, Cassell says
“has a temporal element” (1991: 36)—­as do its opposites, “health” and “per-
sonhood.” Moreover, most, if not all, of these characteristics of “personhood”
(whose harm or destruction defines suffering) can be described as a not-­yet-­
completed narrative. (Personhood is an important element of checklist 2,
“Beginning Interview Schema,” in appendix 2.)
Here is one such narrative focused on a patient’s chief concern in the
patient-­physician relationship.

Mrs. Jones, an elderly woman with serious bedsores, was faced with the
necessity of surgery. But hearing the surgical plan from the attending
physician while accompanied by her daughter in the hospital, she refused
surgery, even after the doctor informed her that she would die of infection
without surgery, because the sores would not heal. Both mother and
daughter listened carefully, and the mother stated, “I can’t have surgery
today, because the moon is over my chest and I will die of a heart attack in
surgery.” Her daughter agreed and explained that she had her mother’s
durable power of attorney and that they both make all major decisions
based on the Farmer’s Almanac and the major zodiac signs. Frustrated, the
physician asked them to think it over and let him know when they could
schedule surgery. Every day, Mrs. Jones and her daughter rejected surgery
because of some problem with the moon and its phase. In the face of this
seeming stubbornness, the physician confronted the patient, and the
following morning, the daughter informed him that they had hired a
different doctor, one whom they trusted.
When the attending physician contacted the new physician by
telephone, the latter laughed and said that he would see Mrs. Jones, but
only after she left the hospital once her illness was resolved. Two days later,
Mrs. Jones refused surgery again, insisting that the moon was over her
abdomen and that surgery would ruin her bowels. The new doctor was at
the nursing station, so the attending physician explained the situation and
asked the new doctor to accompany him into the room and talk to Mrs.
Jones and her daughter. The new doctor reluctantly agreed. Upon his
entering the room, the patient and her daughter smiled, and the room
immediately warmed.
“Hello, Mrs. Jones,” he said, shaking her hand. He then turned to the
daughter and introduced himself. They were all aglow.
“I hear you need some surgery,” he said enthusiastically.

The Chief Concern of Medicine  /  87

 “Not so sure,” Mrs. Jones replied.
“Let me look,” showing concern. “Yep, you sure will need surgery on
this. When do you suppose we can do this?”
The patient looked nervously at the daughter. The daughter shifted in
her chair and looked briefly at both doctors.
“Well, my daughter makes all my decisions, and the moon is over my
abdomen now, so . . .”
“Oh!” he responded, “you use the almanac?”
“Yes,” the patient said.
“Do you plant your garden by it too? How was your garden this year?”
This was followed by a three-­minute colloquy on tomatoes, corn, and turnip
greens.
“So, the moon is over your abdomen?” The new doctor moved closer to
the bed and touched her belly. “And this would mean . . .”
“Bowel trouble,” Mrs. Jones replied.
“And if it’s over your head?”
“A stroke.”
“Oh my!”
“And your chest?”
“Heart attack.”
“Boy, then we can’t do that!” the doctor replied.
He turned to the daughter and asked, “Do you have an almanac?”
“Yes,” she said slowly.
Then back to the patient, “Where would the moon need to be to do
surgery?”
The patient looked shocked, glancing quickly around the room. “Well, I
guess, uh, oh, well . . .”
He moved back to the bed, kindly touched her lower leg.
“How about your lower leg here?”
“I guess so.”
Looking at the daughter, the doctor inquired, “When is the moon over
the lower legs?” Immediately he moved to the chair where she sat and
helped her look it up. They studied and discussed, changing their minds a
few times. It was a negotiation to behold.
“The seventeenth. That’s it,” the daughter said emphatically.
“Yes, that would be a safe day. Three days from now. We will get it
scheduled, and Mrs. Jones, you are going to do so well.” With the patient
looking surprised at her daughter, the new doctor left the room, looking

88  /  the chief concern of medicine

enthusiastically over his right shoulder as he said, “I’ll drop by every day
and make sure of it.”

In this narrative—­to which we return at the end of this chapter—­the

patient presents her doctors with a not-­yet-­completed narrative. While the
second physician understands the degree to which this narrative is about the
patient herself, her “personhood” (who she is) and her chief concern in rela-
tion to her illness, the first physician simply attends to his own narrative, that
of a clear-­cut medical problem, focusing only on biomedical knowledge and
solutions. Such solutions present themselves—­and sometimes without prob-
lems—­as complete in themselves, just as the positivist science we examined
in chapter 1 assumes that the facts of “reality” are already (“infallibly”) com-
plete in themselves and need neither negotiation nor consideration in larger
contexts of understanding. But because the features of personhood are nec-
essarily not-­yet-­completed, the second physician seems to understand that
sometimes the patient-­physician encounter is the site of practical delibera-
tion and negotiation—­in medicine, deliberation about “health” and, more
generally, about eudaimonia—­that is, the site of the work of phronesis. That
work, as we have suggested and as this narrative suggests as well, is the delib-
eration concerning the (sufficient) constituent elements of the “ends” of the
stories patients bring to physicians, stories whose shape take up and articu-
late the chief concern that a patient always brings with his ailment. As we
have seen, Nussbaum argues that “practical insight is like perceiving in the
sense that it is non-­inferential [as opposed to the inferences of evolutionary
biology], non-­deductive [as opposed to the deductions of mathematics and
mathematical physics]; it is, centrally, the ability to recognize, acknowledge,
respond to, pick out certain salient features of a complex situation” (2001:
305). The salient feature of this complex situation is the fact that, for what-
ever reason (fear of hospitals or medicine, habit, a kind of faith in the alma-
nac), the patient’s dependence on the almanac is part of the negotiation be-
tween physician and patient; it is part of who she is.
Besides the deductive and inductive (inferential) logic that Nussbaum
describes, there is also, as we argue in chapter 4, a logic of discovery, “abduc-
tion” (or perhaps a logic of “speculation”), which can and should situate itself
within senses of systematic understanding, dealing, as we said, with neces-
sary but not sufficient truths. Such truths are the objects and, indeed, the
creations of deliberation—­the deliberation at the heart of patient-­centered
care—­but they are not simply arbitrary, even if the first physician judged the

The Chief Concern of Medicine  /  89

patient’s dependence on the almanac extraordinarily arbitrary. In fact, there
is another way to understand narrative. Narrative, as we shall see, gathers
together scattered factors and, to one degree or another, judges the impor-
tance of its gathering. Such judgments, however, are provisional: they take
place outside the imperative of choosing once and for all (e.g., choosing be-
tween the folk medicine of the almanac and the evidence-­based medicine of
professional medicine). In this way, narrative suspends the law of the ex-
cluded middle. Instead, it offers versions of comprehension—­configurations,
analogies, wholes that do not erase parts—­that can, in fact, be superimposed
on one another precisely to create “middles.” In this way, narrative, as we
already noted that A. J. Greimas has argued, is “neither pure contiguity nor a
logical implication” (1983: 244). Rather, it gives rise to a warranted assertion
about the world, aiming at organizing or preparing for (as Francis Steen ar-
gues) some action in the world.
Earlier, we mentioned three possible definitions of the “vague” concep-
tion of health corresponding to definitions of Aristotle’s katharsis: the ab-
sence of disease, the presence of well-­being, and a provisional sense of get-
ting on with life. The first physician in the preceding narrative seems only to
conceive of health as the absence of disease, while the patient—­perhaps like
a majority of patients—­conceives of health as a combination of all these de-
scriptions: surely the almanac creates a sense of well-­being and offers a sense
of getting on with life, both aspects that the second physician engages as he
talks about the almanac and its provisional folkloristic wisdom. In any case,
these abstract conceptions of health create a framework for the deliberation
of the sufficient “ends” of the stories patients bring to physicians, which are
neither arbitrary nor necessary and sufficient, stories whose shape takes up
and articulates the chief concern that a patient always brings with his ailment.
This is why we believe that the experience and the stories of experience that
patients bring to physicians are not simply unique—­or what Aristotle calls
“ultimate”—­particulars but also participate in “general rules and principles”
that Nussbaum sees as part of technē (1990: 66). If this is so, then, as Nuss-
baum says, “a general account may give us necessary conditions for choosing
well” (1990: 66, 93)—­even if it cannot specify the sufficient conditions—­
which might still allow us to design a systematic array of skills for narrative
phronesis that will help a physician achieve the status of a phronimos. In any
case, the beginning of such a technē for phronesis is the simple expedient of
making the “chief concern” a formal aspect of the patient-­physician interview
and its recorded transcript. It is an expedient that ensures that narrative de-
liberation will be an explicit aspect of that interview as well.

90  /  the chief concern of medicine

A General Account of Narrative

A general account of narrative is as reasonable as a general account of gram-

mar and can offer us an understanding of experience beyond ultimate par-
ticulars. Just as language and thought and their felt immediacy, in Oliver
Sacks’s argument, possess “a structure of an immensely intricate and formal
kind,” so the felt immediacy of experience also has such a cognitive structure,
even if we are “unconscious” of it in the same way we are “unconscious . . .
[of] the tissues, the organs, the architectural make-­up of our own bodies”
(1989: 74–­75). We are suggesting that narrative, in its felt immediacy, pos-
sesses an intricate and formal structure.4 Such a “general account” is particu-
larly useful in understanding narrative, particularly in accounts of narrative
action and narrative meaning. As we noted in chapter 2 (and describe more
fully later in this chapter), Greimas provides general accounts for both in
relation to what he calls the “actants” of narrative—­the narrative agents that
can, at times, be assumed by seemingly inanimate agents, such as the ring in
The Lord of the Rings—­and in his category of the receiver-­actant in narra-
tive, who receives the sought-­for good at the end of a narrative. What makes
actantial analysis pertinent to Aristotle’s notion of practical reason is that
practical reasoning—­an important element of what we are calling narrative
knowledge—­completes itself in action. In a moment, we will talk about the
end of narrative—­its point and concern—­as it is defined in terms of this re-
ception of the sought-­for good.
But now, let us describe the salient features of narrative here.5 We start
with Barbara Herrstein Smith’s profoundly simple description of narrative as
“verbal acts consisting of someone telling someone else that something hap-
pened” (1980: 232). We begin here because, like Phelan, Smith emphasizes
the act of narrative just as Aristotle emphasizes the act of practical reason in
the Nicomachean Ethics. Moreover, this description—­which nicely describes
the patient-­physician relationship, as Rita Charon has noted (2006b; Charon
and Wyer 2008)—­entails a small number of salient features useful to physi-
cians in their encounters with patient narratives. These features, we believe,
are most clearly pronounced in literary narratives: after all, the aesthetics of
what we are calling “art narratives” call attention to the general working of
narrative by emphasizing the order of narrative features. Anton Chekhov
powerfully articulates this aesthetic insight when he notes that “one must not
put a loaded rifle on the stage if no one is thinking of firing it.”6 Narrative
(including literary narrative) organizes disparate events into complex action
in which an array of happenings becomes the sequence of action that can be

The Chief Concern of Medicine  /  91

apprehended—­retrospectively and simultaneously—­as a whole. In its most
basic form, narrative presents an initial situation, a change or reversal of that
situation, and—­most important—­retrospective comprehension of what has
taken place. Thus, as J. Hillis Miller notes, “the minimal personages neces-
sary for a narrative are three: a protagonist, an antagonist, and a witness who
learns” (1995: 75), though he adds that the protagonist, antagonist, or reader
may be the witness.7 Narrative comprehension accomplishes what Paul
Ricoeur has called the “synthesis of the heterogeneous,” by organizing a se-
ries of events “into an intelligible whole, of a sort such that we can always ask
what is the ‘thought’ of this story” (1984: 65): it grasps a meaningful whole.8
For narrative, as for the simpler form of the sentence, the whole is more than
the sum of its parts, more than simply a collection of “data” added together,
just as “schema theory,” as Thomas Nickles notes, “denies that human per-
ceptions and judgments consist in atomic events such as the passive ideas of
the British associationists” (1998: 78). Steen notes that “in cognitive terms,
forming a narrative is an act of connecting a succession or mere co-­occurrence
of agents and objects into a causally ordered, intuitively graspable whole”
(2005: 87), and Umberto Eco describes this process in terms of Peircean
semiotics, as the transformation of “a disconnected series” into “a coherent
[textual] sequence” that allows us to recognize the “‘aboutness’ of the text
which establishes a coherent relationship between different and still discon-
nected textual data” (1983: 213).
In chapter 4, we note that in his discussion of abduction—­which we take
to be a formulation of Aristotle’s practical syllogism—­Peirce describes a sim-
ilar phenomenon: “the essence of an induction is that it infers from one set
of facts another set of similar facts, whereas hypothesis [or abduction] infers
from facts of one kind to facts of another” (1992: 150). These different kinds
of fact—­like the phenomena of a story’s action and its being “witnessed” in
the form of retrospective comprehension—­suggest an implicit understand-
ing of narrative within these features, perhaps an understanding of narrative
as simple as Smith’s: that narratives “convey representations of actions
through the dynamic interplay of two temporalities,” the temporal action of
the story and the temporal action of its telling (Kreiswirth 2000: 313).9 These
“temporalities” are particularly marked in the narrative intercourse of pa-
tient and physician, where the story and the telling are reinforced by the
different sensibilities of the “lay” narrative phenomenology of the patient—­
even when the patient is a physician—­and the “professional,” more or less
“scientific” retrospective comprehension of the physician (see Hunter 1991:
chap. 7). The story of Mrs. Jones particularly emphasizes this. What allows

92  /  the chief concern of medicine

for the retrospective comprehension of narrative is the overdetermined fact
that a narrative has an “end” (the combined completion and “point” of a
story) that offers (however provisional it may be) a sufficient sense of a “goal,”
a “thought,” an “aboutness,” or even the “chief concern” of narrative we are
focusing on here, which, like Charon’s “desire,” makes the disparate events
into a meaningful whole. The fact that narrative is, in its nature, goal
directed—­that it occasions “deliberation” in the making sense of its parts in
terms of its completed wholeness and “point”—­connects it with Aristotle’s
phronesis, the process of practical reason. Phronesis, in these terms, we are
arguing, always suggests an implicit narrative insofar as it orders the mere
co-­occurrence of agents and objects into meaningful action. Moreover, expe-
rience itself, insofar as it is the object of practical reasoning, always presents
itself in narrative form. If this last assertion is correct—­and it is a qualified
assertion in that it describes experience as the object of practical reason (we
put forth a “strong” version of this assertion later)—­then an understanding of
the schema of a “general structure” of narrative can help create the teachable
techniques (technē) for practical reasoning.
In this description of narrative, the first two features of its general struc-
ture exist in the fact that it has a sequence of events from which arises an end,
its completion and concern. A third feature of its general structure is that it
has recognizable agents, actors (animate or inanimate) that initiate action
and/or are the objects of action. The great difference between Aristotle’s
practical reason and Plato’s theoretical reason is that Plato’s reason elimi-
nates recognizable agents and replaces them with transcendental “forms” or
laws of existence that do not seem to “act” at all but that merely reflect a
universal state of affairs that can be “wisely” acknowledged or “erroneously”
ignored (the state of affairs of nomological science that we mentioned ear-
lier). A fourth feature of the general structure of narrative is that it is both
articulated and received: it presents changes over time in terms of the agents
of its actions (Miller’s protagonist and antagonist). It also possesses a fifth
feature, a witness who learns or is “concerned” about the end of the narrative
(its point or its termination). This feature describes why the notion of “con-
cern” more fully describes the goal or point of narrative—­its “end”—­in rela-
tion to practical reason than does Ricouer’s and Eco’s “thought” and “about-
ness”: concern, implying a witness (in medicine, both the concerned patient
and the concerned physician), allows for the narrative power of not-­yet-­
completed stories.10 Moreover, this feature of narrative is also closely tied to
the accidents, “luck,” and unanticipated occurrences that narrative takes up
(and Nussbaum explores with great eloquence in The Fragility of Goodness):

The Chief Concern of Medicine  /  93

in Ulysses, Stephen Dedalus claims that there are no “accidents” for the man
of genius; but in truth, there are no accidents for narrative, insofar as narra-
tive takes up events and makes sense of them so that someone can learn.11
How the witness learns in relation to narrative—­we have seen this is true in
phronesis as well—­is from experience: a sixth feature of narrative is that it
organizes and, in a stronger argument, shapes12 experience. The stronger
argument is most fully instantiated in examinations of the “metaphysical”
stories of religion (and in the “paradigms” of scientific understanding that
Kuhn posits) that so “organize” experience that the immediate, felt experi-
ence of its adherents is shaped by the narrative “aboutness” that they take to
be the world itself. It might well be that all metaphysical beliefs—­including
metaphysical atheism, which assumes that blind forces shape existence—­are
imbued with the shaping power of narrative. Even a nontheistic metaphysi-
cal belief in rationality (e.g., Plato’s previously mentioned or that of the logi-
cal positivists examined in chapter 1), which assumes that abstract theoretic
reason is the basis of existence and precedes and supersedes any narrative
forms, implies a simple narrative of first and second, reason (protagonist)
versus irrational haphazard events (antagonist), and an “end,” the triumph of
nonnarrative reason over worldly events (structure over action? science over
narrative?),13 such triumph being both its end and its point.
Let us repeat this list of features defining narrative, encompassing its “ac-
tion” and its dynamic of “two temporalities.” Narrative has

1. a sequence of events,
2. an end, and
3. recognizable agents.

Moreover,

4. narrative is both articulated and received;

5. it possesses a witness who learns—­who is “concerned”—­about the
end of the narrative (its point or its termination); and
6. its witness learns from experience.

Note that the two parts of this list embody the “two temporalities” of narra-
tive, the time of the story’s events and the time of its telling.
In chapter 2, we also described a final feature of narrative—­though this
might be its “first” feature—­the fact that it is recognizable as narrative. In
relation to the salient features of narrative we are describing, we should add
that young children, who can recognize ill-­formed sentences (and even con-

94  /  the chief concern of medicine

jugate irregular verbs as if they were regular verbs), also recognize ill-­formed
narratives, series of events

without recognizable sequence and intelligible conclusion,

without recognizable agents,
without an implied storyteller recounting events from which someone or
other can learn,
without a sense that the story is a version of experience altogether (Nuss-
baum’s “experience and stories of experience” [1990: 74]) and not
simply a list or chart of events.

This last (or really first) feature of the self-­evident recognizability of narrative
suggests, as we have said, that narrative apprehension and understanding
might well be a cognitive inheritance, a particular human, “natural,” way of
understanding experience.14 This is what we are describing as narrative
knowledge. Such a catalog of salient features—­features that, in the abstract,
are necessary and sufficient for a narrative to be recognized as such, even
though none of these abstract features entail “sufficient” elements for its nar-
rative realization—­is important because an understanding of the “general
structure” of narrative can help create the methodical skills of technē for the
practical reasoning of medicine.

Narrative Phronesis: Schema-­Based Medicine

The nontechnical deliberations of phronesis function in a fashion similar to

that of narrative, discovering what counts as the goal or end in a particular
practical situation. But simply because they are “nontechnical,” as David
Wiggins describes them (1980: 228), does not mean that the deliberations of
practical reason do not lend themselves to the art, craft, and systemizing
procedures—­in a word, to the “method”—­of technē. At the beginning of
Narrative Medicine, Rita Charon defines narrative in a manner that is com-
patible with the outline of the features of narrative we have described. Not-
ing that narratives “can be defined as stories with a teller, a listener, a time
course, a plot, and a point,” she suggests that health care workers can obtain
“the skills needed to listen to narratives of illness, to understand what they
mean, to attain rich and accurate interpretations of these stories, and to grasp
the plights of patients in all their complexity” (2006a: 3). She describes these
skills as the ability of “recognizing, absorbing, interpreting, and being moved

The Chief Concern of Medicine  /  95

by the stories of illness” (4). Taken together, these skills achieve what she,
like us, calls “narrative knowledge.”

If narratives are stories that have a teller, a listener, a time course, a plot, and
a point, then narrative knowledge is what we naturally use to make sense of
them. Narrative knowledge provides one person with a rich, resonant grasp
of another person’s situation as it unfolds in time, whether in such texts as
novels, newspapers stories, movies, and scripture or in such life settings as
courtrooms, battlefields, marriages, and illnesses. . . . Unlike scientific knowl-
edge or epidemiological knowledge, which tries to discover things about the
natural world that are universally true or at least appear true to any observer,
narrative knowledge enables one individual to understand particular events
befalling another individual not as an instance of something that is univer-
sally true but as a singular and meaningful situation. (9; see also 45–­48 for an
extended discussion of “singularity”)

Later in her discussion, she mentions Russian formalism and notes that
“these early formalists aspired to a scientific examination of text, that is to say,
a reproducible, generalizable system of understanding and of describing the
anatomy of a story,” but she concludes that “by now, in poststructuralist
times, we do not believe that a story can be dissected scientifically to reveal
the same meaning to more than one observer” (40). We mention her analysis
because it—­and the version of poststructuralism she alludes to—­is an ex-
ample of what Roman Jakobson (a leading proponent of Russian formalism)
describes as “one-­sided pluralism” that presupposes “a mechanical agglom-
eration of functions” (1987a: 43, as opposed to “one-­sided monism,” such as
the positivism discussed in chapter 1). Here and elsewhere, but not always,
Charon seems to define narrative as private and unique (“singular”) experi-
ence rather than as a motor for common understanding and action that can
give rise to the methodical engagements of technē. We say “but not always”
because, throughout her work, she also demonstrates how literature allows
us to apprehend shared frameworks of understanding, the narrative “model-
ing” of our epigraph, to help people become more competent physicians,
able “to recognize, absorb, interpret, and be moved by stories of illness”
(2006a: vii). But even so, informing medical practice with such understand-
ing might be accomplished in a more practical way than—­or at least through
a complementary program to—­the “intensive narrative training” she advo-
cates in her book (viii). Such a sense of practical reading will allow us to read
narrative texts (as, in fact, Dr. Charon does) with the purpose of teaching

96  /  the chief concern of medicine

medical students and physicians to learn to attend to repeatable and system-
atic aspects of stories that are, in fact, noticeable by more than one observer,
which still do not lapse into the transcendental (and nonphenomenal) under-
standings of mathematical physics or the descriptive accuracies of evolution-
ary biology described in chapter 2.
This might be clear if we situate our discussion of narrative and phronesis
in relation to the widely accepted notion of evidence-­based medicine. In an
important article focused on a “unified approach” to evidence-­based medi-
cine, David Eddy—­who developed early papers describing the role of guide-
lines in medical decision making and claims to be was the first to use and
publish the term evidence-­based guidelines (Eddy 2005: 9 [author
description])—­ argues vigorously that evidence-­ based guidelines (EBG)
must be included in any working definition of evidence-­based medicine,
along with what he calls “evidence-­ based individual decision making”
(EBID). Eddy claims that EBID is, in fact, what is usually meant by evidence-­
based medicine (2005: 15, 17), and he contends that “without EBG, physi-
cians would have to go it alone.” “It is one thing,” he argues, “to help physi-
cians become more critical users of research papers, but quite another to
expect them to conduct systematic reviews of all the research that is perti-
nent to a decision, using rigorous methods” (15). The EBG Eddy describes
are, in fact, the algorithms of Atul Gawande’s “read-­do” checklists we de-
scribed in the introduction.15 Here, then, we are arguing that just as evidence-­
based medicine needs the algorithmic checklist of EBG (as well as the com-
pilation of the tested treatments—­ the “evidence review”—­ of “clinical
evidence” we described in the introduction) to avoid the “risk that what
makes sense from the narrow viewpoint of an individual physician and pa-
tient might not make sense from the broader viewpoint of a program or pop-
ulation” (Eddy 2005: 15), so the narrative medicine Charon has developed
might benefit from schemas and checklists that would allow physicians to
become more critical users of narrative without necessitating “systematic re-
views of all of the research [and, moreover, all of the practice] that is perti-
nent” to understanding narrative discourse (here we are paraphrasing Eddy’s
description of EBG [2005: 15], previously cited).
Although he is focused on EBG, Eddy is discussing the “product” of
evidence-­based medicine more generally. He describes “four important fea-
tures” that take up the three “closely interwoven” dimensions of science
(epistēmē) that Nussbaum outlines in her discussion of phronesis in Love’s
Knowledge (1990: 55–­82). He argues that (1) for EBG, “the ‘product’—­
whether it be an evidence review, a guideline, or another type of policy—­is

The Chief Concern of Medicine  /  97

generic” (2005: 13). Such a generic product encompasses Nussbaum’s de-
scription of science as “commensurable” across different phenomena, so that
individual cases can be understood as existing within categories or “types.”
Eddy also argues that (2) the effect of EBG on a physician’s care is “indirect,”
that is, that guidelines “are intended to enable, guide, motivate, or some-
times force physicians and other types of providers to deliver certain types of
care to people; they do not directly determine the care provided to a particu-
lar patient” (13). Such a generic understanding of guidelines also encom-
passes the fact that science gives priority of the general over the particular in
Nussbaum’s description. Eddy’s requirement that (3) EBG “use an explicit,
rigorous process” (13) encompasses Nussbaum’s description of the unemo-
tional and unimaginative nature of the science against which Aristotle devel-
oped his notion of practical reasoning (which includes imagining or consider-
ing nonexistent phenomena). Eddy’s requirement that (4) “the work of
analyzing the evidence and developing a guideline or other policy is done by
small groups of specially trained people” (13)16 is outside of Nussbaum’s
three closely interwoven assumptions of nomological science (though im-
plicit in it). But the four features of EBG that Eddy outlines do comport with
the four features of technē that Nussbaum catalogs in The Fragility of Good-
ness (2001: 95), which we have already cited: the generic nature of EBG
corresponds to the “universality” of technē; its indirection, to technē’s “teach-
ability”; its rigor, to technē’s “precision”; and its specialized analysis of the
evidence, to technē’s “concern with explanation.” In other words, Eddy’s de-
scription of EBG—­and the wider “products” of evidence-­based medicine as
well—­takes in the “science” that Nussbaum argues is the opposite to phrone-
sis and that Brian Boyd (in the manner of “one-­sided monism”) claims does
not include the systematic studies of narratology.
On the contrary, it is our contention that in the practice of medicine, the
“practical reasoning” of narrative knowledge can be taken up by technē gov-
erned by “schemas” homologous with the “evidence” of evidence-­based
medicine. A “homology” in biology possesses the same “kind of structure” (as
the Oxford English Dictionary notes) but not the same function: for instance,
the bat’s wing and the human hand are homologous. In this way, the schema
of the salient features of narrative are organized in the same (“structural”)
relation to medical practice as the algorithms of EBG, such as the “Guide-
lines on Perioperative Cardiovascular Evaluation and Care for Noncardiac
Surgery” we have mentioned or the Apgar score for newborn infants we dis-
cuss in a moment. (These two forms of evidence-­ based medicine—­the
guideline and the “score”—­correspond to a strict method of rigorous testing

98  /  the chief concern of medicine

and the method of empiricism we mentioned in the introduction, even if
they function differently.) Still, EBG and schema-­based guidelines function
differently, even if they have a similar relation to medical practice. Most rig-
orously, evidence leads to strict algorithms of behavior, Eddy’s EBG, while
the schemas we are describing lead to deliberation and negotiation. Standing
between these extremes—­participating in both—­is the less “rigorous” evi-
dence supplied by empirical experience. One model for such evidence-­based
medicine is the Apgar score for newborn infants. Atul Gawande has written
a thoughtful history of the “score” (2007), describing how what he might
describe as a checklist of measures of well-­being for infants—­color, pulse,
irritability, breathing, muscle tone—­creates what Dr. Virginia Apgar called a
“simple, clear classification or ‘grading’ of newborn infants” (1953: 22). Ap-
gar’s list is comprised of necessary and, perhaps, sufficient categories for in-
fant viability (circulation, heart, nerves, lungs, muscular development),17
while the structural features of narrative, along with strategies for discerning
the narrative “concern” or “point” and strategies for habituating “virtuous”
and useful behavior in medicine are based on necessary but not necessarily
sufficient features that can help guide judgment and action.
In other words, the schemas of narrative, strategies for physician-­patient
interaction in the course of the HPI based on those schemas, and schemas of
“virtues” in the context of the patient-­physician relations can offer physicians
simple, clear classifications for understanding, interaction with, and action in
relation to—­and in concert with—­their patients, homologous with the Apgar
score. Like the Apgar score, such schemas delineate salient features to at-
tend to, even if, unlike the Apgar score, those features remain provisional
and subject to deliberation and negotiation. Sometimes schemas suggest
provisional “guidelines” homologous with Eddy’s EBG, such as our sugges-
tion that a patient’s “chief concern” be a formal element in the patient-­
physician interview that would create an explicit moment or site of delibera-
tion based on two of the salient features of narrative, namely, that narrative
has an end and that it is articulated and received. At other times, as we argue
in chapter 8, salient features of narrative such as its small number of recog-
nizable agents and its sequence of events give rise to “vicarious” experience
from which a witness can learn.18 In other chapters, we offer other schemas:
in chapters 5 and 6, schematic verbal responses by physicians that express
and, we believe, provoke empathy; in chapter 7, the schema of “hot words”—­
particular words in the patient’s story—­that should trigger physician atten-
tion; also in chapter 7, Roman Jakobson’s schematic description of the six
elements of any speech act; and in chapter 9, a nonexhaustive list of Aristo-

The Chief Concern of Medicine  /  99

telian “virtues” that grow out of the actions of medical practice that also serve
to focus attention in the way that the Apgar score does. (In that chapter, we
also present the American Medical Association’s “protocol” for developing
and articulating goals of medical care.)
As we noted in the introduction, such schemas, first of all, present a con-
cise arrangement—­a list, a table, or a chart, comparable to the systematic
declensions of grammar or, better, to the periodic table of chemistry—­that
makes implicit relationships among its parts or “features” (elements) explicit.
But a schema also offers an example of a phenomenon in a manner that a
narrative offers—­and, indeed, provokes—­the example of (vicarious) experi-
ence itself. Finally, a schema describes a generally accepted or “normal”
worldview that, conceived as a “paradigm” (in Kuhn’s sense of the word), al-
lows for the possibilities, described by Thomas Kuhn, of “a conceptual or
methodological change in the theory or practice of a particular science or
discipline” (Oxford English Dictionary, s.v. paradigm). In all of these under-
standings, the conception of schema-­based medicine we are suggesting both
assumes and demonstrates that one can approach narrative and interchange
in a manner of systemizing procedures (technē), if one does not assume that
systematization needs to be, at best, necessarily and sufficiently “formulaic”
(or quantitative) in the manner of mathematical physics or, at least, suffi-
ciently “explanatory” in the manner of evolutionary biology. Instead, it can
offer a systematic program—­a technē—­for practical reasoning leading to an
end of action in relation to the different functions of deliberation and nego-
tiation rather than formulaic truth or retrospective explanation. In this way,
schema-­based medicine is homologous with the two forms of evidence-­based
medicine we have described. (In appendixes 2 and 3, we present schemas
related to three sets of “skills”: listening [narrative knowledge], interviewing,
and ethical action.)
If one does not assume that the methodical skills of technē require either
the formulaic-­quantitative reasoning of mathematical physics or the means-­
ends reasoning of evolutionary biology, one can approach narrative in terms
of construed “speculation” based on necessary but not sufficient data, the
very schemas of narrative that can, in fact, be organized into a systematic
starting point—­a technē—­for practical reasoning that is universal, teachable,
precise, and concerned with explanation. Patrick Colm Hogan describes
such a necessary but not sufficient description of narrative under the cate-
gory of prototype (2003), and the studies in evolutionary psychology that
Slingerland and Boyd cite—­as well as the particular work of Steen—­do so
under the category of neural systems or cognitive modules. But structural

100  /  the chief concern of medicine

narratology attempts to articulate a general structure of narrative in relation
to its salient features; that is, it is possible both to teach and to practice in a
systematic fashion the “skills” that Charon describes of narrative comprehen-
sion and medical phronesis in relation to the salient features of narrative. In
this way, a general account of narrative organized around its necessary but
not sufficient structural features can lend itself to technē that is universal,
teachable, precise, and concerned with explanation. Such a technē is not
comprised of necessary and sufficient procedures to articulate formulas ad-
equate to the phenomenon examined (as one might find in mathematical
physics and in the double-­blind randomized control trials of evidence-­based
medicine) or descriptions of what might comprise sufficient data to articulate
a means-­end explanation (as one might find in evolutionary biology and in
the empirical evidence at the base of the Apgar score). Nevertheless, it could
create schemas and even algorithms of possibilities that might help shape the
deliberations of phronesis in a systematic, but not definitive, method, just as
Charlie Parker systematically practiced eight or ten hours a day to achieve
the “method” of improvisation, which is not quite definitive. (As we noted
earlier, Nussbaum argues that improvisation is a necessary element of practi-
cal reason [see 1990: esp. 94–­97]. In a very different tenor, Steen argues that
improvisation is a necessary element in the “construals” of adaptive narrative
structures recognizable in the “playfights” of rhesus monkeys [2005: 97–­
100].) Such a system, we are suggesting, can be found in a structural narra-
tology based on the action and actors of narrative, which Phelan and Smith
describe; the action of phronesis, which Aristotle describes; the salient ele-
ments of narrative, which we describe in this chapter; and the everyday ac-
tions of physicians in their work, as discussed in Part 2 of this book.
At the heart of narrative are the six features we have outlined, all of which
focus on the action of narrative: (1) its sequence of events and (2) the actions
of its agents, culminating in its (3) “end” (both its completion and its goal or
point); (4) the fact that narrative is articulated and received—­that it possesses
a “teller” and a “listener” and presents “the dynamic interplay of two tempo-
ralities” (Kreiswirth 2000: 313)—­which results in (5) the acquisition of knowl-
edge by a witness who learns; and (6) the fact that it approximates “experi-
ence” itself.19 There is a model of the “general structure of narrative” that
accounts for the first four of these features and that might suggest, as well, the
comprehension of the fifth feature leading to the sixth feature. As we men-
tioned earlier, Greimas creates an “actantial” analysis of narrative. By “ac-
tants,” he means the agents of narrative—­he calls them actants because, as
we noted, inanimate objects in narrative can function as agents—­and he de-

The Chief Concern of Medicine  /  101

scribes these actants as defined by spheres of activities (1983: 197), thus com-
bining the sequence of action and the agents of narrative, two of the features
we have described. Taking up Vladimir Propp’s analysis of the Russian won-
der tales and Claude Lévi-­Strauss’s reduction of the thirty-­one elements in
Propp’s analysis, Greimas drastically limits the number of actants to six:

hero,
heroine (wished-­for good),
helper,
opponent,
sender,
receiver.20

In heroic tales, the wished-­for good is the desired heroine; and in Aristotle,
it is eudaimonia itself (perhaps the very “bliss” of Charon’s “desire”).
More generally, and in terms of evolutionary cognition, Steen uses the
example of “Little Red Riding Hood” to describe “the predation theme ubiq-
uitous in mammalian play [that] is put to novel and specifically hominid uses”
(2005: 101), in terms of four categories (besides the “setting”) that, we sug-
gest, correspond to Greimas’s actants. Thus he describes

the agent (Little Red Riding Hood), instantiating Greimas’s “hero”;

the setting (the forest);
the goal (survival), instantiating Greimas’s “wished-­for good” or “object”;
the obstacle (the wolf), instantiating Greimas’s “opponent”; and
the little girl’s resources (her imperfect understanding of the danger),
instantiating Greimas’s “helper.” (2005: 92)

Steen models his categories on the predation theme and nicely describes
“playfights” of rhesus monkeys instantiating the elements and functioning of
narrative to “construe” future behavior; and he notes that improvisation
(which, as we have seen, Nussbaum recognizes in phronesis) is a necessary
element in the “construals” of adaptive narrative structures and is recogniz-
able in their “playfighting” (2005: 97–­100; Steen does not discuss Greimas).
Greimas models the actants on the parts of speech of the sentence—­
speech acts rather than Steen’s acts of improvised play—­reasoning that just
as we absorb, unconsciously, what Sacks calls the “immensely intricate and
formal” structure of language within the first few years of life, so we similarly
absorb the intricate formal structure of narrative within those first few years.

102  /  the chief concern of medicine

(Evolutionary cognition posits that the ability to “absorb” both language
structures and narrative structures from experience is an inherited evolu-
tionary adaptation.) Such a schematic account of narrative structure creates
a conscious awareness of the working and comprehension of narrative and
perhaps—­as some have suggested—­of “experience” itself. It also allows us to
recognize the narrative ingredient in Aristotle’s practical reasoning—­
reasoning pursuing ends—­for the attainment of practical wisdom in life and
of the status of a phronimos in medicine. In Greimas’s model, the hero func-
tions like the subject of a sentence; the heroine (or wished-­for good) func-
tions like the object of a sentence; and in his early discussions, the helper and
opponent function like adjectives (though Greimas later described them as
more generally functioning like the modalities of a sentence). The sender
and receiver, in combination, define the situation of narrative communica-
tion, the teller and listener that Charon describes. (As representing an actan-
tial “frame” for the act of narration itself, the sender and receiver also sug-
gest the interplay of two temporalities in narrative.)
An important aspect of Greimas’s actantial analysis of narrative that
makes the connection between narrative and phronesis explicit is that the
actants are “syncretic”: that is, a particular actor in a narrative can serve more
than one actantial role. Most important, one or another of the four initial
actants—­hero, heroine, helper, opponent—­is always combined with the “re-
ceiver” at the end of the narrative, and this syncretism, in fact, defines the
particular genres of a narrative as it marks the end of a narrative altogether.
The categories of genre can be understood as versions of Hogan’s “proto-
types.” Genre also is a precise example of Gureckis and Goldstone’s descrip-
tion of “the key function of a schema” as providing “a summary of our past
experiences by abstracting out their important and stable components”
(2011: 725) and of Nickles’s sense that a schema is “a device for structuring a
complex situation or set of inputs into an organized whole” (1998: 78). Here
is a schematic list of four particular genres of art narrative as Greimas de-
scribes their defining features in terms of actants:

Heroic melodrama (epic): a heroic narrative, where the hero also re-
ceives the wished-­for goods (in myth and tradition, the bride and the
kingdom); this is the form of the Russian wondertale that Propp stud-
ied and of many myths and folktales that Lévi-­Strauss studied.21
Comedy: a comic narrative, where the heroine receives the wished-­for
goods (in myth and tradition, the hero as husband and the estate of
marriage).

The Chief Concern of Medicine  /  103

 Tragedy: a tragic narrative, where the helper receives the wished-­for
goods (both the storied knowledge of what has taken place on the
level of the individual destruction of the hero and the promised re-
construction of the community on the brink of collapse with the de-
struction of the hero, which is often accomplished by the helper [e.g.,
Creon or Horatio], on the level of the social).
Irony: a more or less “modern” narrative, where the opponent receives
the wished-­for goods (to destroy them on the level of the individual
and to transform them on the level of general value).22

In this schematic account of narrative actors and narrative genres,23 we are

positing a necessary but not sufficient provisional structure of narrative.
Awareness of such a structure of salient features to attend to can help a phy-
sician hear her patient more fully and analyze together with him what is to be
done. For example, with this schematic understanding of narrative in mind,
it is easy to see that the attending physician in the medical narrative of Mrs.
Jones that we presented earlier assumed for himself the role of hero, pursu-
ing the good of his patient’s health, with the “help” of his knowledge of med-
icine in general, faced with the opponents of her condition in particular and
her resistance to treatment based on folkoristic medical belief. The second
physician in the narrative assumed for himself the role of helper, imagining
that his patient is the hero and that, together, they can achieve the wished-­for
good of her health. In other words, an understanding of the features of nar-
rative allows a physician to conceive of his work in terms of different possible
narrative roles he can assume within a particular situation. After all, there are
patients who want their doctors to take charge, like a hero, even as there are
patients who seek a helper. Sometimes, unhappily, there are patients who
even conceive of their physicians as, somehow, their opponents; perhaps this
was Mrs. Jones’s assessment, and nothing the first physician did mitigated
this judgment. Dr. Kelekian in Margaret Edson’s Wit, discussed in chapter 9,
can be understood, by patient and audience alike, as inhabiting this role of
opponent.

The Narrative Phronesis of Medicine

The necessary but not sufficient general account of narrative we are present-
ing lends itself to a technē of possible understandings, rather than to the
mastery of necessary and sufficient formulations or sufficient explanations. If

104  /  the chief concern of medicine

technē’s most usual translations in English are “science,” “craft,” and “art,” as
Nussbaum suggests, then we can imagine it in terms of the science of univer-
sal formulas, the craft of sufficient explanation, and the art of possibilities of
deliberation. The art of possible deliberation would be guided by a schema,
something, we already noted, analogous to the periodic table, a systematic
framework for deliberation. Such a systematic framework would be general
(or even universal), teachable, precise, and concerned with explanation, un-
derstood as the goals governing practical reason. A technē of deliberation
would create a framework in which the end of narrative would call out for
consideration, even by physicians who have not had the opportunity or time
for more intense narrative training.
In medicine, this would be particularly clear and particularly useful. Phy-
sicians are confronted with the not-­yet-­completed narratives of patients. Pa-
tients come to physicians with stories that do not yet have an end, and it is
from the physicians that they wish to obtain such an end, either by direction
(with the doctor as hero) or by deliberation and negotiation (with the doctor
as helper). In other words, patients come to physicians with a basic demand—­
“Make me well”—­and three basic questions:

“What is my condition?” (i.e., “What do I have?”),

“What should I do?” and
“What, specifically, do I want?”

The last question is often asked much less explicitly, particularly when there
is no easy answer to the demand. While the demand seeks a necessary and
sufficient answer, and while the first and second questions seek a sufficient
answer, the question “What do I want?” describes the field of deliberation—­
the site of narrative phronesis—­that is, as we are suggesting here, closely
connected to the “chief concern” of the patient and closely connected to the
practical reasoning and the narrative knowledge of medicine altogether. It is
in relation to this last question that a schematic “periodic table” of narrative
phronesis can help develop for the physician the art of the possible—­possible
understandings of “health”—­in relation to the demands of illness and the
costs and benefits of treatment.
We have already suggested that the salient features of narrative schemas
are more readily discernible in art narrative than in popular narrative, insofar
as art narrative more self-­consciously takes up narrative features to create
aesthetic patterns and responses. So we conclude this chapter with a short
analysis of a story by Grace Paley that describes the encounter between a

The Chief Concern of Medicine  /  105

patient and his storytelling daughter, “A Conversation with My Father.” This
art narrative offers greater narrative detail than the story of Mrs. Jones, and
such detail allows for a more precise understanding of how it articulates and
conveys narrative knowledge. This story, like the story “Magic” that Phelan
analyzes (see n. 6 in the present chapter), presents “parallel acts of telling”
between a character in the story and the story itself, acts that promote strong
“focus on teller, technique, story, situation, audience, and purpose: all the
elements that help determine the shape and effect of the story” (Phelan
1996: 4). In other words, the kind of attention that art narrative commands—­
like the attention museums command—­forces a kind of detachment from
the situation of telling; it makes more discernible the difference between the
discourse (how a story is presented) and the story (the interrelation of narra-
tive elements themselves). Although we rendered Mrs. Jones’s story in the
third person, we originally encountered it in the first person, narrated by the
first attending physician. His point—­his chief concern in telling the story—­
was precisely to distinguish his own interaction with his patient from the
more effective and pragmatically caring action of his colleague, the second
physician. In doing so, the first physician narrator (sender) offers a lesson for
students and other physicians, on the “telling events” that constitute “an ef-
fortful process we undertake only to direct the attention of others to events
real or imagined” (Boyd 2009: 382). In this way, popular narrative (as distin-
guished from art narrative) performs an action in the world with some puta-
tive goal—­the very functional realism we described in chapter 1.
The attention that art narrative commands and provokes, again as Phelan
demonstrates, is different from this: it encourages the discernment of the
“cognitive, emotive, and ethical responses” that narrative provokes and of
“the complexity of the relationship between facts, hypotheses, and theories”
(Phelan 1996: 14–­15). In Paley’s story, the narrator’s eighty-­six-­year-­old fa-
ther, suffering from heart failure and “sitting on one pillow, leaning on three,”
“offers last-­minute advice and makes a request” (1974: 161). His request for
his daughter is relatively simple: “‘I would like you to write a simple story just
once more,’ he says, ‘the kind de Maupassant wrote, or Chekhov, the kind
you used to write. Just recognizable people and then write down what hap-
pened to them next’” (161). His daughter then thinks to herself that she

would like to try to tell such a story, if he means the kind that begins: “There
was a woman . . .” followed by plot, the absolute line between two points
which I’ve always despised. Not for literary reasons, but because it takes all

106  /  the chief concern of medicine

 hope away. Everyone, real or invented, deserves the open destiny of life.
(161–­62)

In this observation, Paley’s narrator—­and Paley herself, insofar as the stories

the narrator’s father objects to are very much like stories Paley has written—­
touches on the aesthetics and politics of storytelling as Walter Benjamin de-
scribed it in the essay we cited in chapter 2, where he describes how story-
telling, like practicing physicians, offers counsel and, indeed, “wisdom” as
well. (We should note again that phronesis is translated as both “practical
reason” and “practical wisdom.”) Such wisdom and counsel, Benjamin ar-
gues, arise from the fact that, in his judgment, stories are necessarily open-­
ended—­not-­yet-­completed—­while novels gain the power from their com-
pletion in the death of its characters. “The novel is significant,” Benjamin
writes, “because this stranger’s fate by virtue of the flame which consumes it
yields us the warmth which we never draw from our own fate. What draws
the reader to the novel is the hope of warming his shivering life with a death
he reads about” (1969: 101).
For Benjamin, stories are different: they perform the deliberative work
of phronesis. They do the work of deliberation insofar as an “oral tradition”
accomplishes this work—­“that slow piling one on top of the other of thin,
transparent layers which constitutes the most appropriate picture of the way
in which the perfect narrative is revealed through the layers of a variety of
retellings” (1969: 93). One can imagine the story of Mrs. Jones functioning
this way, as it is repeated and retold to students and physicians. But Paley
self-­consciously does this, piling story upon story in “A Conversation with My
Father”—­the story of daughter and dying father and the stories her narrator
tells, of a mother and drug-­addicted son. In the face of her son’s addiction,
the mother in the narrator’s story begins using drugs herself, to be close to
her son—­something that the narrator cannot do with her dying father—­and,
in the end, the son overcomes his addiction and will not see his addicted
mother. In the course of the narrative, the narrator tells the story twice, be-
cause her father repeatedly asks for realistic details, such as we find in Chek-
hov and de Maupassant. Paley’s narrator attributes this to the fact that her
father “had been a doctor for a couple of decades and then an artist for a
couple of decades and he’s still interested in details, craft, technique” (1974:
164). But the story itself suggests, as D. S. Neff has noted, that this can also
be attributed to the fact that “the daughter retreats to the comforting realm
of metaphor while the father strives to demystify her evasions in an attempt

The Chief Concern of Medicine  /  107

to help her accept his imminent death” (1983: 119). In any case, “A Conver-
sation with My Father” becomes a narrative that explores the nature of sto-
rytelling itself. Thus the daughter in Paley’s story notes that she often mis-
judges her characters, thinking them more extraordinary than they are, and
that “you just have to let the story lie around till some agreement can be
reached between you and the stubborn hero” (1974: 164).
The father, Paley’s stubborn hero, and his daughter present two of the
genres of narrative that Greimas suggests in the schematic account of genre
implicit in his work: tragedy and comedy. In calling on this genre schema,
we are pursuing a somewhat superficial reading of this narrative, a necessar-
ily “quick” reading based on schematic narrative features that, for literary
critics, might well be a starting place of analysis rather than its achievement.
In this way, the systematic review of narrative features we are conducting is
parallel to what Eddy describes as the “systematic reviews of all the research
that is pertinent to a decision, using rigorous methods” (2005: 15), which
create the shorthand of “guidelines” or procedures that a physician can fol-
low. In the schema-­guided understanding, we can see this opposition of
tragedy and comedy by asking who receives the cultural value at the story’s
end. In tragedy—­and the father explicitly exclaims, “Tragedy! Plain tragedy!
Historical tragedy! No hope. The end” (1974: 167)—­it is the helper (in Pal-
ey’s story, the daughter) who is left to carry on at the story’s putative end (the
death of her father), without the hero. In comedy, the object of desire is
syncretized with the receiver and establishes a flourishing world united with
the hero. In the story the daughter tells her dying father in Paley’s narrative,
the boy—­the object of his mother’s desire—­recovers his true (“healthy”) self
in the presence of his new girlfriend. In the second, more elaborate narra-
tive that the daughter tells her father, the narrative depicts the son’s addic-
tion as “not hopeless”; in fact, he meets a young woman and “in the organic
heat of her continuous presence he could not help become interested once
more in his muscles, his arteries, and nerve connections. In fact, love them,
treasure them” (1974: 165). In this opposition of two narrative genres, as
Neff has written in a fine account of this story from the vantage of end-­of-­
life medicine,

the father’s subjective experience as a dying physician is validated by seem-

ingly objective patterns of tragic art. The daughter nurtures a comic perspec-
tive because her age and health enable her to comfort herself with half-­
evasions of ultimate truth that help humankind to live with death and survive
with hope. (1983: 123)

108  /  the chief concern of medicine

The story as a whole, however, in its aesthetic enactment of this opposition,
“concludes,” as Neff says, with “ironic stasis”—­the very kind of the modern
genre of irony that Greimas’s genre schema suggests—­where the opponent,
death, seems irresistible.
Even so, the parallel stories in Paley also leave us with something else as
well. As Neff notes, while the characters in this story “never fully understand
each other, . . . it is the initiative shown by both parties that matters”: both
father and daughter are trying to find consolation and love in the face of
death by employing narrative. “The expressive wars of Paley’s characters,”
Neff concludes, “make us realize that love exists beyond the confines of trag-
edy and comedy, and that the most mature art, like the most ethical physi-
cian, must revel in a capacity for self-­transcendence in an endless quest to
encompass life’s inexplicable mixture of endings and renewals” (1983: 123–­
24). Both Paley and her character do this through the aesthetics of narrative;
that is, both the narrator’s story of the woman across the street and her son
and Paley’s story of father and daughter offer the kinds of aesthetic detail that
Chekhov calls on when he insists that one must not put a loaded rifle on the
stage if no one is thinking of firing it. The second version of the story that
Paley’s narrator tells her father begins, “Once, across the street from us,
there was a fine handsome woman, our neighbor. She had a son whom she
loved because she’d known him since birth (in helpless chubby infancy, and
in the wrestling, hugging ages, seven to ten, as well as earlier and later)”
(1974: 164). In this opening—­as in Benjamin’s essay—­we can discern the
chief concern of this story in the very details and even the “unsaid” details
(“as well as earlier and later”): namely, the love between parents and chil-
dren, the connections between generations. This concern permeates all the
elements of this short narrative, the six salient features we have described:

the parallel sequence of events (divorce between children and parents);

recognizable agents (inhabiting recognizable narrative roles: hero/object
of desire; parent/child);
the story’s end (literally the words “the end” at the end of the story, as her
father says, “Poor girl, to be born in a time of fools, to live among
fools. The end. The end. You were right to put that down. The end”
[166]);
the fact that the story the narrator tells is clearly articulated and received,
and so, too, is “A Conversation with My Father”; and
the fact that the narrative itself gives rise to a sense of experience itself, in
its characters and in those who listen to the stories.

The Chief Concern of Medicine  /  109

The final element of this narrative is the witness who learns—­in fact, the nar-
ration’s two witnesses, both daughter and father, who learn. In this narrative,
the daughter rewrites her story, and the father also learns from experience:
“He inserted the tubes into his nostrils and breathed deep. He closed his
eyes and said, ‘No’” (167). But the larger story’s readers—­lay readers and
physicians—­are also witnesses who learn from the “experience” of this nar-
rative and renew their concern in the face of death.
What we, as readers, also learn is the way in which the “point” of a story
is negotiated between listener and teller: each clarifies and complicates the
other in the work of phronesis. What physicians and medical students learn
is the very concern that is at the heart and at the “end” of a story: how a dying
person tells and hears a different story from the living; how the absoluteness
of endings—­even the “happy” end of eudaimonia as well as the “tragic” end
the father in the story feels—­can be inflected within the community of nar-
rative. Paley’s story silently addresses the patient’s first question (not his de-
mand) that we described earlier, “What is my condition?” The “condition” of
characters, storyteller, and listener—­mother and son, father and daughter,
reader and writer—­is that of mortality. Moreover, this condition gives rise to
a response to the patient’s question “What should I do?”: the response is to
talk about it directly or indirectly, in deliberations concerning both hope and
hopelessness, love and loss, ending life and ongoing life. The answer to the
patient’s question “What do I want?” hovers around the two not-­ yet-­
completed narratives Paley presents. The father ends by saying “truth first,”
meaning, among other things, the truth of his dying condition. But when
Paley first published this story in Enormous Changes at the Last Minute, she
added a note at the beginning of the collection of stories: “Everyone in this
book is imagined into life except the father. No matter what story he has to
live in, he’s my father, I. Goodside, M.D., artist, and storyteller.—­G. P.” Here
she includes other truths, including the “experience” narrative affords us and
the work—­and wisdom—­of practical reasoning that it occasions. Such a
schematic, “aesthetic” grasping of this story—­Phalen would call it a “rhetori-
cal” in its very deliberations among possibilities—­can follow from schemas
and algorithms of reading and listening (outlined here and in later chapters
and appendixes) that can teach engagement, understanding, and discern-
ment to physicians striving—­as we see in both physicians in Mrs. Jones’s
story and in the profession by and large—­to do the best by their patients.

110  /  the chief concern of medicine

4
the logic of diagnosis
Peirce, Literary Narrative, and the
History of Present Illness

In chapters 2 and 3, we examined the practical wisdom of the physician in

relation to narrative and, particularly, the chief concern of the narratives pa-
tients bring to their physicians. In this chapter, we will continue examining
the role of narrative in the practices of medicine, but with particular focus on
the ways narrative can contribute to diagnostic skills. Specifically, we will
examine the logic of hypothesis formation that Charles Sanders Peirce ar-
ticulated at the turn of the twentieth century, and we hope to demonstrate
that his “logic of abduction,” as he called it, approximates the “practical syl-
logism” that Aristotle describes in the Nicomachean Ethics and elsewhere.
At the heart of this practical syllogism is hypothesis: “as Aristotle often tells
us,” Martha Nussbaum notes, “teleological explanation requires the intro-
duction of a special notion of necessity, the ‘hypothetical’: if a goal is to be
reached, certain things must take place or be present” (1978: 177). The sys-
tematic achievement of a precise hypothesis is the work of both the physician
and Peirce’s logic of abduction. In other words, diagnosis is also a phronetic
skill, and Peirce, particularly, described its systematic procedures, its technē.

Introduction

As we have noted, the most frequent procedure a doctor performs is a pa-

tient interview. Interviews occur over two hundred thousand times in the
professional lifetime of a physician. This verbal and nonverbal interaction
forms the backbone of the patient-­doctor relationship. Despite this being the

/  111  /
most common procedure, the physician’s performance in this arena results in
the most common complaints about doctors: “My doctor does not listen to
me” and “My doctor does not seem to care.” Interestingly, patient dissatisfac-
tion almost never centers on the idea that the doctor does not seem to know
enough medicine. It is also common wisdom in medical education that the
most powerful diagnostic information is the patient interview, specifically the
History of Present Illness (HPI), which, in fact, is a significant focus of this
book. The HPI is the portion of the patient’s story of illness in which the
patient tells the symptoms, the time frame of the illness, the relationship of
the various symptoms, and his or her interpretation of them. The physician’s
task in this portion of the interview is to understand the patient’s story in the
context of the nonverbal clues for such things as anxiety, anger, or depression
that may also be present. Very often, the physician must facilitate a story
from a patient experiencing one of these uncomfortable emotions. As we
have suggested, the inclusion of the patient’s “chief concern” as well as her
“chief complaint” could go a long way toward facilitating the story and, in-
deed, realizing phronesis on the part of the physician. In any case, the cumu-
lative task of facilitating and engaging in the HPI requires enormous skill,
which is not encouraged in much of the curricula of medical school. Many
studies in the medical education literature report that medical students be-
come worse at these tasks as medical school progresses. If the doctor can
successfully obtain the story (HPI) and put it together appropriately, he or
she must then apply a rigorous logic to this information in order to arrive at
the correct diagnosis. Without a sense of this logic, problems leading to im-
proper diagnoses can—­and often do—­attend the HPI.
The process just described can be understood—­and incorporated into
the practices of working physicians—­by discerning the logic of diagnosis in
relation to literary narrative. The elements and structures of narrative—­
especially art narratives found in novels and short stories—­illuminate, in
many ways, the narratives that patients tell their doctors (besides the refer-
ences in chapters 2 and 3, see also Charon 2004; Charon 2006b; Hunter
1999: esp. 305–­8). The purpose of this chapter is to examine the basic meth-
ods and skills that allow successful physicians to develop and utilize the HPI
to the fullest extent for the purposes of diagnosing the patient’s condition,
just as the preceding chapter examined narrative for the purposes of devel-
oping the negotiation of the goals of medicine and the particular definition of
health that governs the treatment of the diagnosed condition. We began with
that aspect of the role of narrative both to set forth a systematic understand-
ing of narrative that might appeal to people trained in science and also to

112  /  the chief concern of medicine

describe the ends of medicine before studying the method (technē) of diag-
nosis and treatment. Like narrative knowledge, both Aristotle’s “practical syl-
logism” and Peirce’s “logic of abduction” are susceptible to the systematic
practices of technē.1 In this chapter, we examine the logic of hypothesis for-
mation, the uses of a knowledge base, and the reflective feedback of the
physician-­interviewer in relation to literary narrative. We are assuming that
the creation of hypotheses is not simply a process of good “guessing” but,
rather, is a skill that is acquired. This skill, like the narrative knowledge of the
preceding chapter, falls under Aristotle’s category of phronesis and, in fact, is
closely related to the kinds of understanding that narrative discourse facili-
tates. As we have already noted, people—­even young children—­can distin-
guish between well-­formed and ill-­formed narratives with the same skill they
use to distinguish between grammatical and ungrammatical sentences.
These seeming intuitions are skills that are learned—­that is, they can be en-
couraged, refined, and sharpened—­by making them more consciously ex-
plicit to people in their execution. By discovering, in what often seem to be
lucky, intuitive guesses, the provisional retrospective comprehension of nar-
rative we have discussed, physicians can discern the logic of hypothesis for-
mation and develop forms of attention that can make the facilitation of the
HPI and subsequent diagnoses less haphazard. An important place for such
discovery, this chapter argues, is the analysis of detective stories and their
relation to Peirce’s abduction. Detective stories provide powerful narrative
analogues to both HPIs and the diagnoses they lead to.
The diagnostic process, like the process used by both Sherlock Holmes
and Auguste Dupin in the detective stories of Arthur Conan Doyle and Ed-
gar Allan Poe, has been referred to as “hypothetico-­deductive” reasoning
(Kaplan 1995: 20–­31). Diagnosis has at least three elements. The most
obvious—­and often seemingly the only element—­is a large knowledge base,
empirical knowledge about illnesses and their symptoms. But diagnosis also
requires a “method” of hypothesis formation, a procedure for beginning di-
agnosis. The knowledge base is always brought to bear on the presentation of
illness after some method of procedure, even if its method is not deliberated
on and remains unconscious or habitual: the existence and results of an
always-­present “method” (even when the experience feels like self-­evident
intuition) is the governing assumption of pragmatism we described in chap-
ter1, even if the logical positivists believed they had access to “pure” self-­
evident perception, uncluttered by cognitive schemas and historical social
conventions. For this reason, we begin here—­and spend the most time—­
describing the method, or what we are calling the logic, of hypothesis forma-

The Logic of Diagnosis  /  113

tion. The third element of diagnosis is reflection on the presentation in rela-
tion to the “hypothetical” possibilities of diagnosis that arise out of the
conjunction of the logic of analysis and medical knowledge that the
physician—­like the detective of narrative fiction—­brings to the patient’s
story, the HPI. Such reflection underscores the provisional nature of the re-
sult or ends of method. In this chapter and more fully in Part 2 of this book,
we will characterize this as the “pause and reflection” that stimulates inter-
pretation both in encountering patients and in reading narrative, and we
describe it here as the third element of diagnosis. Such a moment of pause
and reflection is, in fact, the moment of deliberation and negotiation that is
part and parcel of narrative knowledge. In chapter 3, we argued that it takes
place between the teller and the listener, in the telling and retelling of stories
that Walter Benjamin took to be the source of narrative power. In the logic
of diagnosis, it takes place within contemplations of what Peirce calls differ-
ent kinds of “characters” or “characteristics” of fact (1992: 140).

The Logic of Hypothesis Formation

Abduction

The initial element of diagnosis is the logic of hypothesis formation. As we

mentioned, this can be more or less conscious, and most experienced physi-
cians have worked out this “logic,” through years of practice, so that it is vir-
tually habitual. (Precisely such habitual behavior has led many to assume that
the “practical reason” of phronesis does not lend itself to systematic univer-
sality, teachability, precision, and self-­conscious concern with explanation.)
At the end of the nineteenth century, the American philosopher Charles
Sanders Peirce studied and attempted to formulate the reasoning of hypoth-
esis formation in what he called the logic of “abduction.” Abduction seeks an
explanation of a particular fact or event by finding some salient features of
the particular fact that allow it to be explained by some more general causal
principle: “abduction,” Peirce writes, “is the process of forming explanatory
hypotheses” (1931–­58: 5.127). In the logic Peirce formulated, abduction
forges a connection between a “case” and a “rule,” what Thomas Nickles
describes in his definition of a schema as “the old Greek and Kantian prob-
lems of relating universals or abstract concepts to particulars in humanly ac-
cessible ways” (1998: 78). Nevertheless, the crucial problem is determining
what is “salient”—­as much in particular diagnoses as in the more general
categories of health and of the ethics of phronesis. Harry Frankfurt has noted

114  /  the chief concern of medicine

that “Peirce gives no systematically coherent account of abduction” (1958:
593). Even so, Peirce does formulate a description of abduction in a syllo-
gism that sounds remarkably like a narrative.

The surprising fact, C, is observed

But if A were true, C would be a matter of course
Hence, there is reason to suspect that A is true. (1931–58: 5.189)

That C follows A as a “matter of course” is what we are contending is the

narrative element of abduction—­it is precisely the “sequence of events” we
described in narrative—­and, indeed, is the reason that self-­conscious under-
standing of narrative can contribute to successful diagnoses. In fact, as we
argue, the connection between “case” and “rule” is the very “point” of a story
grasped as a meaningful whole.
In what has been come to be called his “Bean Bag analogy,” Peirce de-
scribes how abduction differs from induction and deduction. In the follow-
ing example, we are modifying Peirce’s syllogism in order to more clearly
elucidate its applicability to medicine (and also to reflect the apprehension of
“case” and “rule” as a meaningful whole).

deduction
Rule—­All the children in this class have measles.
Case—­These children are from this class.
∴Result—­These children have measles.
[A state of affairs (present tense)]

induction
Case—­These children are from this class.
Result—­These children have measles.
∴Rule—­All the children from this class have measles.
[Action: they should have been quarantined (past subjunctive)]

abduction
Result—­These children have measles.
Rule—­All the children in this class have measles.
∴Case—­These children are from this class.
[Action: they must be quarantined (future imperative)]2

Besides modifying the “content” of Peirce’s syllogisms, we have also added,

in induction and abduction, an “action” associated with the case. (The time-

The Logic of Diagnosis  /  115

less “nomological” nature of deduction allows not for action but just for a
state of affairs.) We have an “action” because the end of Aristotle’s “practical
syllogism” is action, and we want to demonstrate the relationship between
Aristotle’s practical syllogism—­related, as it is, to the practical reason of
phronesis—­and Peirce’s logic of abduction. In Peirce’s logic, abduction works
toward the “case” rather than the “result” of deduction and the “rule” of in-
duction, and it is precisely the “case” that is the site of action. In the Nicoma-
chean Ethics, Aristotle argues that “the intuitive reason involved in practical
reasonings grasps the last and variable fact, i.e. the minor premise” (6.11;
trans. Ross)—­the “case” in the deductive syllogism—­and the minor premise
calls for action. In this way, deduction simply describes a state of affairs—­
necessary and sufficient conditions of truth—­governing no action at all. In-
duction, in this analysis, describes the sufficient but not necessary truth of a
matter of (past) fact, and if it governs any action at all, it is the contrary-­to-­
fact subjunctive of purely theoretical action. Abduction, finally, ends with the
case and, implicitly, with the future oriented promise of purport—­of what
needs to be done—­that we discussed in chapter 2. As Nussbaum argues, “the
so-­called conclusion [of the practical syllogism] is, in the practical case, not a
proposition at all [neither, we should add, is it a present-­tense matter of fact
or a past-­tense subjunctive contrary-­to-­fact], but an action. That is, the fac-
tors that . . . Aristotle will call premises lead to action, not just to verbalizing
or thinking” (1978: 186).
Such practical action grows out of hypotheses, and in situating abduction
in relation to deduction and induction, Peirce has suggested that these three
kinds of reasoning are all “based upon the idea of an hypothesis” (Burks
1946: 308). “Abduction invents or proposes hypotheses,” Arthur Burks has
argued.

It is the initial proposal of an hypothesis because it accounts for the facts.

Deduction explicates hypotheses, deducing from them necessary conse-
quences by means of which they may be tested. Induction tests or establishes
hypotheses. . . . “Abduction [Peirce writes] is the process of forming an ex-
planatory hypothesis. It is the only logical operation which introduces any
new idea; for induction does nothing but determine a value, and deduction
merely evolves the necessary consequences of pure hypothesis” (5.171).
(Burks 1946: 303)3

In our measles version of Peirce’s Bean Bag analogy, the implicit hypothesis
in the abduction syllogism is that there is some (logical? empirical?) connec-

116  /  the chief concern of medicine

tion between the facts of having measles and being a member of a particular
class: the particular implicit hypothesis is that measles is contagious, so that
it issues from the fact that “these children are from this class.” Abduction
invents the hypothesis by suggesting a temporal/causal sequence, which is
inexplicit in the Bean Bag analogy: measles, unlike Peirce’s white beans, is a
condition that has a discoverable history. (As in narrative, the causal element
transforms the temporally presented facts into the seemingly instantaneous
apprehension of a “meaningful whole.”) Induction tests this hypothesis:
given the (hypothetically) contagious nature of measles, it assumes that chil-
dren from the class have it, and it examines a reasonable number to confirm
its assumption. Finally, deduction explicates this state of affairs; that is, the
Rule “All the children in the class have measles” can be rewritten as an ex-
plicit statement of the implicit hypothesis of the abduction syllogism “In this
class, measles is contagious,” leading to a more explicit syllogism:

deduction
Rule—­In this class, measles is contagious.
Case—­These children are from this class.
∴Result—­These children have measles.

Abduction transforms the general rule from universal statement to historical

event, which, unlike the timeless state of affairs in deduction (and in the
formulaic science of mathematical physics) and the matter of past fact in in-
duction (and in the explanatory science of evolutionary biology), calls for
subsequent events, subsequent action.4 Aristotle’s “practical syllogism” ends
in action or “event,” and by describing abduction as ending with the case—­
the minor premise—­Peirce’s abduction does so as well. Both “methods,” as
Georg Henrik von Wright has said of Aristotle’s practical syllogism, create
“an enlargement of the province of logic” (cited in Nussbaum 1978: 180).
In important ways, abduction particularizes the general rule. The aim of
abduction is not the logical definition of a particular instance (Deduction) or
the articulation of a general Rule (Induction). Rather, its aim is to define the
relationship between instance and rule, the discovery that a “fact” is a “case.”
For this reason, abduction calls for the rewriting of the assumptions brought
to a situation in order to situate those assumptions in historical time (“in this
class”), in a time for action. As Peirce himself describes it: deduction “is
merely the application of general rules to particular cases” (1992: 132), and
induction “is the inference of the rule from the case and result” (133), while
abduction is concerned with the manner in which the rule manifests itself as

The Logic of Diagnosis  /  117

a cause in a temporal sequence. Thus he argues that abduction “is where we
find some very curious circumstance, which would be explained by the sup-
position that it was a case of a certain general rule, and thereupon adopt that
supposition” (135).

Abduction and Narrative

As the preceding discussion suggests, the logic of abduction most closely

describes what physicians do when they apprehend within an HPI the “sur-
prising fact” or “very curious circumstance” of symptoms as presenting a par-
ticular case of an illness. If in induction, as Peirce argues, “we conclude that
facts, similar to observed facts, are true in cases not examined,” then “by
hypothesis [abduction], we conclude the existence of a fact quite different
from anything observed.”5 Induction, he concludes, “is reasoning from par-
ticulars to the general law; [abduction], from effect to cause. The former
classifies, the latter explains” (1992: 143). The logic of abduction connects
empirical Result and the quite different Case. The Case is different from the
Result because the Case cannot be observed but can only be hypothesized
(these children are not in that class when they present themselves with mea-
sles). Abduction, faced with the “very curious circumstances” that occasions
its reasoning altogether, offers the hypothesis that the event (of “these chil-
dren”) constitutes a Case. Because abduction aims at discovering a “Case”—­
discovering, that is, that a particular fact or circumstance is a “case” of a more
general rule—­it is bound up in the temporalities of narrative and narrative
knowledge: the existence of an event as a “case” of a more general proposi-
tion is analogous to the existence of an event as an “episode” in a narrative
that presents itself as a “meaningful whole” (see chapter 6 and Hunter 1999:
306–­8).
This chapter—­and The Chief Concern of Medicine as a whole—­assumes
that narrative is defined by the fact that it presents a “meaningful whole,”
that one can grasp a global sense of a narrative in the same way we grasp the
meaning of a sentence that is not reducible to any one element of the sen-
tence. Throughout this book and particularly in chapter 8, we argue that the
explicit narratives of stories and the implicit narratives in some poems trans-
form simple, seemingly isolated phenomena into meaning; they create what
A. J. Greimas describes as “the still very vague, yet necessary concept of the
meaningful whole set forth by a message” (1983: 59). Such a “meaningful
whole” is the overall sense or point of a story—­its “thought,” its “aboutness.”
It is the meaning we take away from the story, the “moral” of the tale, and/or

118  /  the chief concern of medicine

even the sense of overall “genre” we have already described. Thus we say
Hamlet, Oedipus, and even the death of John Kennedy are all “tragedies,”
despite the fact that they are so different. We make this judgment (or simply
have a more or less unarticulated sense of their similarity) because each of
these very different narratives of Hamlet, Oedipus, and Kennedy configure
or “grasp” a series of events—­ intellectual promise, prominent political
power, unforeseen yet recognizable violence—­in a manner that conveys or
provokes particular cognitive and emotional responses. In this way, a “vague”
sense of a whole unified meaning emerges from the elements of narrative
presented. Similarly, the combination of red dots on the skin, persistent fe-
ver, nasal discharge, and evidence of contact with others possessing these
attributes might well be measles. A sense of the meaningful whole of narra-
tive is particularly prominent in detective fiction, whose explicit goal is to
present a fact or a situation that allows the many events of the narrative to fall
into place—­to be explained—­as elements within a larger, “whole” pattern of
action, of cause and effect.6
For this reason, the structure of abductive reasoning is suggested by Au-
guste Dupin in Edgar Allan Poe’s “The Murders in the Rue Morgue” when
he argues, in effect, that (1) there is no evidence of the killer’s escape, (2) the
killer is not on the premises, and (3) therefore there must be evidence of the
killer’s escape (1985: 259). That is, in abduction, the “surprising fact” (no
evidence of the killer’s escape) must be accounted for as a “case” that follows
from a hypothesized rule in relation to the facts (“result”)—­accounted for,
that is, as a “matter of course” in a narrative. Part of the procedure of taking
a patient’s history is to rule out things that have not been observed and to
discover “pertinent negatives.” Physicians ask patients what they have not
noticed: for instance, “Did that tenderness on your arm occur after a fall?” or
“How long after your tooth began to hurt did this low, persistent fever be-
gin?” The inclusion of such “negative” evidence—­evidence not observable in
the manner of the positive facts the Vienna school thought was the whole of
reality (see chapter 1)—­partly makes the explanation of cause different in
kind from the logical reasoning of deduction and formulaic science and from
the discovery of facts in induction and explanatory science (though both logic
and discovery can contribute to such explanations).
Such explanation is closely connected to the working of narrative under-
standing, as opposed to the logical understanding of deduction and the em-
pirical understanding of induction.7 Neither the logical conclusion that these
children have measles nor the conjecture that all the children in the class
have measles tells a story in the way that the logic of abduction tells a story in

The Logic of Diagnosis  /  119

its connections of effects and causes, that “these children have measles be-
cause they are from this class.” Moreover, such connections of effects and
causes call for the subsequent action of Aristotle’s practical syllogism. In
chapter 3, we described the ways that narrative organizes disparate events
into complex action in which an array of happenings becomes the sequence
of action that can be apprehended—­ “retrospectively” and “simul­
taneously”—­as a whole and, for that reason, acted upon. As we have seen for
narrative, the whole is more than the sum of its parts, more than simply a
collection of “data” (or “phenomena” or “atomic events”) added together.
Umberto Eco describes this process in terms of Peircean semiotics, as the
transformation of “a disconnected series” into “a coherent [textual] sequence”
that allows us to recognize the “‘aboutness’ of the text which establishes a
coherent relationship between different and still disconnected textual data”
(1983: 213). Peirce himself argues that “the essence of an induction is that it
infers from one set of facts another set of similar facts, whereas hypothesis
[or abduction] infers from facts of one kind to facts of another” (1992: 150).
The second order of fact pursued by the logic of abduction, Peirce sug-
gests, is “very frequently a fact not capable of direct observation” (1992: 150).
Similarly, a “medical fact” not capable of direct observation is often the
“cause”—­the disease—­underlying symptoms that patients present to physi-
cians in the narratives of present illness they articulate. On this level of anal-
ysis, narrative understanding allows the grasping of the connection between
instance and rule, between effect and cause. The rule articulates the “about-
ness” Eco describes; it articulates a meaning—­in the case of medicine, a di-
agnosis of a “general” disease or condition; in the case of measles, the “con-
tagion” implicit in the Rule “All the children in this class have measles,” to
which the particular symptoms (instances) are related as a Case. This can
only be the hypothesis of abductive logic, because although the general Rule
is given (as in deduction), its implications are not “unpacked”; and although
the Case is also given (as in induction), the Case, like the Rule, has further,
implicit significance that, as Aristotle suggests, can be realized in action. It is
precisely the relationship between Rule and Case that must be established
from the “given” data of possible rule and particular instance, and that rela-
tionship exists as an implicit narrative: “these children have measles because
they are from this class.” (For a discussion of “unpacking” in relation to the
humanities, see appendix 1.)
Peirce suggests the narrative nature of abduction when he distinguishes
abduction from induction in terms of the fact that induction begins with
“objects” and “facts” while abduction begins with the “characters” or “char-

120  /  the chief concern of medicine

acteristics” of phenomena (e.g., the attribute of measles or, better, the attri-
butes of small red dots on the skin, fever, and nasal discharge), which have to
be configured within particular categories or frameworks. “Hypothesis [ab-
duction],” Peirce writes, “has been called an induction of characters,” and
“characters are not susceptible of simple enumeration like objects; [rather],
characters run in categories.” It is the work of abduction, Peirce goes on to
argue, to isolate “a single line of characters, or perhaps two or three, and . . .
take no specimen at all of others” (1992: 140). The work of abduction is not
simply to apprehend an instance as a Case but to apprehend simultaneously
the Case and the Rule by discovering the framework in which the relation-
ship between event and understanding can be defined as that of a Case and
a Rule, so that a chosen fact is salient (i.e., a “case”). Paul Ricoeur has de-
scribed this particular mode of understanding as “configurational”: “the con-
figurational mode,” he writes, “puts its elements into a single, concrete com-
plex of relations. It is the type of comprehension that characterizes the
narrative operation” (1984: 159). Umberto Eco describes this operation
more concretely: “The real problem is . . . how to figure out both the Rule
and the Case at the same time.” In the Bean Bag analogy, he continues,
“Peirce could have decided that the crucial element was not where [which
bag] those beans came from, but—­let us say—­who brought them there”
(1983: 203). The “crucial element” is the framework of understanding that
allows a fact or event to be configured and comprehended as a Case. The
“thought” or genre or “point” of a story—­its end as we describe it in chapter
3—­is such a framework; its comprehension is the work and the goal of narra-
tive, a speculated “construal.” In medicine, such comprehension is the diag-
nosis, the “explanation” of the symptom, which suggests both cause and
treatment. The most important occasion for this explanation—­for those
trained to listen in certain ways and pursue what Sherlock Holmes calls “rea-
soning backwards” (Sebeok and Umiker-­Sebeok 1983: 39, citing “A Study in
Scarlet”)—­is the History of Present Illness.

The Power of Knowledge

We have been discussing the initial element of diagnosis, the logic of hypoth-
esis formation, since our aim is to make this—­ often unconscious or
unconsidered—­aspect of diagnosis more discernible and thus to allow for its
more self-­conscious enactment. But the most obvious element of diagnosis,
as we mentioned, is the knowledge base. Knowledge is important because it

The Logic of Diagnosis  /  121

is necessary to validate old hypotheses and to generate new ones, by suggest-
ing the possible frameworks of understanding (mentioned previously) that
infuse meaning into otherwise trivial signs (a process that creates the war-
ranted assertions of functional realism). In the terms we have been develop-
ing, the knowledge base often allows the particular instance to be appre-
hended as a Case of a more general situation. The functioning of such
knowledge is clear in one of the many little narratives Peirce presents in
“Deduction, Induction, and Hypothesis,” a narrative that reads very much
like the stories of Arthur Conan Doyle, Peirce’s contemporary.

A certain anonymous writing is upon a torn piece of paper. It is suspected

that the author is a certain person. His desk, to which only he has had access,
is searched, and in it is found a piece of paper, the torn edge of which exactly
fits, in all its irregularities, that of the paper in question. It is a fair hypothetic
inference that the suspected man was actually the author. The ground of this
inference evidently is that two torn pieces of paper are extremely unlikely to
fit together by accident. (1992: 139–­40)

Later in the same paragraph, Peirce argues that “if the hypothesis were noth-
ing but an induction, all that we should be justified in concluding . . . would
be that the two pieces of paper which matched in such irregularities as have
been examined would be found to match in other, say slighter, irregularities.
The inference from the shape of the paper to its ownership is precisely what
distinguishes hypothesis [abduction] from induction, and makes it a bolder
and more perilous step” (140). In this example, the key difference between
induction and abduction is conditioned by the knowledge of another “kind”
of fact, namely, the knowledge that only the suspect “has had access” to the
desk. This fact—­which Peirce only mentions here in passing and does not
mention again in his argument—­is different in kind from the evidence of the
torn paper, both because it is focused on a different object from the induc-
tive conclusions about the paper and also because it is not observable: like
the prior existence of Napoleon that Peirce also presents as simply a hypoth-
esis (135), it is a “fact” that is not capable of being empirically observed.
Neither are abstract, “general” illnesses observable except as an inference
based on a particular combination of symptoms. Such knowledge seemingly
“outside” the parameters of the logical problem—­and outside the logical
positivism we discussed in chapter 1—­allows the bolder, more perilous activ-
ity of abductive logic.
The job of medical training is to give physicians possession of such

122  /  the chief concern of medicine

“second-­order” knowledge. More dramatically, both Edgar Allan Poe and
Arthur Conan Doyle emphasize the great breadth and depth of knowledge
that their detectives possess in the stories we examine here and in our later,
“practical” discussions of the patient-­physician relationship in Part 2 of this
book. Some signs at the murder scene in Poe’s “The Murders in the Rue
Morgue”—­such as the position of the body in the chimney, the strange marks
around the neck of one of the victims, and the ribbon found by the lightning
rod—­were meaningless to the police but not to Dupin. This evidence would
be trivial details if not for Dupin’s knowledge of wild animals, human anat-
omy, and the navy and its sailors. Instead, they are crucial in Dupin’s under-
standing that the deaths in the story are the result of irrational violence
rather than murder. Similarly, Holmes’s knowledge of tobacco and cigars in
“The Resident Patient” is crucial to his apprehension that the death in that
story is murder rather than suicide, because it suggests that there were other
people involved. In both of these instances, the global category of “murder”
(vs. “irrational violence” or vs. “suicide”) defines the “aboutness” of the sto-
ries. In these instances, “violence” and “murder” are what Peirce calls the
“characters” (or “characteristics”) on which abduction focuses. Such a focus
transforms classification (i.e., the empirical fact of “death”) into explanation
(i.e., the understanding of that death as “irrational violence” in Poe and as
“murder” in Doyle). Finally, we should emphasize here that the “characters”
or “characteristics” that Peirce describes are precisely what schemas gather
together in accounting for experience and comprehension.

Reflection

The third element of diagnosis is reflection. The physician shares with the
detective the need to attend to the manner of their own interpretive action
as well as the condition of the patient. The process of playing one’s hunch or
hypothesizing a connection between a particular instance and a particular
rule must be followed by testing the validity of that connection in relation to
some overall “meaning”—­the “aboutness” of a narrative, the particular “ill-
ness” behind symptoms—­in which the instance is seen to be a Case (of a
disease or of a crime, such as “murder”). This is the ability of the detective,
physician, or abductive logician to recognize the “aboutness” of the facts—­
the ability to apprehend them as evidence—­in order, as Eco says, to establish
“a coherent relationship between different and still disconnected . . . data”
(1983: 213). We are calling this element “reflection” because the hypothesis

The Logic of Diagnosis  /  123

generation of abduction does not follow logical rules that could be pro-
grammed into a computer (e.g., to play chess); nor does it follow empirical
rules of evidence collection and classification, which could also be pro-
grammed, logarithmically, into a computer (see Hunter 1999: 308–­9). Rather,
abduction follows feedback rules such as those articulated by information
theory—­and developed in the experience and skillful practices of reading
narratives—­in which skills grow through experience, which cannot be pro-
grammed but can only be accumulated (though John Holland [1995] sug-
gests that even this accumulation and “characterization” of experience can
be programmed). Such accumulation, as we suggest in chapter 1, follows the
trajectory of pragmatic realism, and as we note in chapter 3, it can be aided
and focused by schemas—­themselves forms of pragmatic realism. The de-
tective who completes the loop of hypothesis generation and hypothesis test-
ing is the detective who learns and improves. Likewise, the diagnostician
who is reflective in his or her approach—­who makes the “facts” of her or his
activity part of the “logic” of diagnosis—­will continue to improve with experi-
ence. Such reflection calls on “characterization.” All observations are not
necessarily interchangeable; they can be of different modal orders, particu-
larly the modalities of seeing and hearing, both of which should be resources
of the HPI. The young physician has a great knowledge base, with little ex-
perience to test it. The experienced physician who has not been reflective of
process and outcome has failed to learn from his experience the kinds of
phenomena to attend to. Like the police in detective stories, such unreflec-
tive “experienced” physicians too easily fail to apprehend details that disrupt
preconceived generalizations, in part because they think all (empirical) ob-
servations are the same. Such learning itself, moreover, can be aided and
focused by means of the technē of phronesis and abduction.

Abduction and Diagnosis

The three elements of diagnosis we have described—­hypothesis formation,

testing against a knowledge base, and reflective understanding of the
process—­nicely fit into Peirce’s schema of logical inferences of invention,
testing, and explication. But equally important, they also describe what we
do when we read narratives and what physicians do when they encounter the
patient’s HPI. Thus, in an interview—­one we return to in Part 2—­Dr. Rita
Charon has noted that

124  /  the chief concern of medicine

 stories have plots. Illnesses have symptoms. In a strange way, when a doctor
is trying to diagnose a patient, when a doctor is hearing about many symp-
toms, events, sensations, feelings, things out of the ordinary from a patient
describing new symptoms, in a funny way what the doctor does in diagnosis
is pretty much what he or she does in reading for the plot. . . . Now, . . .
whether it’s a joke somebody tells me or a long, complex novel like Beloved,
the activity of the reader is to register each event, whether or not they’re told
chronologically, and to reconfigure them using our imagination and our
memory so that they make at least provisional sense.
And, so, isn’t that what we do, again, as I’m sitting in the office listening to
the woman with abdominal pain. . . . [A]nd I, as the diagnosing doctor, have to
somehow register these events, configure them in my mind so that they make
provisional sense. (Vannatta, Schleifer, and Crow 2005: chap. 2, screen 52)

Charon is describing the ways in which both readers and doctors make hy-
potheses about what they hear and encounter, gather new evidence, and re-
flectively reconfigure understanding, again and again. Detective fiction is
about these encounters, as Auguste Dupin or Sherlock Holmes encounter
stories, create hypotheses, test them, and reflect on them, over and again.
But as we suggested in the preceding chapter, this describes one of the sa-
lient features of narrative, the witness who learns.
Physicians encounter narratives. We demonstrate such an encounter
here, using an incident in which a resident admitted a middle-­aged woman
from Wewoka, Oklahoma, during an extraordinarily busy night.

As he entered her room, the woman was buried in covers, her face
without expression, her skin sallow in appearance, as if she were chronically
ill or depressed. There were no family members present—­they had
complained her thinking was “messed up” and had left at midnight. The
room was barren except for a small pile of mostly worn-­out clothes; a pair
of rayon stretch pants were pulled through the rounded handles of a vinyl
purse sitting on a chair. Her responses were short, usually not to the point,
and irritated. Feeling angry at her failure to help in the diagnosis, the
resident hurried through her narrative of recent events, past history, and
systems review. When asked, she specifically denied taking any medication.
Still, it was clear to the resident that the patient’s problem was that of
hyponatremia, the dilution of the sodium concentration in the blood. Since
the blood is basically a saltwater solution, reasons for the decreased sodium

The Logic of Diagnosis  /  125

concentration should not be an unsolvable riddle. Medications and their
affects on brain hormones or kidneys, an underactive thyroid gland,
psychogenic water drinking, adrenal insufficiency, congestive heart failure,
chronic renal failure, low albumin levels in the blood, ascites (free water in
the abdominal cavity), stress, pain, vomiting, diarrhea, the syndrome of
inappropriate antidiuretic hormone—­each was a possible “cause” of her
condition, a Rule that would allow the woman’s condition (Result) to be
apprehended as a Case. Yet neither the resident’s questions nor his physical
examination provided an answer to the cause—­and subsequent
treatment—­of her sodium dilution.
When he met with the attending physician the next morning, all the
resident could report was that the patient was a “bad historian.” “Was she a
bad historian,” the attending physician asked, “or were you an inadequate
interviewer?” The attending physician questioned the patient and asked if
she were taking medication and whether she had something to add to her
history. “Why do you keep asking me all these questions?” she asked, as she
glanced at the nightstand and then down toward the end of the bed.
Afterward, the attending physician mysteriously announced to the resident
and interns that he expected the patient’s purse to contain chlorthalidone, a
diuretic that commonly causes hyponatremia. When they returned to the
patient, she was curled up under the bedclothes with the blanket over her
head, and the purse that was evident the night before was nowhere in sight.
The attending physician asked the patient to get her purse “so I can look at
the pills in it.” She rolled over toward the bedside table, pointed to it, and
told the intern she could get it out for her. In the purse were, among other
things, four pill bottles, containing a thyroid medication, a tranquilizer, a
pain medication, and the diuretic chlorthalidone. “Do you take these pills
every day?” the attending physician asked. “Most days,” she responded,
adding, “I didn’t take any yesterday because I felt bad.” The patient lay
back down, pulled the covers over her head, and said she wanted to be
alone.

A narrative such as this demonstrates the ways that physicians, in their

encounters with patient narratives, pursue hypothesis formation, test the hy-
pothesis against a knowledge base, and develop a reflective understanding of
the process. The resident possesses a knowledge base yet lacks the experi-
ence to interpret the patient’s nonverbal language of looking at the night-
stand. The surprising fact of this narrative is the patient’s glance at the night-
stand, which becomes a matter of course if we assume that the nightstand

126  /  the chief concern of medicine

contains evidence that catches her in her untruth. Moreover, while the resi-
dent has a knowledge base, it is not quite as experienced and deep as the
attending’s knowledge base: the resident does not know how commonly hy-
ponatremia is the result of chlorthalidone; neither does he know that patients
sometimes withhold pertinent information. In fact, he has not yet gained
enough experience—­enough practical reason—­on which to develop as keen
a hypothesis as the attending physician.8

The Detective Stories

We are suggesting that the hypothesis-­generating process of diagnosis—­a

process that informs physicians’ encounters with the HPI—­is closely con-
nected to the manner in which that narrative discourse creates meaning or
significance. For this reason, we believe, physicians can learn significant di-
agnostic skills (as well as the more “global” skill of speculating and negotiat-
ing with patients the nature of the goal of medicine, “health”) by studying
narratives (see Hunter 1999; Charon, Connelly, et al. 1995; Charon 2004;
relevant citations in chapters 2 and 3); they can, in fact, acquire the reflective
“experience” we have described in relation to diagnostics. As we have
mentioned—­and as the narrative of the woman with hyponatremia suggests—­
the narrative genre that most explicitly focuses on abduction and hypothesis
formation is that of the detective story or novel. In a detective story, the de-
tective is a witness who learns from the narratives he or she encounters: the
detective inhabits a world of rules, a system of general laws, and is presented
with an array of particular narrative and evidentiary instances that need to be
apprehended as connected to a particular rule or a particular characteriza-
tion of events. Similarly, a doctor is a witness who learns from the narratives
he or she encounters: inhabiting a world of rules, a system of general classes
and subclasses of diseases, the physician is presented with a particular narra-
tive (explicit and implied) and physical evidence (a symptom or set of symp-
toms) that need to be apprehended as connected to a particular rule, to be
seen as a Case of a particular disease or condition. Thus it is no accident that
Peirce’s exposition of abduction repeatedly offers small narrative situations
in order to present the distinction he is making between inductive and ab-
ductive logic (both of which he opposes to deductive logic).
The classic detective story is considered to have been developed by Ed-
gar Allan Poe and Arthur Conan Doyle, the latter of whom was, in fact, a
trained physician. The two detectives they created—­Poe’s Auguste Dupin,

The Logic of Diagnosis  /  127

created in the mid-­nineteenth century, and Doyle’s Sherlock Holmes, cre-
ated nearly a half century later—­are model detectives who witness stories
and learn. In “The Murders in the Rue Morgue,” Poe presents the detective
to be a man of unusual talents. He possesses enormous knowledge and is also
a master of understanding human emotions by studying facial expressions
and other body language: this, indeed, demonstrates his ability to apprehend
coherent relationships among different and disconnected facts. (“Most men,”
Dupin says, “wore windows in their bosoms” [Poe 1985: 249].) Moreover, the
detective is able to use logic in a manner uncharacteristic of most people.
Early in this story, Dupin demonstrates his remarkable ability to hypothesize
by guessing that his companion, the narrator, was thinking of a bad tragic ac-
tor named Chantilly. “Tell me, for Heaven’s sake,” the narrator exclaimed,
“the method—­if method there is—­by which you have been enabled to
fathom my soul in this matter” (250). Dupin goes on to explain the “links” of
the narrator’s thought: “the larger links of the chain run thus—­Chantilly,
Orion, Dr Nichols, Epicurus, Stereotomy, the street stones, the fruitier”
(250). Reasoning backward—­ reasoning reflectively—­Dupin remembers
what the narrator forgets, so that he is able to create the larger links of nar-
rative where the narrator had only experienced disparate facts. The narra-
tor’s collision with the fruitier, which began his chain of thought, is a different
order of fact from the narrator’s final thought about the actor; Dupin demon-
strates that different and disconnected data can be apprehended together in
relation to a single train of thought. This is the “aboutness” of the narrative,
the “point” of the story, which we discussed earlier; it allows Dupin to ap-
prehend disparate facts as “a single line of characters” and to transform
events into explanation.
Dupin makes every event into a Case, or signifying instance, of his com-
panion’s character. This passage goes on to meditate on this train of thought
by presenting a narrative where, before, there were a set of facts that pre-
sented such an “apparently illimitable distance and incoherence between the
starting point and the goal” (250) that the narrator did not even remember
all of them. Dupin makes these facts into a story. “We had been talking of
horses,” Duplin explains,

if I remember aright. Just before leaving the Rue C—­. This was the last sub-
ject we discussed. As we crossed into this street, a fruitier, with a large basket
upon his head, brushing quickly past us, thrust you upon a pile of paving-­
stones collected at a spot where the causeway is undergoing repair. You
stepped upon one of the loose fragments. . . . I was not particularly attentive

128  /  the chief concern of medicine

 to what you did: but observation had become with me, of late, a species of
necessity.
You kept your eyes upon the ground [until we encountered] . . . riveted
blocks. Here your countenance brightened up, and perceiving your lips
move, I could not doubt that you murmured the stereotomy, a term very af-
fectedly applied to this species of pavement. I knew that you could not say to
yourself “Stereotomy” without being brought to think of atomies, and thus of
the theories of Epicurus; and since, when we discussed this subject not very
long ago, I mentioned to you how singularly, yet with how little notice, the
vague guesses of that noble Greek had met with confirmation in the late
nebular cosmogony, I felt that you could not avoid casting you eyes upward
to the great nebula in Orion. (250–­51)

Dupin goes on to note that a negative review of the actor Chantilly the previ-
ous day cited a Latin line also referring to Orion and that the narrator knew
of this reference, so “it was clear, therefore, that you would not fail to com-
bine the two ideas of Orion and Chantilly” (251).
In this passage, Dupin emphasizes the extraordinary powers of observa-
tion of human behavior needed by the detective, and in so doing, he con-
fuses, as Peirce notes, the empirical classifications of induction and the
meaningful explanations of abduction. Thus, even while he asserts his power
of observation, Dupin describes the process of “guessing,” or hypothesis for-
mation, that he uses. Dupin makes hypotheses and then, “reflectively,” tests
them against experience—­which, just as for the physician, is someone else’s
experience. Unlike the police and physicians who do not diagnose crimes
and illnesses particularly well, Dupin does not commit himself to his guess
prematurely. Rather, his observations are both educated and provisional,
open to inclusion of different “lines” of character. Peirce calls the method of
abduction a “fair guess” (1992: 134), but important to our discussion of the
process of abduction in relation to both the detective’s method and the
method of the diagnostician are the ways in which its skills are repeatable
and teachable, the ways it is a form of technē. Thus, in the hyponatremia nar-
rative presented earlier, the attending physician is using and teaching through
example the “abductive” method of Dupin.9
From the ways in which Arthur Conan Doyle repeats the detective tech-
niques that Poe introduced, it is clear that the process of abduction is repeat-
able. At the beginning of “The Resident Patient,” as at the beginning of “The
Murders in the Rue Morgue,” Holmes, watching Dr. Watson, guesses at the
narrator’s thoughts and explains his guess as a form of deduction. This pro-

The Logic of Diagnosis  /  129

cess is not really deduction but hypothesis generation (abduction), just as
Dupin’s process is more than simply the empirical observations of induction.
(This is made clear by the fact that Dupin’s observations are aural rather than
visual: he apprehends and remembers words rather than images.) Holmes’s
logic is not deduction in the strictest sense, because there are other data
(lines of thoughts) that might have been present and that he chooses to ig-
nore in presenting his explanation. Moreover, his guess turns out to be based
on a good hunch and works because Holmes knows Watson so well. This
knowledge is a different “kind” of fact. Holmes’s many conversations with
Watson in the recent past allow him to gather together a large amount of
information that might otherwise seem simply different and disconnected
facts; that is, Holmes combines knowledge and personal experience to ar-
ticulate a logic of abduction. The fact that the logical process used by the
detectives in these stories and by a physician are similar allows us to think
that the “guesses” of abduction are educated guesses—­ Peirce’s “fair”
guesses—­and suggests that detective stories are especially effective in the
education of the diagnostician.
In a passage from “The Resident Patient” (which Doyle also uses, almost
verbatim, in “The Cardboard Box”) Holmes presents the kind of reasoning
Dupin exhibits in narrating Watson’s chain of thought (he even explicitly
mentions Poe’s story). “After throwing down your paper,” Holmes says,

you sat for half a minute with a vacant expression. Then your eyes fixed them-
selves upon your newly framed picture of General Gordon, and I saw by the
alteration in your face that a train of thought had been started. However, it
did not lead very far. Your eyes turned across to the unframed portrait of
Henry Ward Beecher, which stands upon the top of your books. You then
glanced up at the wall, and of course, your meaning was obvious. You were
thinking that if the portrait were framed it would just cover that bare space
and correspond with Gordon’s picture over there.

Watson responds, “You have followed me wonderfully” (A. Doyle 1986: 580).
Holmes goes on to discuss more of Watson’s thoughts based on the interpre-
tation of body language, knowledge of Watson’s old war wounds, and other
knowledge he possesses about his friend. Here again, Holmes emphasizes
his powers of observation without analyzing the ways in which observations
of different orders of fact are brought together to generate an explanation,
what we have variously called a “line of thought,” the “aboutness” of a collec-
tion of facts, or the “point” or “end” of a narrative. In this narrative, Holmes,

130  /  the chief concern of medicine

like Dupin or an experienced attending physician, is “reasoning backwards”:
he is making sense of phenomena by supplying their causes that relate them
to one another; he is connecting Case and Rule. In these instances, the de-
tectives use abduction to “guess” what another person is thinking, even if
Holmes’s observations are unrelentingly visual (note his attention to Watson’s
eyes) even as Dupin’s are aural (attending to the narrator’s words). In any
case, such abductive “guesses,” of course, should happen in the practice of
medicine. In medical school, we teach courses in human behavior to incul-
cate in medical students the ability to read body language and emotional
states as the detectives do in these stories. These observations and their anal-
ysis help the clinician develop hypotheses about the patient’s motives, needs,
and desires (her chief concern)—­and they also help the clinician develop
hypotheses about the patient’s physiological condition (his chief complaint).
In both of these archetypal detective stories, these preambles are pre-
sented to frame the manner in which each detective observes details of the
death scene and of the circumstances surrounding the deaths. In both in-
stances, the detective solves the “murder” when the police have failed by
erroneously jumping to the obvious conclusion too early, before all the data
are analyzed, classified, and, most of all, characterized carefully. The police
follow methods of induction, which leads them to exclude information as ir-
relevant because they have, from the start, a particular theory in view. In this,
they aim at classification rather than explanation. In “The Murders in the
Rue Morgue,” the police assume that “murder,” rather than irrational vio-
lence, is the controlling framework of understanding, and thus they cannot
see (or really hear) what is there to observe, that the nonlanguage of the sup-
posed colloquy between killer and accomplice suggests that the killing was
perpetrated by an orangutan rather than a person. Dupin says that they have
fallen into the gross but common error of confounding the unusual with the
abstruse. Similarly, in Doyle’s “The Resident Patient,” the police assume sui-
cide instead of what Holmes calls “a deeply planned and cold-­blooded mur-
der” (1986: 594), because they cannot see what there is to observe. (In the
medical case of the woman with hyponatremia, the resident assumes, with-
out further consideration, that the patient is truthfully supplying all the evi-
dence.) The kind of mistake the police make—­the assumption that the goal
of diagnosis is classification rather than explanation—­is that of clinicians who
narrow the differential diagnosis too early, failing to account for all the data
(both positive and negative) and to attend to the manner or modality of their
own observations. When Watson says to Holmes that what a detective saw
“was quite invisible to me,” Holmes replies, “Not invisible, but unnoticed,

The Logic of Diagnosis  /  131

Watson. You did not know where to look, and so you missed all that was im-
portant.” Holmes goes on to tutor Watson: “Never trust to general impres-
sions, my boy,” he says, “but concentrate yourself upon details” (Sebeok and
Umiker-­Sebeok 1983: 21, citing “A Case of Identity”). Narrative comprehen-
sion teaches physicians that diagnosis is a form of explanation, not a method
of classification.

The Design of Hypothesis

What Holmes means by “details” and Dupin by “observation” conditions ab-

duction rather than induction. “Abduction,” Peirce writes,

makes its start from the facts, without, at the outset, having any particular
theory in view, though it is motivated by the feeling that a theory is needed to
explain the surprising facts. Induction makes its start from a hypothesis
which seems to recommend itself, without at the outset having any particular
facts in view, though it feels the need of facts to support the theory. Abduc-
tion seeks a theory. Induction seeks for facts. In induction the study of the
hypothesis suggests the experiments which bring to light the very facts to
which the hypothesis had pointed. (cited in Sebeok and Umiker-­Sebeok
1983: 24–­25)

This description of abduction has an excellent parallel in the diagnostic pro-

cess of medicine. In our previous narrative example, the attending physician
faced with the “fact” of hyponatremia finds a hypothesis that recommends
itself based on his understanding of the additional fact (not quite known by
the resident) that chlorthalidrone is a commonly prescribed diuretic that
commonly causes hyponatremia. Thus the physician’s wider theory, like
those of Dupin and Holmes, is that patients’ stories include nonverbal signs
that can and should be read. This theory transforms the “abstruse,” such as
either the unusual presentation of a common illness or an uncommon illness
manifesting common symptoms, into simply a surprising fact—­a different
order of fact—­that can be tested in the cause-­and-­effect relationship of nar-
rative: in this instance, that the patient’s nonverbal responses might well in-
dicate that what seems mysteriously abstruse might only be “unusual” resis-
tance to the medical establishment (though what the physician teaches the
resident and interns is that such resistance is not, in fact, so unusual). Simi-
larly, in “The Resident Patient,” the victim was found hanging in his room

132  /  the chief concern of medicine

alone, but Holmes’s esoteric knowledge of tobacco allows him to hypothesize
(abduct) that other people had been in the room with him and that the death
was a different order of fact from that of “suicide.” In the “The Murders in
the Rue Morgue,” Dupin’s knowledge of maritime life (the knot in the rib-
bon found at the “murder” scene) and his sense that the reported abstruse
languages of the killers might be the unusual noise of an orangutan allow him
to hypothesize that the killings were not “murder.”
Both of these detective stories—­ like the story of the woman with
hyponatremia—­provide rich and interesting narrative experience for physi-
cians. They can be used to demonstrate the process of developing the HPI,
a goal of which, much like that of a detective story itself, is to explain seem-
ingly disparate facts. They also emphasize the importance of the psychosocial
observations of both Dupin and Holmes—­that different order of fact—­to
suggest the usefulness of attending to the nonverbal cues of patients in rela-
tion to the content of their HPI. Finally, they present the logic of hypothesis
formation in the activities of the detectives, a logic that can be explicitly ana-
lyzed in relation to other forms of logic. Thus the most important aspect of
such readings for practicing physicians is the possibility they present for the
systematic analysis of the “guesses” of diagnosis. The three-­part description
of diagnosis we presented at the beginning of this chapter—­its logic, its rela-
tionship to different kinds of knowledge physicians bring to their encounters
with patients, and the necessary reflective nature of its understandings—­all
underline the ways that the narrative HPI can facilitate the explanation of
facts. Diagnosis has a particular relationship to narrative insofar as narrative
presents a retrospective mode of understanding—­the “reasoning backwards”
of reflective comprehension—­that can, in fact, be experienced simply by
reading. For this reason, the systematic apprehension of the ways that stories
create explanations—­the explicit articulation of the schemas governing the
apprehension and experience of narrative—­is of the utmost importance to
the practice of medicine.

The Logic of Diagnosis  /  133

 part 2
The Work of Narrative in Practices of Medicine
5
the patient-physician relationship
The Scene of Narration

If, therefore, a physician does nothing more than feel my pulse and put me on the list of
those who he visits on his rounds, instructing me what to do and what to avoid without
any personal feeling, I owe him nothing more than his fee, because he does not seem as
a friend but as a client. . . .
Why then are we so much indebted to these men? Not because what they have sold us
is worth more than we paid for it, but because they have contributed something to us
personally. A physician who gave me more than was necessary, because he was afraid for
me, not for his professional reputation, who was not content to indicate remedies, but
also applied them; who sat at my bedside among my anxious friends, and hurried to me
at times of crisis; for whom no service was too burdensome, none too distasteful to
perform; who was not indifferent to my moans; to whom, although a host of others sent
for him, I was always his chief concern; who took time for the others only when my
illness permitted him. Such a man has placed me under an obligation, not so much as a
physician but as a friend.
—­seneca, De Beneficiius 6.16

As we have seen, the patient brings to the clinical encounter a story, the His-
tory of Present Illness (HPI). As the physician listens and responds to this
story, a special kind of relationship begins to develop between the patient
and doctor. At its best, it is personal and professional at once. It is often
charged with deeply felt emotion on the part of the patient—­fear and anxi-
ety, anger, sadness, or a combination of these feelings—­and with empathetic
and more or less calm attention on the part of the physician. Usually growing
out of the event of storytelling and listening—­the very scene of narration—­
the patient-­physician relationship is a relationship that often is more than
purely professional. Moreover, the relationship between the patient and the
doctor is the basis for any future therapeutic endeavor: all future interactions
between patient and physician are dependent on this relationship.
Literature—­the “art narratives” we discussed in chapter 3—­provide detailed
and well-­focused examples (case histories) of the play of narrative and, con-

/  137  /
sequently for the discerning reader, schemas and strategies for recognizing
and constructing good patient-­physician relationships; they also provide use-
ful examples of poor patient-­physician relationships. In this chapter, in addi-
tion to vignettes and medical narratives, we present a montage of scenes
from novels and short stories that, in their self-­conscious artistry, emphasize
the salient features of narrative that can also always be found in medical
narratives—­salient features of the patient-­physician relationship, of patients’
stories themselves, of the relationship between the teller and the listener
(whose roles alternate in the scene of medical narration). We hope to dem-
onstrate the simplest ways that literary narrative can help educate physicians,
the ways that it focuses attention on particular aspects of what is or can be
enacted in this relationship in the very scene of narrative performances. Suc-
ceeding chapters in Part 2 examine the role of narrative in medicine with
greater attention to the patient’s story as such and the “narrative knowledge”
it contains, to the ways in which the study of literary narrative can enhance
the skills (technē) with which the physician listens to the patient by suggest-
ing schemas of understanding and action. In Part III, we examine the ways
in which narrative can help health care workers to discern the drama of med-
ical practice and the ethics woven into the everyday practices of medicine.
All of these concerns, however, entail and, in fact, embody the different rela-
tionships that arise between patient and physician, all of which are at once
professional and yet—­in their concern for well-­being, suffering, grief, and
devising a working definition of health—­also involve aspects of our lives that
go beyond the relationship of a client simply obtaining the skills and knowl-
edge of a professional.

Power Differential: Appropriate Uses

Of necessity, there is a power differential between patient and physician.

The patient needs the physician in ways that the physician does not need
the patient: the patient ails in relative ignorance, is in a position of supplica-
tion, and, to some degree or other, is in a state of concern that warrants
seeking out a physician. The physician has gone through remarkably rigor-
ous training in the knowledge and practice of medicine and is simply in a
position of power in relation to the patient and his or her ailment. This
power differential is proper and, in any case, unavoidable. Yet for narrative,
it is particularly odd. As Brian Boyd and others have suggested in describing
the work of narrative—­this is embodied in Greimas’s category of sender

138  /  the chief concern of medicine

versus receiver—­it is usually the teller who possesses the authority over the
listener. In the initial narrative between the patient and physician, however,
the listener—­the doctor—­possesses both the authority of her knowledge
and also state-­sanctioned authority of one sort or another. This might be a
function of the fact that the patient’s story is “not-­yet-­complete,” and it
might very well be that the authority of narrative rests with the power to
complete a story, to apprehend its end (see Mattingly 1998: 36–­37 for a
sense of the formative power of endings). In any case, this power differen-
tial at the scene of narration is particularly pronounced in the patient-­
physician relationship, and in this and the following section, this differential
is explored in its appropriate and inappropriate functioning in defining that
relationship.
The power differential can be and often is misused, often because it is
understood not as a structural aspect of narrative but as a matter of fact
between a professional and a supplicant. A sense of the appropriate use of
this power might well make this situation clearer, and in this section, we
examine it by marshaling reflective narrative responses to this situation. In
Intoxicated by My Illness, Anatole Broyard, narrating his situation as a pa-
tient faced with a life-­threatening illness, describes this differential and, in
fact, seeks it out, because he wants a very knowledgeable doctor, someone
who is “intense enough or determined enough to prevail over something
powerful and demonic like illness” (1992: 36). He does not want a physician
without authority, but he wants one who brings authority to the shared
enterprise—­the very deliberation of narrative described in chapter 3—­of
the patient-­physician relationship. (Broyard himself, who died from pros-
tate cancer shortly after he wrote this memoir, was a literary critic and re-
viewer for The New Yorker.) Broyard wants the doctor to be a “storyteller,”
to turn his illness into a narrative. He desires this narrative to draw him, the
patient, into the relationship in a way that facilitates both the doctor’s and
the patient’s participation in the illness/disease and treatment. Broyard ob-
serves that this requires the doctor to translate the scientific story into one
of “natural” language that the patient can understand. He states, “Astute as
[the doctor] is, he doesn’t yet understand that all cures are partly talking
cures. Every patient needs mouth-­to-­mouth resuscitation, for talk is the kiss
of life” (1992: 53).
The shared enterprise Broyard describes helps him define the ideal doc-
tor, the building of rapport, and the ideal patient-­doctor relationship. The
literary form he imagines is the heroic melodrama or epic, Dante’s Divine
Comedy, and the doctor assumes the actantial role of Helper.

The Patient-Physician Relationship  /  139

 My ideal doctor would be my Virgil, leading me through my purgatory or
inferno, pointing out the sights as we go. He would resemble Oliver Sacks,
the neurologist who wrote Awakenings and The Man Who Mistook His Wife
for a Hat. I can imagine Dr. Sacks entering my condition, looking around at
it from the inside like a benevolent landlord with a tenant, trying to see how
he could make the premises more livable for me. He would see the genius of
my illness. He would mingle his demon with mine; we would wrestle with my
fate together. Inside every patient, there’s a poet trying to get out. My ideal
doctor would “read” my poetry, my literature. He would see that my sickness
has purified me, weakening my worst parts and strengthening the best.
(1992: 41)

Here, as patient, Broyard is describing the qualities of the deliberation nar-

rative gives rise to as the physician assumes the roles of both Helper and
Receiver of the narrative (listener). Both the roles we have discussed and the
ideal Broyard discusses are schemas of understanding and action.
Broyard describes this encounter from the vantage of the patient, but he
also suggests the deliberation from the vantage of the physician, when he
describes Dr. Oliver Sacks’s discovery of the “genius” of an illness. One such
example is the case history of “the colorblind painter” that Sacks presents in
An Anthropologist on Mars. The “genius” of an illness that Broyard describes
is what Sacks calls the “world” of an illness, the fact that a serious illness—­
especially a chronic illness—­becomes part and parcel of the patient’s life. (In
this, the term “illness” nicely comports with Kenneth Boyd’s use of the term
[2000], discussed in the introduction to the present book.) For a physician to
participate in the patient’s illness, the doctor must understand not only the
patient’s pathology but its attendant emotions and effects on her entire life.
The physician must acknowledge the “dis-­eased” and, as we have seen, the
“concerned” patient, as well as the medical condition that both confront.
Dr. Sacks’s discussion of a color-­blind painter who had a lesion of the pre-
striate cortex is striking in several ways. Dr. Sacks was able to localize the le-
sion by taking the patient history, performing examinations, and accessing
technology. However, his relationship with the patient obviously did not end
there. In this case, the doctor continued to develop a caring relationship,
helper to hero: in this, he participated in the meaning of the brain lesion for
the patient, so that, as Broyard says, the doctor “walked around inside me,
trying to see how he could make the premises more livable for me” (1992:
43). Most of all, Dr. Sacks functioned for the colorblind painter as a story-
teller, discovering possibilities of narrative meanings of one sort or another—­

140  /  the chief concern of medicine

stories that gave explanation to the patient about his new way of attending the
world—­where the patient simply saw and felt catastrophe. Katheryn Mont-
gomery Hunter (1991) has coined the term “re-­storying” to describe the ways
in which a physician “translates” the story a patient presents into other, “med-
ical” stories for other health care workers and for the patient and his or her
family. The term combines the concepts of narrative storytelling and the “res-
toration” of health or well-­being. This “re-­storying” the patient is a way of
building rapport and developing a positive, meaningful relationship with the
patient. Such a positive relationship has, almost by definition, positive thera-
peutic effects in and of itself, insofar as it supports the patient as he adapts to
the “new world” of treatment, to ongoing life, or even to the end of life.
Finally, at the heart of the shared enterprise of the patient-­physician re-
lationship is the fact that, despite differences in power and differences in
motives to enter the relationship, it is always possible for the physician to
learn from the patient just as the patient learns from the physician. This fact
is at the heart of Dr. Sacks’s work both as a physician and as a writer, as it is
at the heart of the work of other physicians encountered here and through-
out this book: poets such as Dr. John Stone, Dr. Rafael Campo, Dr. William
Carlos Williams; literary critics such as Dr. Rita Charon; memorialists and
case historians such as Dr. Abraham Verghese and Dr. Oliver Sacks; fiction
writers such as Dr. Richard Selzer, Dr. Ferrol Sams, Dr. Anton Chekhov, and
Dr. Williams. This is accomplished by means of the alternation between pa-
tient and physician of telling and listening to stories: the eliciting of the pa-
tient’s chief concern has the effect of empowering the patient as storyteller.
In fact, focusing on the chief complaint empowers the physician, who, in his
position, always knows more than the patient (even when the patient himself
is a physician); focusing on the chief concern empowers the patient, who is
in the position of storyteller, a Sender who, in “telling events,” as Brian Body
notes, enacts “an effortful process . . . to direct the attention of others to
events real or imagined” (2009: 382).

The Paternalism of Power

The patient-­physician relationship ideally might well be structured to be a

shared enterprise, just as storytelling itself is a shared enterprise in Walter
Benjamin’s description (and that of evolutionary cognition). But in fact, the
significant power differential between patient and physician often obstructs
shared cooperation. The first stories we heard were from our parents and

The Patient-Physician Relationship  /  141

childhood caretakers, who shared with us knowledge and understanding.
But in medicine, “paternalism” is more often than not an obstruction that
commonly characterizes and, to some degree, disrupts the patient-­physician
relationship. This paternalism grows out of the tradition of a male-­
dominated profession and the egocentric idea that the “doctor knows best.”
Paternalism is also a consequence of the authoritative nature of the special
knowledge of the profession, which implies that the patient is ordinarily
ignorant. Finally, some believe, it is a consequence of methods used in
medical education that grow out of the assumptions governing scientific
positivism (examined in chapter 1). Thus, in many cases, the physician puts
himself or herself in the position of parent, while assigning the role of child
to the patient.
In his novel The Woman Who Walked into Doors, Roddy Doyle portrays
a young woman, Paula, who finds herself in an abusive marriage. Her hus-
band, Charlo, beats her frequently, and following particularly severe beat-
ings, he often takes her to the emergency department of the local hospital to
be examined. In the emergency department, the physicians and nurses treat
Paula with a paternalistic attitude, leaving Paula to play the role of a child,
insofar as they do not expect her to have anything of importance to say about
her condition.

Someone once told me that we never remember pain. Once it’s gone it’s
gone. A nurse. She told me just before the doctor put my arm back in its
socket. She was being nice. She’d seen me before.
—­I fell down the stairs again, I told her.
—­Sorry.
No questions asked. What about the burn on my hand? The missing hair?
The teeth? I waited to be asked. Ask me. Ask me. Ask me. I’d tell her. I’d tell
them everything. Look at the burn. Ask me about it.
Ask.
No.
She was nice, though. She was young. It was Friday night. Her boyfriend
was waiting. The doctor never looked at me. He studied parts of me but he
never saw all of me. He never looked at my eyes. Drink, he said to himself. I
could see his nose moving, taking in the smell, deciding. (R. Doyle 1996:
164)

The nurses and doctors who treat Paula respond to her as if she were a child.
They allow the abusive husband to remain in the room and, in fact, to answer

142  /  the chief concern of medicine

most of her questions. They call her silly and tell her that she surely must be
more careful, that falling down stairs and running into doors are the activities
of careless children. Reading this narrative creates empathy for Paula—­a
consequence of storytelling to which we return later in this chapter—­and it
also generates antipathy toward the physicians and nurses, not only for their
paternalistic indifference, but for their confederacy in the conspiracy against
Paula. Moreover, Doyle’s first-­person narrative offers a sense of Paula’s psy-
chological situation—­as an adult, whose life history we know, who is dis-
missed as a child or a drunk—­that is less readily apparent in everyday narra-
tives with different kinds of purposes and ends.
William Carlos Williams dramatizes the abuse of power that often accom-
panies paternalism within a patient-­physician relationship in his story “The
Use of Force,” by creating a literal narrative of a physician and a child. This is
also a first-­person narrative, with the physician, not the patient, as teller. In
Williams’s story, a small girl who refuses to open her mouth for examination is
forced with a large spoon, as the doctor gets angrier and angrier: “In a final
unreasoning assault I overpowered the child’s neck and jaws. I forced the
heavy silver spoon back of her teeth and down her throat till she gagged. And
there it was—­both tonsils covered with membrane” (1984: 60). The power of
Williams’s story is conveyed, at least in part, by its remarkable honesty in its
portrayal of the physician’s emotions: his affection toward the little girl, his
contempt for her frightened parents, and ultimately his uncontrollable anger
toward the patient and also toward the larger situation of a small epidemic of
diphtheria. “After all,” he says, “I had already fallen in love with the savage
brat, the parents were contemptible to me” (58). The doctor relates,

The child’s mouth was already bleeding. Her tongue was cut and she was
screaming in wild hysterical shrieks. Perhaps I should have desisted and
come back in an hour or more. No doubt that would have been better. But I
have seen at least two children lying dead in bed of neglect in such cases, and
feeling that I must get a diagnosis now or never I went at it again. But the
worst of it was that I too had got beyond reason. I could have torn the child
apart in my own fury and enjoyed it. It was a pleasure to attack her. My face
was burning with it. (60)

In this representation of anger, Williams is setting forth an aspect of patient-­

physician relationships that is outside the “objective,” scientific practice of
medicine—­the doctor’s righteous and unrighteous anger. It is righteous be-
cause he knows he can possibly save a young life; and it is unrighteous be-

The Patient-Physician Relationship  /  143

cause he is functioning not as a physician but as his patient’s “opponent,” her
enemy. Negative paternalism can be recognized precisely in the roles of nar-
rative described in chapter 3: to be conscious of the structures of narrative
presses physicians (and others) to be consciously self-­reflective. (In chapter
10, we will explore a positive sense of paternalism that many patients, repre-
sented there by Ivan Ilych, seek in their encounters with physicians.)
While Williams’s story presents a literal version of “paternalism” in that
the patient-­physician relationship is also a relationship between an adult and
a child, Richard Selzer’s story “Brute” is much more disturbing in its repre-
sentation of a physician’s exertion of sanctioned power over a patient. In this
story, Selzer’s narrator tells a story, “from the distance of many years and
from the safety of my little study,” of a doctor, who has been on duty for
many, many hours and is extraordinarily tired, and a “huge black man” who
presents in his emergency room, angry, drunk, under arrest, and with a large
deep wound on his forehead. On the stretcher, the patient

strains and screams. But why can he not sense that I am tired? He spits and
curses and rolls his head to escape from my fingers. It is quarter to three in
the morning. I have not yet begun to stitch. I lean close to him. . . . “Hold
still,” I say.
“You fuckin’ hold still,” he says to me in a clear, fierce voice. Suddenly, I am
in the fury with him. Somehow he has managed to capture me, to pull me
inside his cage. Now we are two brutes hissing and batting at each other. But
I do not fight fairly.
I go to the cupboard and get from it two packets of heavy, braided silk su-
ture and a large curved needle. I pass one of the heavy silk sutures through
the eye of the needle through the center of his right earlobe. Then I pass the
needle through the mattress of the stretcher. . . . I do exactly the same to his
left earlobe. . . .
“I have sewn your ears to the stretcher,” I say. “Move, and you’ll rip ’em
off.” And leaning close I say in a whisper, “Now you fuckin’ hold still.” . . .
Even now, so many years later, this ancient rage of mine returns to peck
among my dreams. . . . How sorry I will always be. (Selzer 1996: 61–­63)

In this story, Selzer represents an encounter between physician and patient

that is hardly a relationship but purely a technical transaction, in which, as in
Williams’s story, the physician positions himself as the patient’s “opponent” in
a scene that simply narrates conflict.

144  /  the chief concern of medicine

 On reflecting on this story, Dr. Selzer describes reading or teaching
“Brute” as representing “a lost opportunity for grace” (Vannatta, Schleifer,
and Crow 2005: chap. 2, screen 14). As we shall see in chapter 6, Dr. John
Stone ends his poem “He Makes a House Call” similarly, with a description
of the patient-­physician relationship in terms of the relationship between a
saint and his or her faithful caretakers. In a moment, we examine Flannery
O’Connor’s use of religious themes to enact conceptions of personhood and
relationships among people, which, through its narrative form, can help us
understand the qualities of the patient-­physician relationship. The religious
language of all these representations are related to Broyard’s description of
illness as something “demonic”; such religious language gathers up the “feel,”
so to speak, of the shared enterprise of doctoring, even when the participants
are not equally powerful. Moreover, such language suggests a narrative, a
story, of redemption, restoration (“re-­storying”), community—­or narratives
of the violations of these things. The values of redemption, restoration, and
even community often seem to be the end and goal of these explicit and im-
plicit narratives, demanding, as in Selzer’s powerfully disturbing story, a mo-
ment of reflection in the hurry of events. The religious language used in
them is a call for such reflective moments. (Precisely this intuitive sense of
the “redemptive” nature of health care makes both Williams’s and Selzer’s
stories so horrifying.) Moreover, the religious language offers a different
schema of understanding from that of the all-­knowing (paternal) physician
and supplicating patient. These “cases” of patient-­physician relationship in
Doyle, Williams, and Selzer set forth what Thomas Nickles calls “both small
schemas that are operationalized cases and larger, organizing schemas” that
allow for the construal of new endings growing out of the narrative situation
of the patient-­physician encounter (1998: 79).
A subtler form of power and paternalism is a general arrogance often
displayed by physicians, which is, again, more easily discernible in art narra-
tive. In her story “The Interior Castle,” Jean Stafford tells of a woman under-
going nose surgery following an automobile accident. The procedures are
exceptionally painful. The author portrays the experience of the pain from
the patient’s perspective. In this narrative, the doctor never validates the
pain, does not invest time or energy in developing rapport, and demonstrates
no empathic understanding of the patient’s horrible pain. The patient, Pansy,
we are told, “fought two adversaries: pain and Dr. Nicholas.” The doctor tells
her there is no danger—­“There is no danger,” he says. “Do you think for a
minute I would operate if there were?”—­even though he wonders to himself

The Patient-Physician Relationship  /  145

“if she knew in what potential danger she lay.” This patient-­physician rela-
tionship results in only technical manipulation of the nose and virtually no
caring for the patient.
Before the operation, Dr. Nicholas jokes with his patient: “‘All set?’ the
surgeon asked her, smiling. ‘A little nervous, what? I don’t blame you. I’ve
often said I’d rather break a leg than have a submucous resection.’“ And dur-
ing the operation, while he proceeds, Pansy is

in such pain as passed all language and even the farthest fetched analo-
gies. . . . She was claimed entirely by this present, meaningless pain and sud-
denly and sharply she forgot what she had meant to do. She was aware of
nothing but her ascent to the summit of something; what it was she did not
know, whether it was a tower or a peak or Jacob’s ladder. Now she was an
abstract word, now she was a theorem of geometry, now she was a kite flying,
a top spinning, a prism flashing, a kaleidoscope turning. (Stafford 1969: 179–­
83)

This narrative of the pain experienced during conscious manipulation of the

nasal fracture and its reconstruction represents the experience of pain from
the perspective of the patient, even as the narrative provides the physician’s
arrogant oblivion to his patient’s experience. The story provides the doctor or
the student of health care a pristine account of the arrogant detachment of
the doctor and of the experience of the patient, as well as a starting point
from which to begin developing patient-­physician relationships. Stafford’s
ability to provoke empathy in her narrative even while the physician exhibits
none helps the doctor or medical student to recognize the need for empathy,
for verbalizing and acting on that empathy, so that in the future, his or her
patients might have a different subjective experience of the pain so often
necessary in their relationships with physicians.
An even more striking representation of arrogance is Flannery O’Connor’s
story “The Artificial Nigger.” (The very title of this story—­its use of the igno-
rant and abhorrent language of its chief character—­underlines its represen-
tation of arrogance.) This story does not focus on a patient-­physician rela-
tionship. Rather, it narrates the relationship between Mr. Head and his
young grandson, Nelson, as they pursue a visit to Atlanta from the rural
south, in another version of literal paternalism. What is striking about this
story is not only the arrogance with which Mr. Head treats his grandson—­he
thinks of himself as “a suitable guide for the young” and, in the end, betrays
his grandson to save himself—­but the way O’Connor leads her readers to

146  /  the chief concern of medicine

think of themselves as better educated, more perspicacious, and simply more
fully human than these country “rednecks.” She does this by her language:
the narrator says “Negro,” while Mr. Head uses the viscerally derogatory
term; and throughout the narrative, there is the educated, sophisticated lan-
guage of the narrator—­who mentions Dante and Virgil and seems to have a
working sense of Catholic theology that is clearly beyond the understanding
of her Southern Baptist protagonist. In fact, reading this story in conjunction
with “The Interior Castle” calls attention to the gap in discourse between the
knowledgeable, scientific language of the physician (his “submucous resec-
tion”) and his frightened patient. Here, the categorical distinction in narra-
tology between the story (plot) and the discourse (narration)—­the tale and
the telling, as discussed in chapter 3—­is the motor of the story’s power.
(Practicing physicians do not need the technical distinction as long as they
can use the schema of the “two temporalities” of narrative, the temporal ac-
tion of the story and the temporal action of its telling [Kreiswirth 2000: 313],
in allowing themselves to be consciously aware of the organization of their
patient’s story and its meanings. Moreover, this distinction manifests itself in
action, such as verbally responding to the manner of the patient’s responses.)
Finally, “The Artificial Nigger,” like so many of O’Connor’s stories, is
about Christian revelation and redemption. At the end—­in a language of
Catholic theology foreign to that of Mr. Head—­readers learn of Mr. Head’s
salvation and, in this recognition, might also perceive their own sin of arro-
gant pride.

Mr. Head stood very still and felt the action of mercy touch him again but this
time he knew there were no words in the world that could name it. He un-
derstood that it grew out of agony, which is not denied to any man and which
is given in strange ways to children. . . . He stood appalled, judging himself
with the thoroughness of God, while the action of mercy covered his pride
like a flame and consumed it. . . . He realized he was forgiven for sins from
the beginning of time, when he had conceived in his own heart the sin of
Adam, until the present, when he had denied poor Nelson. He saw that no
sin was too monstrous for him to claim as his own, and since God loved in
proportion as He forgave, he felt ready at that instant to enter Paradise.
(O’Conner 1996: 269–­70)

This story works, so to speak, by situating its readers in relation to the narra-
tive’s characters in such a way that they are able to recognize the characters’
arrogance as their own. Such recognition is created by shifting narrative

The Patient-Physician Relationship  /  147

“positions”—­for characters, readers, and even tellers of stories—­and it is
crucial to one way in which literary narrative conveys knowledge and insight
that is important to medical education and practice. Dr. Stone explicitly
shifts his position at the end of “He Makes a House Call” by likening patient
to saint; Dr. Selzer does so implicitly at the end of “Brute” and explicitly in
his comments on the story. O’Connor does so at the end of this story by num-
bering Mr. Head among the redeemed, one of the saved. Such shifting of
position—­which is, in fact, shifting from one provisional schema-­based un-
derstanding to another—­helps create explicit awareness of what we are call-
ing the very scene of narration.
When we read Flannery O’Connor’s stories—­a story like “The Lame
Shall Enter First” as well as “The Artificial Nigger”—­we encounter a narra-
tive that is organized in such a way that we are forced to consciously assume
the role of the listener-­reader (the “Receiver” in Greimas’s terminology). In
assuming that role or position in relation to the narrative at the end of “The
Artificial Nigger,” we suddenly realize that Mr. Head, this hillbilly than whom
we think we are so much smarter, is capable of being saved and that we are
no better than he is. At the end of “The Lame Shall Enter First,” we see that
Mr. Sheppard, who is a more or less educated man who believes in science
and natural explanations of phenomena, is shocked by the suicide of his son,
and we are shocked, too. The art of O’Connor’s narrative is to situate her
readers in the position that her characters assume—­as Receivers of their
stories’ meanings—­and such positioning forces the listener to attend to her
own responses. When Aristotle describes tragedy in terms of pity and terror,
he is doing the same thing. He is defining tragedy in terms of the response of
the listener.
Using O’Connor’s story to teach medical students about arrogance works
particularly well for several reasons, one of which, paradoxically, is that there
are no doctors or patients in the story. This nonmedical narrative then, allows
students to discuss arrogance in the abstract—­the schema of arrogant judg-
mental power that assumes rather than listens and that allows itself to lie to
and manipulate patients, as Mr. Head manipulates his grandson. Physicians
and students can discover for themselves, through discussion or reflection,
that the concept applies to doctors, that their relationships to patients are
analogous to Mr. Head’s relationship to his grandson insofar as it exhibits
paternalism and power. The story’s stark and offensive title allows the stu-
dent to explore the meaning of titles in literature—­this is another feature of
“art narrative,” as opposed to, say, “Mrs. Jones’s story”—­here emphasizing
the importance of vocabulary in the title’s offensive language. This literary

148  /  the chief concern of medicine

issue is very important in achieving the goal of narrative competence for the
physician, because the language of the physician is, in fact, often so different
from the language of the patient. Like art narrative more generally,
O’Connor’s story can be used to teach several lessons at once. Arrogance
takes the forms of rationalization (Mr. Head’s repeated rationalizations in
this story, as in “The Use of Force” and also O’Connor’s “The Lame Shall
Enter First”), of betrayals of trust (Mr. Head’s denial of “his likeness,” as the
story says), of smug superiority born of having the access to “correct” lan-
guage, or of assuming that one’s charge (whether it be one’s patient or grand-
son or even the characters in a narrative) has nothing to teach one. O’Connor’s
story presents and represents a schema of arrogance in terms of knowledge,
action, attitude, and language and, less explicitly—­but no less forcefully—­
than Grace Paley, represents the scene of narration altogether.

Case-­Based Reasoning: The Development of Rapport

Representation of the scene of narration—­our description of the event of the

patient-­physician relationship—­not only encourages the recognitions that
we have described in O’Connor and others (all of which focus on the witness
who learns); it also encourages the kind of relationship between teller and
listener established on what Brian Boyd calls narration’s “telling events, an
effortful process we undertake only to direct the attention of others to events
real or imagined” (2009: 382). Such “telling events” forge relationships be-
tween the teller and the listener: this is the import of Robin Dunbar’s (1996)
contention that “gossip” describes the evolutionary adaptive function of lan-
guage, that of forging relationships between members of a community. The
narrative a patient brings to the patient-­physician relationship is hardly gos-
sip, but it does create a scene for the establishment of relationship beyond an
impersonal client-­professional interaction; that is, the scene of narration is
the site of (possible) rapport. Encouraging physicians to develop rapport
with the patient early in the relationship is one of the goals of medical educa-
tion, because such rapport is required to build an effective patient-­physician
relationship. Rapport is usually defined as agreement and harmony between
people, a close and trusting relationship. Each of the preceding stories by
Williams, Selzer, and Stafford demonstrates this need by its felt absence.
O’Connor demonstrates this need by offering a story in which Mr. Head
comes to acknowledge his grandson as a valid person. Dr. Stone acknowl-
edges rapport through the language of religious experience. Most medical

The Patient-Physician Relationship  /  149

schools use a variety of methods of developing this skill, including practice
with simulated patients or experiential learning. The use of literature in
teaching strategies for achieving rapport with patients is relatively new. It is
a method that is contextual in nature. In this situation, what we mean by
contextual is that the literary text provides a context—­a vicarious experience—­
within which the reader/listener can recognize and even feel harmony, agree-
ment or disagreement, trust or distrust with characters or with the author/
teller.
Among other functions, storytelling—­literary and nonliterary narrative—­
presents and represents situations of personal value and interpersonal rela-
tionships, the “cases” of the case-­based reasoning Thomas Nickles describes
(1998). In literary narratives, the represented situations of events and feeling
provide the reader with a learning environment devoid of the learner’s ego
investment. Represented situations provide the reader with rich contexts in
which he or she is allowed to imagine the story. The reader can reflect on,
write about, and discuss the content of the story and develop analyses, con-
nections, and analogies to his own life experiences—­in relation to physicians,
to clinical situations—­without actually experiencing it. The reader encoun-
ters a “case” of the development of rapport between the physician and pa-
tient in the context of more or less rich interpersonal relations. Such an en-
counter with narrative is very different from the abstract descriptions or
definitions of the elements of interpersonal relationships that are often pre-
sented in lectures or textbook discussions. In O’Connor, as we suggested, the
situating of the reader in relation to the events of narrative locates the reader
both inside and outside the racist south of the 1950s, inside and outside the
“redneck” mentality, inside and outside the conflict between the narrator’s
reflective theology and the characters’ unreflective responses to the world.
This allows readers to imagine themselves in situations and vicariously expe-
rience the emotions that arise out of those situations, unhampered by the
dismissive shorthand of stereotype. Such shorthand grows out of the unre-
flective attribution of narrative roles—­“actantial” roles—­to characters that
allows, for instance, physicians to dismiss the lower-­class Paula so easily as, in
her drunkenness, the opponent to the physician-­hero seeking health. Such
shorthand is based on stereotypical schemas, and it governs narrative insofar
as the (more or less unconscious) structures of narrative govern our appre-
hensions of narrative knowledge. Yet when these schemas are consciously
apprehended, they are able to provoke critical judgment—­both intellectual
and emotional—­of those situations. In other words, they are apprehended as
provisional. Moreover, such conscious understanding—­even resulting from

150  /  the chief concern of medicine

the stereotype “shorthand” of schemas—­allows for richer apprehensions of
the representations of situations of interpersonal relationships and interper-
sonal actions, provoking self-­conscious emotional responses that learners can
often recognize again in actual clinical situations. Such emotional responses
are provoked outside an actual interpersonal encounter, and as “cases” of
emotional experiences rather than event experiences, they can be more con-
sciously apprehended. (In chapter 9 we offer a more detailed analysis of the
functioning of the vicarious experience provoked by narrative that we are
describing here.)
The relationship between patient and physician functions more effec-
tively when rapport is developed. This requires the doctor to listen to the
biomedical and psychosocial aspects of the patient’s story, hear the patient’s
concerns, and listen carefully to the illness narrative. But besides the pa-
tient’s story and the doctor’s listening, some connection, some exchange,
hopefully will occur between patient and physician. This will demand of the
physician less control and some emotional investment. As Anatole Broyard
says, “It may be necessary [for the physician] to give up some of his authority
in exchange for his humanity, but as the old family doctor knew, this is not a
bad bargain” (1992: 57). Dr. Ferrol Sams’s narrative “Epiphany” provides, in
its “telling events,” both the representation and the provocation of the devel-
opment of rapport at the scene of narration. In this narrative, Dr. Goddard is
treating an uneducated, poor ex-­convict, Gregry McHune. Rapport is re-
quired in this relationship, as it is in most, because future effectiveness of
treatment depends on it. (Sams’s narrative represents this as well.) Dr. God-
dard recognizes the social and educational gap that exists between himself
and his patient and is careful not to let it affect their interaction. Gregry’s
response to Dr. Goddard initially demonstrates that the patient feels rapport
with the doctor.

Back in the treatment room he handed Gregry McHune two small boxes.
“We didn’t have any more samples of Vasotec, but here are some pills that are
good. This is Tenormin and it’s in a form that you only have to take one a day.
Take one every morning and don’t forget, you promised to see me in two
weeks.”
“I won’t forget, Doc, but hell, you didn’t have to do this. I’m a pore man,
but I ain’t no charity case.”
“You’re accommodating your habits and wishes to mine, Gregry, and I’m
trying to accommodate mine to yours. I’ll see you next week.”
“I’ll sure be here.” There was a pause, almost of embarrassment. “I ain’t

The Patient-Physician Relationship  /  151

 never run into no doctor like you before.” He hesitated, “If you care, I care.”
(Sams 1994: 12)

Throughout the narrative, Sams portrays Dr. Goddard as caring for his pa-
tient. It becomes clear that the doctor develops an emotional connection to
the patient, the harmony and agreement of rapport. The doctor’s care and
connection takes the forms of respect and honor for the patient’s story, taking
the time to listen carefully, and, finally, responding to his patient in terms of
the values and vocabulary that the patient brings to the doctor-­patient en-
counter.
Rapport is a relationship built on trust and emotional affinity. The physi-
cian has the responsibility to demonstrate genuineness, honesty, and com-
mitment. The patient will respond to this honesty emotionally. This forms
the beginning of a relationship based on rapport. It is incumbent on the
physician to investigate the uniqueness of every patient and find ways to re-
late to the qualities that define that particular patient. Rapport is more easily
developed with patients who are like the physician—­when the patient and
physician are of same gender and similar cultural background, age, and inter-
ests. When the patient and physician are not similar, development of rapport
can be more difficult to achieve. Reading literary narrative—­especially in
group settings that allow the expression of different understandings and
points of view—­has a role to play in the education of physicians about devel-
opment of rapport. Literature provides a wealth of experience—­vicariously
experienced “cases”—­with other cultures, gender roles, and socioeconomic
groups that the physician may never have experienced. Narrative is about
something particular and therefore creates memories and images in the
reader’s mind that often provoke an emotional response. Both the images
and the emotions of narrative that can give rise to vicarious experiences are
stored in memory, just as the “cases” of the case-­based reasoning Thomas
Nickles describes comprise “memory stores” (1998: 79). This library of im-
ages and emotions, built up over time in response to the more or less disin-
terested engagement with art narrative, is available to the physician when a
patient reminds him of some character—­or, really, some narrative role—­
from narrative read in the past. Such case-­based memory stores can fortify
understanding and emotion for the encounter at hand, both of which can
contribute to the establishment of rapport.
Rapport is essential to the shared enterprise of the patient-­physician re-
lationship and its collaborative nature. Once it is established, the physician
conceives of his work with a patient as a relationship, a collaborative and

152  /  the chief concern of medicine

deliberative effort, and the nature of his role and the weight of his burden
change. Building rapport—­creating harmony, agreement, and trust—­is re-
ciprocal in nature. Dr. Jerry Vannatta narrates the following encounter in his
practice of internal medicine that resulted in the establishment of rapport
between himself and a patient.

I came to this whole interest in narrative, literature, and the practice of

medicine through an experience I had in my own practice. I’m a general
internist, and I had an elderly African American woman who came back to
the office for an office visit after having been in the hospital. I didn’t get to
know her real well in the hospital, because she was cared for primarily by
the residents and the medical students on my service, but when she came
back for an office visit, I was providing the care. And she rapidly told me
that she was having trouble getting her medications. As I was interacting
with her, there was just really no connection being made. That makes me so
uncomfortable when I’m really not connecting with the patient, so, as I
usually do when I’m not connecting well, I backed up and sort of took a
psychosocial history. I basically just said, “Tell me about your life.”
She began to tell me a story about having grown up in east Texas on a
sharecropping farm where her father was a sharecropper. When she was
fifteen, her father made her marry a man who was twenty-­one. It really
wasn’t the man she wanted to marry; she was in love with a sixteen-­year-­old,
but he made her marry the twenty-­one-­year-­old because he could provide
for a living. In fact, she said to me during the story that “he wasn’t very
good at making a living, but he was sure good at making babies,” and she
had seventeen of them. I thought at the time she said that, “My goodness,
that could have rolled right out of a wonderful novel or short story.” She
went on to say that she oftentimes, to make ends meet, walked two miles to
a white man’s house to do domestic work and two miles back. She told me
that sometimes the white man would give her a dozen eggs, and sometimes
he would give her a two-­gallon pail of milk to carry back to the family. Then
she looked at me and said, “Doctor, have you ever carried a two-­gallon pail
of milk two miles?” In fact, I did grow up on a farm, and I can remember
carrying those galvanized pails of water around the farm to the chickens
and whatnot, and I could just see that wire handle just burying itself and
cutting into her hand.
More important, I was thinking that I was seeing a younger version of
this patient carrying this pail of milk on a dusty, sort of rocky road, probably
with not very good shoes. And as I was thinking about her feet, making this

The Patient-Physician Relationship  /  153

journey back, I began to think of this novel, Toni Morrison’s novel Beloved,
which I had just read a few months earlier, the most remarkable novel I had
ever read, a very disturbing story about slavery in America. The protagonist,
Sethe, is running from slavery. She’s pregnant, she’s trying to escape, she’s
tired, and she’s about to deliver a baby. She’s hiding up under a bush, and a
little white girl finds her. One of the things that’s striking about that scene is
her swollen, bleeding, and pussy, infected feet. The image of those feet
came back to me in a flood. The emotions that I had felt, I think, when I
read the novel were seemingly stored in memory. Along with the image of
the feet, these emotions came flooding back to me. And the remarkable
thing that happened in the room was that those emotions were available to
me to be able to connect with this lady. It was not that she was a slave, but
she was telling me a story about her economic enslavement, and somehow
they connected. I don’t know how that works, but it happened nonetheless.
It was an experience that was dramatic for me, and from that point on, we
began to make a more meaningful connection, and we engaged in a sort of
rapid problem solving about her ability to buy her medications and get
them so that she could take them. At the end of the interaction, we stood
up to leave, and a remarkable thing happened, which usually doesn’t
happen in my practice: we embraced. She knew that a wonderful
relationship had begun, and so did I.

In this vignette, physician and patient develop rapport based on a scene

of storytelling where teller and listener find common understanding and ex-
perience by means of the limited number of narrative roles and actions.
More specifically, in Dr. Vannatta’s experience with this patient, the work of
establishing rapport was most likely accomplished by the activation of the
narrative memory store changing his countenance (which was recognized by
the patient), even as that memory of roles and actions of Morrison’s novel
also provided him with unspoken content of the patient’s story. In any case,
in this account, Dr. Vannatta is describing the effectiveness or consequence
(as mentioned in chapter 1) of narrative, here accomplished (in part) by the
kind of identification of listener with plot analogous to the ways we described
O’Connor surprising her readers by leading them to identify with Mr. Head
at the end of “The Artificial Nigger.” Dr. Vannatta is here narrating a “telling
event” (a narrative detail): in this case, his encounter with the protagonist’s
feet in reading Morrison’s Beloved. Such a narrative detail allows for identi-
fication of characters across three narratives: the patient’s, Morrison’s, and
Dr. Vannatta’s own farm memories. This identification is not so much person-­

154  /  the chief concern of medicine

to-­person as it is role-­to-­role—­with the protagonists struggling against recog-
nizable obstacles (the heavy pail)—­so that the relationship between teller
and listener is mediated through narrative forms. Throughout the chapters
of this book, but especially in chapter 8, we will have occasion to analyze
more closely the ways that narrative accomplishes this kind of humanistic
understanding. Here, though, is what might well be the base of humanistic
understanding, insofar as it is the base of schemas, namely, the case as a
memory store: if, in fact, as Nickles argues, “schema instances have a similar
twofold nature, functioning both as memory stores and as procedures for
applying that knowledge” (1998: 79), the functioning of schemas as memory
stores highlights the manner in which exemplary cases are the particular
base to the more general schema memory and schema experience.
In a more formal art narrative, Richard Selzer narrates the creation of
rapport based on a single meeting between a retired doctor and an obviously
chronically ill young boy, who meet in the atrium of a hospital in his story
“Atrium: October 2001.” The doctor develops rapport with the boy by ex-
changing death stories. (Unlike this aesthetic “art” narrative in the Beloved
vignette, Dr. Vannatta never shares his stories of either the farm or the novel
with his interlocutor.) These narratives serve to establish a relationship—­a
friendship of sorts—­based on honesty, trust, and agreement and their reci-
procity, which, like that of narrator and character in O’Connor or daughter
and father in Paley, underlines the formal artistry of literary, rather than or-
dinary, narrative (though the Beloved vignette Dr. Vannatta related is ex-
traordinary in its own way). The honesty of the old man and dying boy is es-
tablished on their shared sense of mortality.
In Dr. Selzer’s story, the retired doctor, lunching in the atrium of the
hospital, becomes acquainted with the boy, Thomas. The doctor and the boy
develop rapport that is deep, meaningful, and reciprocal, even though they
have just met. The rapport is reciprocal because the boy asks for a story, and
the doctor recognized, honestly and without shame, that the boy, even at his
young age, is facing the stark reality of death. In their first encounter, the
doctor is the teller and shares a story about what his last day on earth will be
like. This narrative is much like those of Chekhov (and his “loaded rifle”) in
that it contains telling detail: the fragrance of the forest; the sounds of the
trees; the sensation of a breath, with its poetic rhythm.

I have just finished eating lunch, and I’m sitting on a bench on the atrium a
few paces from the fountain with its murmur and glitter. In a wheelchair
quite nearby sits a thin, pale boy. He’s bald. His lips are crusted and with a

The Patient-Physician Relationship  /  155

 sore at either corner of his mouth. Intravenous fluid drips into his left arm.
The bottle hangs from a metal pole attached to the wheelchair over his head.
In his lap a plastic bottle of water with a straw. Now and then the scabbed lips
flutter apart, and he takes a sip of air, then another. He looks to be about ten
years old and weighs, perhaps, eighty pounds. . . .
“What’s that you’re getting in the IV?” I ask. He glances for a moment at
the bottle on the pole.
“It’s my pet,” he says. “Follows me wherever I go.”
“More like your guardian angel.” He reacts not at all to this statement. I try
again. “Something like a Hospital God. You know, like the ancient gods of the
heart.”
“Lares and Penates,” he mutters. “You a doctor?”
“I used to be, long ago. Retired. I got old.”
“A condition I will never have to face.” I am shocked at the tone in which
he says this. It is devoid of inflection or irony. I search all over my mouth for
something to say. For a long moment we are silent. . . .
“What will you do on your last day on earth?” [he asks me.]
“My last day?”
“The day you’re going to die.”
“Can we talk about something else?” He gives a tiny shake of the head.
The huge eyes insist; beneath them are smudges of violet. I’m caught and
fluttering in that merciless gaze. He raises the water bottle to his lips and
takes a tiny, excruciating sip.
“Life hurts,” he says. “I measure out the time by sips, see how few I can get
along with.” (Selzer 2004: 146–­47)

Dr. Selzer tells the boy a story of his own dying—­he tells it twice—­of how a
former student who is now “a great surgeon” takes his dying mentor to a
quiet, wild woods, “a pious forest” where “great old trees are deeply rooted
in the earth and their canopies sway overhead.” There, Dr. Selzer imagines
dying quietly as night falls, coming with “a feeling of imminence” as he feels
darkness enter his body. Then he seems to die in a manner that is indistin-
guishable from sleep: “I am the whispering of leaves, more guessed at than
seen” (250). The boy, thinking of his own impending death, loves this gift of
the narrative of how an old man might die, so much that he asks him to tell it
again.
The rapport is reciprocal, and the narrative enacts this reciprocity: the boy
sends a letter, delivered posthumously on the following day, relating his death
to be just as Dr. Selzer imagined his own would be. The doctor provided a

156  /  the chief concern of medicine

beautiful and poetic narrative gift to this enlightened fourteen-­year-­old boy, a
story of dying with grace. The boy was grateful for this gift, and the doctor was
transformed by the relationship with Thomas: “He is unto me like a fountain
in my mind, a place where it is always cool and fresh and where I can go to
partake of its coolness” (252). A story such as this—­it is implicit in the Beloved
vignette as well—­enacts the scene of narration insofar as it describes the ways
that storytelling as a formal activity forges felt relationships between teller
and listener. Such relationships might well be, as Robin Dunbar has argued
(1996), the very “purpose”—­the functional reality—­of narrative, its ability to
create bonds between people as they tell and listen to narrative.

Empathy and Narrative

Rapport is an aspect of relationships between people that includes trust,

honesty, and the assumption of goodwill between the parties involved. These
things, as we have seen, can be represented and provoked in literary narra-
tives and the implied narratives of poetry. There is another quality, akin to
rapport, that physicians can bring to or develop within their relationships
with patients. The quality of empathy is, in many ways, at the base of rapport.
This section explores the quality of empathy in terms of the knowledge and
experiences it provides, the ways in which people might learn to be attentive
to it, and the manner in which literature can help us recognize and nurture
it. Still, the definition of empathy has been the site of some conflict. Suzanne
Keen has defined it as “a vicarious, spontaneous sharing of affect”—­the “I
feel what you feel” of empathy as opposed to the “I feel a supportive emotion
about your feelings” of sympathy—­even though she notes that most psy-
chologists believe that empathy is “both affective and cognitive” (2006: 208–­
9). In fact, Keen cites a study, supported by fMRI data, that demonstrates
that “a person perceives that she feels another’s pain, while not literally expe-
riencing the identical sensations”; the study concludes that “empathy is me-
diated by the part of the pain network associated with pain’s affective quali-
ties, but not its sensory qualities” (Keen 2006: 211, citing Singer et al. 2004:
1157). For physicians, it is most important to think of empathy as a cognitive
activity rather than an event of feeling (affect) and, as Keen suggests in dis-
cussing novelists and art narrative, as the cultivation of “role-­taking skills
[that] make them [she means novelists, but we would include regular readers
as well] more habitually empathetic” (2006: 221).
The following vignette, a dramatic narrative of an everyday encounter

The Patient-Physician Relationship  /  157

between a physician and his patient, offers an enactment of empathy, which
can help us to see the role of narrative in empathy and its contribution to
rapport and the establishment of a fruitful patient-­physician relationship.
dr. orwig: Miss Silcox?
ms. silcox: Linda, yes . . .
dr. orwig: Linda, I’m Dr. Orwig.
ms. silcox: It’s nice to meet you.
dr. orwig: Tell me, what brings you in today?
ms. silcox: (heavy sigh) Well, I came because I’m tired. I’m inordi-
nately tired and I know that you don’t know me, but . . . I’m not usu-
ally tired. And nothing I have tried has been helpful.
dr. orwig: (with a look of concern, touching her arm) Tell me a little
bit more about that.
ms. silcox: Well, I first noticed it probably eight or ten weeks ago,
when I was running with my friends. Now we’ve been running the
same course for . . . I don’t know . . . eighteen years, and it’s only
three miles, and I started saying, “Could we just walk this block?” or
“Could we just slow the pace a little bit?” because I just couldn’t
keep up. And finally it got to the point where I just had to give it up.
I couldn’t keep up. I couldn’t do it. I thought the net effect of that
would be that then I’d have the energy I used to spend running to do
other things. But I’m just tired anyway. And now I don’t see my
friends, I don’t go running, I don’t really do anything fun anymore,
’cause I just barely have the energy to do the things I have to do to
get through the day.
dr. orwig: Wow, it sounds like this really changed your life.
ms. silcox: It’s horrible. It’s changed it a lot. And I’m pretty sure
something’s wrong with my body.

As Dr. Orwig enters the room, he recognizes the patient and introduces him-
self. He then listens carefully as Ms. Silcox tells her story regarding fatigue.
He recognizes that the primary emotion here is sadness and that her chief
concern is loss—­the loss of the ability to run with her friends. This psychoso-
cial information is used to understand the patient’s plight. Her particular
plight is that she has lost this very important part of her social life and sup-
port system. He notices her great sigh and sad face and nonverbally acknowl-
edges them with a small gesture. Moreover, he verbally acknowledges her
loss by saying, “Wow, it sounds like this really changed your life.” Dr. Orwig
responds to all of the information his patient presents, both verbal and non-

158  /  the chief concern of medicine

verbal, before pursuing and facilitating her biomedical story. He understands
that this demonstration of empathy—­that is, verbal and nonverbal responses
to her narrative that demonstrate the cognitive apprehension of the patient’s
feelings and concern—­is important in creating rapport with his patient and
in further elucidating her story. By Dr. Orwig’s explicit verbal and physical
responses to the patient’s concerns, the patient knows he cares about her and
understands her plight. Empathy is both a feeling and a form of understand-
ing, both affective and cognitive, but to function in the patient-­physician re-
lationship—­or, for that matter, in many other interpersonal relationships—­it
needs to be made as explicit as possible within the interpersonal encounter
at the scene of narration.
Empathy belongs to the domain of emotions and narrative understand-
ing. It does not spring forth from the logico-­scientific study of medicine. As
we have said, empathy is an affective as well as cognitive understanding of
another’s feelings, pain, or concern.1 When the doctor responds—­verbally, or
through acts or gestures of kindness—­on the basis of this understanding of
another’s pain, the patient knows the caring of the physician and has positive
evidence of it. Responding verbally and/or through acts of kindness is impor-
tant because the empathetic understanding by the physician may go unno-
ticed by the patient and, therefore, have no effect on the relationship. In
most cases, as in Sams’s “Epiphany” and in the encounter between Dr. Orwig
and Ms. Silcox, the physician’s empathy is a constituent element of doctor-­
patient rapport—­sometimes its cause, sometimes its effect. As such, it pro-
motes trust, honesty, and goodwill in the patient-­physician relationship.
Steven Johnson surveys experimental work in cognitive psychology that
demonstrates empathetic understanding in children as young as four. (Keen
2006 cites this work as well, as we did in chapter 2 in relation to theory of
mind.) “Human beings are innate mind readers,” he writes, explaining, “Our
skill at imagining other people’s mental states ranks up there with our knack
for language and our opposable thumbs. It comes so naturally to us and has
engendered so many corollary effects that it’s hard for us to think of it as a
special skill at all. And yet most animals lack the mind-­reading skills of a four-­
year-­old child. We come into the world with a genetic aptitude for building
‘theories of other minds’ and adjusting those theories on the fly, in response
to various forms of social feedback.” Johnson goes on to argue that our very
sense of self-­awareness—­our sense of personhood altogether—­is a function
of the social-­communicative skills of mind reading, skills of empathetic un-
derstanding. “Only when we begin to speculate on the mental life of others,”
he notes, “do we discover that we have a mental life ourselves.” “Among the

The Patient-Physician Relationship  /  159

apes,” Johnson writes, “we are an anomaly in this respect: only the chimps
share our compulsive mixed-­sex socializing. (Orangutans live mostly solitary
lives; gibbons as isolated couples; gorillas travel in harems dominated by a
single male.) That social complexity demands formidable mental skills: in-
stead of outfoxing a single predator, or caring for a single infant, humans
mentally track the behavior of dozens of individuals, altering their own be-
havior based on that information. Some evolutionary psychologists believe
that the extraordinary expansion of brain size between Homo habilis and
Homo sapiens (brain mass trebled over the 2-­million-­year period that sepa-
rates the two species) was at least in part triggered by an arms race between
Pleistocene-­era extroverts.” As Johnson reports, some researchers have iso-
lated “mirror neurons” in chimps that fire when a chimp performs a particu-
lar activity (e.g., putting food in its mouth) and that also fired “when the
monkey observed another monkey performing the task.” Such “synchronic”
firings for self and others, he speculates, might well be “the neurological
root” of empathy, “which would mean that our skills were more than just an
offshoot of general intelligence, but relied instead on our brains’ being wired
a specific way.” Johnson goes on to suggest that people suffering from autism
might well “suffer from a specific neurological disorder that inhibits their
ability to build theories of other minds” (2002: 196–­202; see our discussion
of mirror neurons in chapter 2, n. 2, as well as Iacoboni 2009).
In an interview, Dr. Rita Charon defines empathy as a combination of
cognitive and emotional understanding—­a kind of “recognition” of the hu-
manity, and the human suffering, of another person. “Empathy,” she has
said, “is the method, or the tool, that gets you toward engagement. Empathy
is that ability to recognize the plight of another person and to be moved by
it. Empathy does not require that I have experienced what the patient is ex-
periencing” (Vannatta, Schleifer, and Crow 2005: chap. 1, screen 35). The
“recognition” discussed by Dr. Charon is a type of understanding of the pa-
tient’s plight that we are describing in this chapter and that many of the nar-
ratives we have cited represent and provoke.2 Such recognition also entails
being willing to invest one’s self emotionally in the patient and her story in a
direction, as Charon says, toward engagement. When the physician and pa-
tient engage in this manner, they experience a deeper, more meaningful
relationship—­one built on mutual understanding, trust, and a kind of identi-
fication. This engagement describes rapport and is established through the
development of empathetic recognition and understanding.
The imaginative understanding of the whole situation in empathy—­the

160  /  the chief concern of medicine

scene of narration in the patient-­physician relationship—­links it powerfully
to the goal of grasping the meaningful whole of narrative. For this reason,
“cases” of literature and literary narrative are particularly effective in repre-
senting and provoking empathy. Empathy is a response and an emotion gen-
erated by an act of recognition, as Dr. Charon has said. Such recognition can
be provoked by an image (e.g., Sethe’s feet in the Beloved vignette), an imag-
inative identification (e.g., that between the doctor and Thomas in Selzer’s
story), or a sense of a “whole” story falling into place (e.g., O’Connor’s de-
scription of “the action of mercy” at the very end of “The Artificial Nigger”
[1996: 269]). The recognition may be in the form of visual input or narrative
comprehension as created by an author or by the physician as he organizes
data—­stories and facts—­presented by the patient. The recognition may even
result from vicarious memories gained through works of literature or art pre-
viously experienced. (We discuss vicarious experience of narrative more fully
in chapter 9.) Experienced empathy for an ill patient may be gained through
becoming ill oneself or by reading about such an experience, in, for example,
The Death of Ivan Ilych. As one reads Tolstoy’s The Death of Ivan Ilych, it is
impossible not to recognize the agony Ivan feels as he is poorly understood
by his doctors, family, and friends, because Tolstoy makes explicit what is
usually implicit, namely, the particular feelings and responses Ivan has to his
illness and to the ways those in his life respond to his illness: the failure of
Ivan’s family to recognize and acknowledge his plight—­their failure to ex-
hibit empathy for the suffering that is part of Ivan’s and all our lives—­is a
significant cause of his suffering. Tolstoy’s story provides insight into Ivan’s
plight, and through its narrative language and events, the reader vicariously
experiences Ivan’s desires to be understood.

Teaching and Learning Empathy

In the patient-­physician relationship, empathy as experienced by the physi-

cian allows her to “connect” with the patient, to develop or acknowledge the
feelings of harmony, agreement, and trust that characterize rapport. It also
helps the physician to attend to the patient’s concerns and, in many instances,
facilitates diagnosis. When these feelings are demonstrated in language or by
acts of kindness, they deepen and enrich the therapeutic experience for both
the patient and the physician. Empathy helps the physician find meaning in
the relationship between doctor and patient. Empathy is also more readily

The Patient-Physician Relationship  /  161

demonstrated by some individuals, as if it is built into their personality struc-
ture. For those to whom empathy is second nature, the study of literary nar-
rative can provide experiences that validate their impulses to connect with
and comfort others. For those who, for a variety of reasons, do not readily
feel or acknowledge their own feelings of empathetic understanding, active
algorithms—­schemas—­can guide the physician. Physicians can be taught to
express empathy by means of schematic rules of behavior like the following:

1. Attend to the chief concern of the patient: listen for it or, as we are
suggesting, make it an explicit part of the protocols of the History
and Physical Exam.
2. When the concern is expressed, explicitly acknowledge its impor-
tance (as did Dr. Orwig, e.g., in saying “Wow, it sounds like this really
changed your life”).
3. Paraphrase the expressed concern so that the patient will explicitly
know her concern was heard and understood. (See checklist 5, “Pa-
tient Engagement,” in appendix 2.)

Many believe that empathy is a character trait that one either possesses
or does not possess. But in fact, empathy is an event that takes place within a
relationship—­at the scene of narration we are describing here. As a rela-
tional event, like narrative itself, it thrives on feedback and interchange.
When, as children, we told Sally that Johnny liked her and then told Johnny
that Sally liked him, we often found Sally and Johnny becoming friends just
because they had a sense of one another’s care in the active (if perhaps not
fully conscious) responses to this knowledge. In a similar fashion, a physi-
cian’s expressed empathy often leads to its cognitive and affective reality—­its
functional reality—­in the warmth of a patient’s response. Moreover, such
expressions and fact can be learned to be habitual through their repeated
action. Empathy, in fact, is an important aspect of phronesis, and it contrib-
utes to the physician’s development of himself as a phronimos.

The question of sincerity: Here and in chapter 6 (see especially “Story

Filters”), we are presenting schematic responses and questions that
physicians can and should bring to the scene of narration—­to the active
engagement of the narrative of the History of Present Illness—­which is at
the heart of the patient-­physician relationship. In his consideration of
ethics, Aristotle makes perfectly clear that his practical syllogism ends in
action rather than ideas or feelings (cognition or affect). The active

162  /  the chief concern of medicine

 engagement that we are arguing is a constituent feature of narrative: the
deliberation of narrative, the witness who learns, the “telling” relationship
between teller and listener, the very “experience” of the intersubjectivity of
narration, and the felt sense of “experience” that narrative give rise to all
participate in active engagement, and they are acts that, taken together,
create the functional reality described in chapter 1. In this instance, they
are acts that provoke engaged responses and create the functional reality of
empathy. In other words, these responses and questions to the patient’s
story are acts of kindness and gestures of comfort that—­like the active
inclusion of the chief concern in the protocol of the History and Physical
Exam—­can and should be the beginning of therapy. They are practical and
ethical actions that take their place within schema-­based medicine that
might benefit from—­and, we believe, give rise to—­the feeling and
understanding (affect and cognition) of empathy, but the sincerity or
intensity of the feelings and understandings they express do not have to
correspond to feelings and understanding. Rather, they are acts arising out
of (and as an integral part of) engaged narrative; these acts, in themselves
and in the responses they provoke, are functionally real empathy.

The efficacy of empathy in making a difference in care is multifold. It

fosters the patient’s honest storytelling (as opposed to the woman with hypo-
natremia); the physician’s attentive listening; and, most important, the diag-
nosis that arises from the patient-­physician encounter. Dr. Rafael Campo has
described his use of a poem by David Baker directly as the facilitator of a
relationship between himself and a patient. In this instance, the poem, which
was about the same illness the patient had, allowed the doctor and patient to
access a common language for developing a narrative about the patient’s
plight to which they could both relate. The act of sharing the poem with the
patient was an act of kindness, or empathy, and Dr. Campo states that it
granted his patient the ability “to articulate to me in a more clear way what
she was going through,” and that it granted him, as her physician, the ability
to gain “insight into what she was going through” (Vannatta, Schleifer, and
Crow 2005: chap. 2, screen 40).
In addition to facilitating the treatment of patients, the doctor’s empa-
thetic understanding can also bring certain rewards to physicians themselves.
Physicians who train themselves to be more empathic almost universally re-
port higher job satisfaction. Thus, Dr. Charon suggests that the engagement
to which empathy leads the physician is what the patient needs. The patient
then gains from the relationship as a result of this “recognition and under-

The Patient-Physician Relationship  /  163

standing” by the doctor. This patient satisfaction is obvious to the physician,
and, in return, physician satisfaction is improved as well. It seems, then, a
paradox that when physicians work hard to find ways to “connect” with their
patients, they commonly receive more out of the resulting relationship than
they invested. For most physicians, this return on investment—­the ability to
adequately care for others—­is one of the reasons they entered medicine in
the first place.
It has been noted by many observers that physicians as a group tend to be
lacking in empathy and its demonstration. Common wisdom says that the
logico-­scientific organization of medical education, the time-­stressed sched-
ule of medical school, and the emotional cost of dealing with suffering, dis-
ease, and death tend to decrease empathy in a medical trainee. Some observ-
ers even believe that this distancing is, to some degree, necessary in order for
the medical student to become a mature, competent physician. However,
many physicians report, and most patients agree, that physicians as a group
need to express more empathy toward their patients. Medical schools, it
seems, need empathy training or education in their curricula. In his poem
“What I Would Give,” Dr. Rafael Campo describes the desire to give empa-
thy to his patients.

what i would give

What I would like to give them for a change
is not the usual prescription with
its hubris of the power to restore,
to cure; what I would like to give them, ill
from not enough of laying in the sun
not caring what the onlookers might think
while feeding some banana to their dogs—­
what I would like to offer them is this,
not reassurance that their lungs sound fine,
or that the mole they’ve noticed changed is not
a melanoma, but instead of fear
transfigured by some doctorly advice
I’d like to give them my astonishment
at sudden rainfall like the whole world weeping,
and how ridiculously gently it
slicked down my hair; I’d like to give them that,
the joy I felt while staring in your eyes
as you learned epidemiology

164  /  the chief concern of medicine

 (the science of disease in populations),
the night around our bed like timelessness,
like comfort, like what I would give to them.
(Campo 2002: 16)

In discussing this poem in an interview, Dr. Campo suggested that empathy

can indeed be taught and learned: “To me, that’s a poem about empathy, and
really, that’s, I think, what this other poem that I shared with my patient was
about also. And that’s what poetry, I think, can express. I often find colleagues
will say to me, ‘Well, you can’t teach compassion, you can’t learn to be more
empathetic.’ And I think, actually, by reading poetry, by immersing ourselves
in these narratives, these biocultural narratives, if you will, to use sort of a
fancy academic-­sounding phrase, that indeed we can, we can become more
empathetic. We can learn to be more compassionate, or at least be able to
express compassion, perhaps, more effectively” (Vannatta, Schleifer, and
Crow 2005: chap. 2, screen 4).
In a fashion similar to Dr. Campo, Dr. Richard Selzer suggests that em-
pathy can be learned and taught through practices of writing. If medical edu-
cation teaches vocabularies that, in their scientific precision, are specialized
and technical to the point of reducing patients to conditions, we should take
care to find a common language with and for patients as a way of discovering
the “whole situation” of empathetic understanding. Thus, in an interview,
Selzer noted that

the doctoring informed my writing, and that was obvious. But did the writing
inform my doctoring? And, I think it did, but it was more subtle, so that I
wasn’t conscious of it at any time. I knew I was different. Everybody else
knew I was different. That was obvious. And when I made rounds, my re-
marks to the students and the interns and the residents and the nurses were
those of a writer. It pertained to the medicine, but I was writing. And further-
more, since I had no time to study writing or to practice it, really, I used my
speech, my daily speech, ordinary speaking as an instrument to educate my-
self so that I spoke as I wrote, which I think is still the case in some, I mean
you can see that even now. And it was interesting because when my books
began to be published and the medical world finally adopted them, many
people would ask to come on rounds with me. Some of my readers would ask
to come on rounds with me so that they could hear it firsthand. I hope this
doesn’t sound egotistical, but I knew that I had blazed a trail. I was aware of
it. (Vannatta, Schleifer, and Crow 2005: chap. 1, screen 45)

The Patient-Physician Relationship  /  165

 Still, reading literature—­encountering cases and studying narrative sche-
mas—­is a much more readily available resource for students, doctors, and
other health care providers than writing. The patient stories they encounter
every day are narratives—­presented through language shaded by diction,
interpreted through metaphor, and communicated with emotion. They take
their place among the storytelling all people share. By teaching literature to
medical students and residents—­or, more simply, by providing the schemas
of narrative understanding and awareness that we are presenting in this
book—­we can help them gain competence at attending to narratives. As texts
such as The Death of Ivan Ilych, The Plague, the stories of Dr. Williams, and
the poems of Dr. Stone are encountered and studied, readers learn to hear
and interpret patients’ narratives more competently. The reading of experi-
ences other than our own, such as Toni Morrison’s Beloved or Leo Tolstoy’s
Death of Ivan Ilych, lays the ground for an emotional connection with pa-
tients and suffering that we may not have otherwise experienced. In the ex-
ample of Beloved, the experience of slavery is vividly and vicariously experi-
enced. This vicarious experience of the novel itself, and the actual experience
encountered at the scene of narrative (particularly when people come to-
gether to discuss the book and their responses to it), build memories, which
can be called on in the future to help establish an empathetic understanding
of and connection with the patient.
A final narrative example of a physician showing remarkable empathy
and courage in face of overwhelming crisis—­presented at the conclusion of
this chapter that has attempted to build various narrative “cases” into a sense
of the scene of narrative altogether—­is that of Dr. Rieux in Camus’s The
Plague. This novel universalizes the condition of illness and makes medical
responses to widespread illness—­ including empathy, rapport, and even
identification—­its explicit narrative action. Moreover, it also makes the rep-
resentation of illness—­the language by which it is presented—­work to pro-
voke empathetic responses in readers. Dr. Rieux, the narrator, usually com-
municates his observations in the objective language of the logico-­scientific
domain (he even represses his own first-­person relation to the story he tells),
but occasionally his observations are in the emotive-­cognitive language of
narrative knowledge, which reflects his empathy even as it provokes it in his
reader/listeners.

And just then the boy had a sudden spasm, as if something had bitten him in
the stomach, and uttered a long, shrill wail. For moments that seemed end-
less he stayed in a queer, contorted position, his body racked by convulsive

166  /  the chief concern of medicine

 tremors; it was as if his frail frame were bending before the fierce breath of
the plague, breaking under the reiterated gusts of fever. Then the storm-­
wind passed, there came a lull, and he relaxed a little; the fever seemed to
recede, leaving him gasping for breath on a dank, pestilential shore, lost in a
languor that already looked like death. When for the third time the fiery wave
broke on him, lifting him a little, the child curled himself up and shrank away
to the edge of the bed, as if in terror of the flames advancing on him, licking
his limbs. A moment later, after tossing his head wildly to and fro, he flung off
the blanket. From between the inflamed eyelids big tears welled up and
trickled down the sunken, leaden-­hued cheeks. When the spasm had passed,
utterly exhausted, tensing his thin legs and arms, on which, within forty-­eight
hours, the flesh had wasted to the bone, the child lay flat, racked on the
tumbled bed, in a grotesque parody of crucifixion. (Camus 1975: 214–­15)

In this passage, Camus—­and, we learn, his narrator Rieux himself—­narrate

the seeming immediate sensations of pain in a way that allows them to be
cognitively and affectively apprehended. Metaphors of breath and wind,
shipwreck, and fire build up to the use of the figure of Jesus—­called to mind
by the reference to a “grotesque parody of crucifixion”—­to describe the suf-
fering child. The young boy’s suffering is turned into a narrative of ship-
wrecked burning, so that his condition—­fever, convulsions, pain—­becomes
a story in which the narrator, Dr. Rieux, and the reader can imagine them-
selves in the same position of the child. The final image of parodic crucifixion
calls up the narrative of a life of unprovoked and undeserved suffering. The
religious imagery here—­like that of Dr. Stone and Flannery O’Connor—­
provokes feelings of empathetic understanding.

The Patient-Physician Relationship  /  167

6
the patient’s story
The Apprehension of Narration

The physician enjoys a wonderful opportunity actually to witness the words being born.
Their actual colors and shapes are laid before him carrying their tiny burdens which he is
privileged to take into his care with their unspoiled newness. He may see the difficulty
with which they have been born and what they are destined to do. No one else is present
but the speaker and ourselves, we have been the words’ very parents. Nothing is more
moving.
But after we have run the gamut of the simple meanings that come to one over the
years, a change gradually occurs. We have grown used to the range of communication
which is likely to reach us. . . . And then a new meaning begins to intervene. For under
the language to which we have been listening all our lives a new, a more profound
language underlying all the dialects offers itself. . . .
It is that, we realize, which beyond all they have been saying is what they have been
trying to say. . . . We begin to see that the underlying meaning of all they want to tell us
and have always failed to communicate is the poem, the poem which their lives are being
lived to realize. No one will believe it. And it is the actual words, as we hear them spoken
under all circumstances, which contain it. It is actually there, in the life before us, every
minute that we are listening, a rarest element—­not in our imaginations but there, there
in fact. It is that essence which is hidden in the very words which are going in at our ears
and from which we must recover underlying meaning as realistically as we recover metal
out of ore.
—­The Autobiography of William Carlos Williams (1967: 361–­62)

In chapter 5, we examined the scene of narration; here, we examine the pa-

tient’s narration itself, the narrative knowledge it gives rise to, and the ways
that knowledge fails to be apprehended by physicians. As we have already
noted, the story a patient brings to the physician is usually among the first
and most important pieces of information about that patient that health care
workers encounter. These stories—­narrated by the patient or, in special
cases, by others—­present information organized in specific ways that call for
specific kinds of listening; that define, to a large extent, the patient-­physician
relationship; and that help define the scope of healing and care in particular
cases. Many things are important about the patient story, the first of which is

/  168  /
that it is often the most important diagnostic information the physician is go-
ing to have. Another, overlooked factor is that it allows us to understand that
much of the burden of doctoring is a shared burden, just as, we noted in
chapter 3, narrative itself can fruitfully be understood in relation to its shared
deliberation. When the physician is getting ready to enter the room to see
the patient, it should dawn on her that the patient has a story he wants to tell.
In fact, that story is what created the need to come and see the physician in
the first place, and physicians sometimes forget that the person sitting in the
consulting room made the appointment because he has a story to tell. The
doctor did not send his people around the neighborhood gathering these
people up to come because he had something to tell them. But sometimes
physicians act this way; they sometimes act as if they have something to tell
their patients, rather than thinking that the patient’s story is going to make
the difference in what the physician says. In fact, if the physician will take a
little time to remember that the patient has a story to tell, he will also under-
stand that it is that story’s agenda that is going to run the show—­or, to use a
train metaphor, that the patient and her story will drive the train. Under
these circumstances, the physician has a primary job of listening and attend-
ing to that story in special ways, and the whole enterprise of doctor-­patient
interactions goes better. While the patient has a story to tell, she must join
with her physician to discover the “end” of the story, the patient’s chief con-
cern inflected by the physician’s knowledge about medicine and his phronetic
ability to discover with his patient what values and judgments govern the
situation of illness. Because both phronesis and narrative engender delibera-
tive skills and actions (technē), the burden of solving the patient’s conundrum
by himself is lifted from the physician, and the job—­and its attendant
stress—­becomes easier. The job is to listen carefully (listening for what is
said and for what is not said), to facilitate the parts of the story that are not
there, and to join with the patient in articulating what is important, the pa-
tient’s chief concern. But the physician does not have to drive the train; the
patient drives the train, and the burden for doing all the work is lifted from
the doctor.

The Meaningful Whole of Narrative Knowledge

The story a patient brings to a physician is often rich with information and
understanding that is presented in a very different manner from the knowl-
edge people are trained to deal with in health care. Earlier, we described this

The Patient’s Story  /  169

as “narrative knowledge,” a term we share with Dr. Rita Charon and others.
“We have always two universes of discourse,” Dr. Oliver Sacks writes in The
Man Who Mistook His Wife for a Hat, “one dealing with questions of quan-
titative and formal structure, the other with those qualities that constitute a
‘world’. . . . We can usually tell a man’s story, relate passages and scenes from
his life, without bringing in any physiological or neurological considerations”
(1987: 129). While physicians and others need to consider physiological and
other biomedical phenomena in dealing with patients, these considerations
quite often have to be based on the narrative knowledge presented in the
patient’s story.
When a patient presents herself to the physician, she brings with her, first
of all, the “narrative evidence” of her story. To many, such evidence might
seem unclear, ambiguous, uninformed. The patient’s story, like the poems of
Dr. Stone and Dr. Williams examined in this section, offers observations and
arrangements of items, physical and emotional evidence and explicit symp-
toms, implicit and overt time sequences conveying its information, and mo-
tives to speech—­the salient features of narrative we have already examined.
Rather than the art narratives that were the primary examples we discussed
in chapter 5, the abstract features of narrative we examined in chapter 3, or
even the seemingly “logical” narratives of detective fiction we discussed in
chapter 4, we begin here with the extremely sketchy narrative of an apparent
stroke victim that the physician elicits at the beginning of his encounter with
his patient and his daughter.

doctor orwig: Tell me what’s going on, what happened?

patient (robert johnson): Broke a dish . . . today, fixing breakfast
and . . . I called Rosemary and . . . she brought me here. I seem
to . . . My right arm . . . dropped . . . and my right leg . . .
orwig: So you’re weak on your right side, arm and leg. And you have
trouble with speech. This just started this morning. . . . If it’s all right,
I’ll ask Rosemary a few questions. Can you tell me what happened?
rosemary: This morning he called . . . one, one and half hours ago. I
couldn’t understand him, what he was saying. . . . Dish. It kind of
scared me. He had weakness of right side . . . Limping a little bit. . . .
Called clinic.
orwig: Has this happened before, Mr. Johnson? Let me ask some
other things. Have you fallen? (—­No [nodding head].) Any pain? (—­
No.) Headache? (—­No.) Fever? (—­No.)
rj: Traveling.

170  /  the chief concern of medicine

 orwig: You’ve been traveling?
rosemary: He went to Boston. Got back yesterday. He’s been gone al-
most a week.
rj: Went to funeral.
orwig: You went to a funeral in Boston. When you got back, yesterday,
were you . . .
rj: Sore. Stiff. From flight.
orwig: I notice you had bypass surgery a couple of years ago. Any
chest pain since then?
rj: Going. Terminal. (Airport?) Plane. Some tightness.
orwig: So just this week [there’s been chest pain]?
rj: Sat down. Went away.
orwig: So that’s relatively new. Remind me, do you smoke?
rj: Quit.
orwig: Are you taking any medicine now?
rj: One pill. . . . Aspirin.
orwig: Any other? One a day. OK. Let me tell you, Mr. Johnson, what
we need. I’d like to examine you. Then take some tests. Let’s do that
next. It’s kind of scary.

Even an encounter as relatively simple as that between Robert Johnson, his

daughter Rosemary, and Doctor Orwig presents some of the ambiguities in-
herent in the patient-­physician encounter. Insofar as this is true, the patient’s
storytelling requires different kinds of attention from the scientific attention
of biomedicine. It requires attention to what is missing—­what is unsaid—­as
well as what is said, attention to what Mr. Johnson does not or cannot say as
well as what he does say. It requires attention to the manner of presentation
as well as the matter presented, in this case Mr. Johnson’s problems with
syntax and vocabulary. It requires attention to the emotional state as well as
the information presented. It also attends to indirect evidence from inter-
ested third parties. Here, Mr. Johnson’s daughter, Rosemary, supplies miss-
ing information and fills out the narrative of what happened to her father.
The doctor attends to her anxiety as well as the patient’s. In important ways,
the patient’s story quite often has more than one participant—­more than one
narrator and more than one actor or “hero”—­including family members and
friends as well as the patient. In addition, the comprehension of the patient’s
story requires the translation from one idiom or vocabulary into another, of-
ten from one kind of life experience to another.
As we have seen, one traditional place to find a model for these kinds of

The Patient’s Story  /  171

attention is in literature—­in narratives and poetic language—­insofar as the
narrative of literary texts allow us to discern more readily the necessary sche-
mas and structures that organize narrative as they are repeated and empha-
sized in the patterns of art. As we saw in chapter 4, particularly clear exam-
ples of narrative attention can be found in classical detective fiction. Sherlock
Holmes was created by a physician, Dr. Arthur Conan Doyle, who based his
detective both on his medical school teacher Dr. Joseph Bell of Edinburgh
and on the literary example of Auguste Dupin, the detective in Edgar Allan
Poe’s stories. In chapters 3 and 4, we examined the kinds of knowledge and
information recoverable in prose narrative, but quite often—­as in the case of
Robert Johnson—­the language physicians encounter seems closer to the
cryptic language of poetry. Here, then, we will return to a discussion of nar-
rative knowledge in relation to the explicit and implicit narratives in the po-
ems by two physicians, Dr. John Stone and Dr. William Carlos Williams, in
order to demonstrate the ways narrative knowledge and the particular forms
of attention such knowledge calls for is of the utmost usefulness to physicians
and other health care workers. Such narrative knowledge is organized around
the notion of the meaningful whole of a story, which we touched on earlier.
The explicit narratives of stories and the implicit narratives in some po-
ems transform simple, seemingly isolated phenomena into meaning; they
create what A. J. Greimas describes as “the still very vague, yet necessary
concept of the meaningful whole set forth by a message” (1983: 59). As we
noted earlier, such a meaningful whole is the overall sense or point of a story,
the meaning we take away from it, the “moral” of the tale, and/or even its
sense of overall genre. It is, we said, the chief concern of the narrative as a
whole and what Rita Charon calls the “desire” of a narrative. Earlier we gave
an example of this cognitive—­and often affective—­experience by describing
the way people might claim that Hamlet, Oedipus, and the death of John
Kennedy are all “tragedies,” despite the fact that they are so different. We
more or less intuitively (or seemingly intuitively, because, we are arguing,
such seemingly “immediate” apprehensions are mediated by the cognitive
structures of narrative) grasp (as a witness) a series of narrative elements—­
such as recognizable agents (personages with intellectual promise) and a se-
quence of events (unforeseen yet recognizable violence)—­organizing them-
selves together to create an end or point of the story, in a manner that conveys
or provokes particular cognitive and emotional responses. Such a narrative,
grasped as a complete whole, also entails it being told (articulated and re-
ceived) and representing or approximating experience itself. In this way, a

172  /  the chief concern of medicine

“vague” sense of a whole unified meaning emerges from the elements of
narrative presented. Similarly, we say that the combination of persistent low-­
grade fever, elevated white blood cell count, the demonstrated absence of
infection, and problems in a wide range of organs, combined in a young
person with a particular social history, might well be polyarteritis nodosa (a
medical condition described later in this chapter).
Meaningful whole is a difficult term—­this is why Greimas calls it “vague,
but necessary.” It is “necessary” in terms of understanding narrative particu-
larly but also in understanding how meaning in general works. How is it that
we hear a sentence and somehow absorb from it a meaning that is not reduc-
ible to any part of that sentence? One useful example for seeing how it works
is the genre of detective stories we already discussed in chapter 4. These
narratives, we already suggested, are important for doctor-­patient relation-
ships because the detectives in these stories are very much positioned like
doctors—­they are, after all, “consulting detectives”—­in the pursuit of diag-
noses.
In “The Murders in the Rue Morgue,” there is one moment we did not
analyze earlier that can help with the concept of “meaningful whole.” Dupin,
the detective, reads in the newspaper the accounts of all the witnesses, and
among these accounts are the testimony of six witnesses who seem to have
heard a dialogue between the murderers on the stairs. One person was
clearly speaking French, and the other murderer was speaking an unknown
language. The police interview six people. Two of them are native French
speakers from Paris. One of the French speakers thinks this unknown assail-
ant spoke Spanish, although he says he does not speak Spanish himself. An-
other French speaker says this assailant spoke Italian, though he does not
speak Italian himself. A third witness is a Dutchman, and he is convinced
that this unknown assailant spoke French. A fourth is an Englishman, who is
convinced that this assailant spoke German. These languages, German and
French, are languages that these witnesses do not speak. A fifth witness is a
Spaniard, who is convinced that the assailant spoke English. The sixth wit-
ness is Italian and is convinced that the assailant spoke Russian. So for most
of the languages that witnesses claim to hear, there are native speakers of
those languages, and they say it is not their native language but another lan-
guage. Both the police and Dupin have this evidence, and Dupin puts it to-
gether. He takes the parts and makes a meaningful whole. He reasons that
this disparate evidence—­six different witnesses, all claiming to hear a lan-
guage they do not speak—­points to an unspoken fact that this assailant was

The Patient’s Story  /  173

not speaking a language at all; it points to a categorical, rather than a factual,
problem. By the end of the story, we learn that the assailant is an orangutan
and does not speak French, English, or any of the proposed languages.
Dupin is discerning or apprehending a meaningful whole out of disparate
evidence. He is finding evidence that is not there, which is very different
from the positive facts that, as we saw in chapter 1, logical positivism and
much of the “scientific” training in medical education assume are the only
real evidence. Nobody says, “I heard an orangutan,” but Dupin discovers
what is missing by attending to what we might fancifully call the “negative”
facts in the case. Quite often, a physician is put in the position of having to
figure out what is not there, what is missing. What disease does all this evi-
dence point to? The meaning that gathers together elements and makes con-
nections and sense out of them and yet is not necessarily presented as such
is what linguists mean by the term meaningful whole. Moreover, narratives in
general do this, and literary narratives, as we have been arguing, teach us
especially well how to become conscious in our understandings of the mean-
ings and function of stories. One of the things literature does is force its read-
ers, if they take the time and trouble to read it, to figure out its theme, its
meaning, its chief concern—­what is going on here.
The apprehension of the meaningful whole of language, narrative, and
literature calls for skills in different kinds of attention from that of positive
science. Such skills, afforded by literature and narrative, are like the skills or
technē in writing or performing music: through repeated practice and discus-
sion of particular stories and texts, through the experience of what seems
very close to phronesis, readers become habitually sensitive to the “mean-
ingful whole” of a narrative, its chief concern. What is learned in such prac-
tices of reading is an expanding list of relevant issues we bring to discourse—­
including the discourse of the patient’s story—­that include a sense of the
meaningfulness of things unsaid, attention to certain kinds of emphasis or
lack of emphasis, and the interplay of words and bodily postures (which we
described in the activities of August Dupin and Sherlock Holmes as listening
and watching). These ways of directing attention aim at grasping some pro-
visional sense of the whole meaning first, rather than initially seeking the
most important element, part, or fact. We should add, however, that when
Charles Sanders Peirce suggests we attend to a “surprising fact” to begin
with—­what we might call some anomaly in a narrative or text—­he is suggest-
ing that we begin with an element or part, one that is not self-­evidently im-
portant, but precisely one that seems to disrupt coherent wholeness. Be-
cause the narrative skills we are describing attend to a “whole” that is not
usually explicitly articulated in a narrative and attend to surprising anomalies

174  /  the chief concern of medicine

that do not easily integrate themselves into a narrative, the narrative skills we
are describing are different from the methods of logico-­scientific knowledge
and biomedical knowledge that build from simple and compatible (“com-
mensurable”) elements to complex and compatible elements and therefore
create ways of understanding that can reduce complex phenomena to simple
elements. As we saw in detective fiction in chapter 4, both narrative skills and
logico-­scientific methods quite often work together. But rather than logical
“method,” systematic and schematic practice—­such as the practicing of mu-
sical scales, the activities of many-­voiced discussion, or even “unpacking”
schemas of limited possibilities of multiple interpretation (as we saw in defi-
nitions of health)—­aids in the acquisition of narrative skills. Such practice—­
with the example of practicing, say, Bach’s well-­tempered preludes and
fugues with the end of mastering the techniques of the clavichord—­is often
organized around the habits that explicit schemas embody and produce.

Narrative Knowledge and the Practice of Medicine

The knowledge embodied in stories is categorically different from that of

nomological science. As we noted in chapter1, since the beginnings of mod-
ern science in the seventeenth-­century Enlightenment, scientific knowledge
has based its accomplishments on the assumption that phenomena could be
understood by focusing on the parts—­quantifiable elements—­that make up
that phenomena. Scientific analytic knowledge assumes that the whole is
equal to the sum of its parts. For more than a century, the great achieve-
ments of health care in diagnosing, treating, and preventing illness and dis-
ease have been based on the accomplishments of scientific biomedicine. This
tradition of understanding can be summed up in the career of René Des-
cartes (1598–­1650), who, as a mathematician and philosopher, articulated a
thoroughly materialist view of the world. Descartes asserted that spirit or
mind and matter were incompatible. Matter was, above all, substantial; it
possessed “extension,” and it was subject to mathematical (quantifiable)
analysis. (Among other things, Descartes invented analytic geometry, the al-
gebraic analysis of space.) For Descartes, matter was essentially mechanical,
and such a mechanistic view assumes that all phenomena can ultimately be
explained in terms of matter moving in accordance with the laws of nature
and in which the whole of any phenomenon is simply the sum of its parts.
Spirit, mind, or soul—­which Descartes also believed in—­was without sub-
stance, immortal, and the defining feature of human life. Descartes even
describes a mechanical model of the human animal, analogous to the me-

The Patient’s Story  /  175

chanical clocks of his time. (Later philosophers describe his description of
the human as “the ghost in the machine.”) Throughout his life, Descartes
was interested in medicine, which he regarded as a key to understanding the
natural world, since he believed that the living body of people and animals
alike were simply part of the material, natural world. His work includes stud-
ies titled “Formation of the Foetus,” “Description of the Human Body,”
“Treatise of Man,” and “The Passions of the Soul.” He was an early practitio-
ner of autopsy.1
Nevertheless, the narrative knowledge we discussed in chapter 3 is an-
other form of knowledge that, from time immemorial, has aided and supple-
mented scientific medicine. As we noted earlier, this form of knowledge
seems to be indicated by some supporting physiological—­“Cartesian”—­
evidence, namely, the two distinct neural mechanisms in animals and pri-
mates: one for the storage of “procedural memory,” the learning and recall
of “action patterns” that simple as well as complex organisms can accom-
plish; and another for “episodic recall,” the memory of events and series of
events necessarily associated with narrative. The recall of patterns is the
form of Descartes’s materialist “abstraction” of universal scientific law; “epi-
sodic recall” is memory of events, memory of narrative, the case “memory
store” Nickles discusses. Such episodic recall is the humanistic knowledge of
storytelling and narrative.2 In narrative, unlike scientific analytic knowledge,
the whole is greater than the sum of its parts. Take a compound word, such
as Dr. Williams’s example, wheelbarrow. Its meaning is not the added mean-
ings of the words that form it (wheel + barrow), but, rather, a larger meaning
that encompasses and emerges from its elements. In the same way, the ele-
ments of a story—­Dr. Stone’s combination of memory of his patient and his
present visit to his patient—­come together to form a meaningful sense of a
whole narrative.
More than in a particular word, though, one can trace the working of nar-
rative knowledge—­humanistic understanding—­in a poem. The poem “He
Makes a House Call” by Dr. John Stone—­a noted cardiologist and poet—­
allows us to explore the nature of humanistic narrative knowledge more
closely and to see more clearly the kind of information recoverable from the
patient’s story.

he makes a house call

Six, seven years ago
When you began to begin to faint
I painted your leg with iodine

176  /  the chief concern of medicine

threaded the artery
with the needle and then the tube
pumped your heart with dye enough

to see the valve

almost closed with stone.
We were both under pressure.

Today, in your garden,

kneeling under the sticky fig tree
for tomatoes

I keep remembering your blood.

Seven it was. I was just
beginning to learn the heart

inside out.
Afterward, your surgery
and the precise valve of steel

and plastic that still pops and clicks

inside like a ping-­pong ball.
I should try

chewing tobacco sometimes

if only to see how it tastes.
There is a trace of it at the corner

of your leathery smile

which insists that I see inside
the house: someone named Bill I’m supposed

to know; the royal plastic soldier

whose body fills with whiskey
and marches on a music box

How Dry I Am;

the illuminated 3-­D Christ who turns
into Mary from different angles;

The Patient’s Story  /  177

 the watery basement,
the pills you take, the ivy
that may grow around the ceiling

if it must. Here, you

are in charge—­of figs, beans,
tomatoes, life.

At the hospital, a thousand times

I have heard your heart valve open, close.
I know how clumsy it is.

But health is whatever works

and for as long. I keep thinking
of seven years without a faint

on my way to the car

loaded with vegetables
I keep thinking of seven years ago

when you bled in my hands like a saint.

(Stone 1980: 4–­5)

“He Makes a House Call” tells a story of a doctor, a cardiologist, visiting his
patient seven years after a heart operation. The patient welcomes him into
the garden, the living room, and the basement, and as part of the visit, she
gives the doctor some vegetables. Meanwhile, during his encounter with the
patient, who, here in her house, is the person in charge, the doctor keeps
thinking of the operation those many years ago. Together, the visit and the
memory teach the doctor a new definition of health—­“whatever works / and
for as long.” In this poem, Dr. Stone helps define the meaningful whole that
emerges from the details of this incident in the image of a doctor holding his
patient the way that the faithful might hold a dying saint. The blood that
passes from one to another between doctor and patient becomes as sacred as
the suffering of saints.
Dr. Stone himself has spoken movingly about this poem. “In the writing
of that poem,” he notes,

I discovered at least two things about this encounter and about medicine in
general. The first is a definition of health, which I can still defend and would

178  /  the chief concern of medicine

 gladly defend today. Health is whatever works and for as long. A utilitarian
view, probably befits the internist. And the second one is an emphasis on the
sacred relationship between doctor and patient, emphasized in the last line,
“When you bled in my hands like a saint.” The common dousing in the blood
of the patient is a very important part of the practice of medicine. It’s usually
a metaphorical dousing in the blood of the patient, but an involvement in his
or her life to a marked degree. It’s the most privileged encounter in the pro-
fessions, as privileged as the theologians among us. (Vannatta, Schleifer, and
Crow 2005: chap. 2, screen 18)

The definition of health in this poem is very different from the World Health
Organization’s description of health as “the complete physical, mental and
social wellbeing, and not merely the absence of disease or infirmity” (cited in
Boyd 2000: 12). According to the poem, Dr. Stone learned that health is best
defined in terms of a schema of its behavior—­its “utilitarian” or “operational”
definition—­rather than some kind of essential definition or, as Kenneth Boyd
says, a kind of “idealistic” definition exemplified by the athlete. Rather than
a definition of necessary and sufficient elements (“the complete physical,
mental and social wellbeing”) or a sufficient but not necessary definition (res-
toration of a previous state of affairs in the elimination of disease), the poem
presents an intellectual conception of health in terms of the necessary “work-
ing” of the patient, without giving the sufficient instances that always and
everywhere would be necessary. The poem conveys its meaning in the con-
trast it offers between the hospital, where the doctor is in charge, and the
house, where the patient, now a householder, is in charge—­the contrast be-
tween past and present. The schematic gathering together of these two
places and these two times allows the concept of a provisional “working,”
rather than a necessary and sufficient “ideal” or a sufficient but not necessary
idea of health, to emerge from the poem.
In doing this—­with its intellectual conception of health in terms of the
“working” of the patient in her house and garden, with her bric-­a-­brac, and
expressing the gratitude for life gathered up and set forth in an armful of
vegetables—­the poem presents an emotional as well as conceptual compre-
hension of its whole, combining, as empathy does, affect and cognition. The
last line presents the metaphor of “saint” that categorically gathers up the
whole of the poem. The final image of the poem emerges from and encom-
passes the narrative; offers an emotional category for the understanding of
the whole, the suggestion that the physician-­patient relationship is analogous
to the faithful-­saint relationship; and, as such, encompasses the affect—­the
feeling embodied in the meaning—­of this religious image. The category

The Patient’s Story  /  179

gathers together concepts that are associated with (and often provoke) strong
feeling—­“saintliness” and “blood”—­in a single image, a categorical whole.
As we saw in chapter 4, Charles Sanders Peirce makes the distinction
between facts and categories of fact in his description of the nature of hy-
pothesis formation. As we saw, it is the work of hypothesis formation, Peirce
argues, to isolate “a single line of characters, or perhaps two or three, and . . .
take no specimen at all of others” (1992: 140). The special nature of charac-
teristics is the manner in which characteristics are organized around qualities
rather than quantities. If scientific analytic understanding is essentially re-
ductive, then Peirce’s hypothesis formation is essentially comprehensive and
comprehending. It relates qualities to one another categorically. Moreover,
like narrative knowledge, such categorical knowledge gathers together a
number of sometimes disparate “facts” within a single understanding in a
schema of understanding and experience, just as a doctor gathers together a
number of symptoms to characterize them as one illness (or several alterna-
tive illnesses in a different diagnosis). In this sense, a category delimits a
meaningful whole. Medical specialties—­ cardiology, infectious disease,
urology—­train their doctors to attend to certain kinds (or certain “catego-
ries”) of disease. This concentrates a great deal of minute knowledge, but
sometimes it also blinds physicians from considering alternative meanings to
the complaints and symptoms they encounter, insofar as these categorical
schemas are not sufficiently understood as provisional.
Consider the clinical case example of Mrs. C., a thirty-­four-­year-­old white
female who presents to the clinic complaining of a three-­day onset of fever,
chills, vomiting, and diarrhea. When this group of individual symptoms
(facts) is gathered up, a meaningful whole (a diagnostic category) is sug-
gested. In this particular example, at least initially, several provisional con-
figurations of several meaningful wholes suggest themselves, including pel-
vic inflammatory disease, gastrointestinal virus, appendicitis, and pneumonia.
Only with further gathering of facts—­itself directed by the possible configu-
rations of categories to account for the facts—­will some of these possibilities
be eliminated so that a clearer picture of the true meaningful whole (accu-
rate diagnosis) can emerge (see fig. 6.1). In this way, clinical diagnoses are, as
Dr. Charon says, analogous to grasping the plot and meaning of a story. Clini-
cians address the problem of making a coherent, meaningful whole out of
the integration of information, experience, understanding, and knowledge
that has been collected.
Here, then, are some ways that narrative schemas can help focus medical

180  /  the chief concern of medicine

 



  



 
 
 



 























 





Fig. 6.1 Diagnoses

practice. Dr. Stone’s poem tells a particular story, a medical story, whose goal
(among others) is to offer a definition of health that depends on narrative
rather than logical analysis, a definition that is “utilitarian” and “operational.”
But even when a poem does not present an explicit narrative, as in Dr. Wil-
liam Carlos Williams’s famous poem “The Red Wheelbarrow,” it can help us
to learn to recognize and recover narrative knowledge. Quite often, the
meaningful whole of the patient’s story is not apparent. The story presents
itself as a series of disparate facts, emotions, anecdotes—­the Robert Johnson
narrative with which we began this chapter is a good example—­that suggest
the patient’s chief concern without articulating his condition and the agenda
motivating the visit, so that, as in Williams’s poem, these elements of narra-
tive and significance need to be gathered together to make a meaningful
whole. For this reason, practice and training in the interpretation of poetry is
particularly useful in developing the competence of health care workers in
recovering the information and meaning of a patient’s story. The kinds of at-
tention and analysis that literary works ask of their readers can help listeners
to a patient’s story to recognize information a patient presents that might
otherwise be missed. In his famous poem, Dr. Williams presents a single
sentence that simply observes details in the environment and asserts value.

the red wheelbarrow

so much depends
upon

a red wheel
barrow

The Patient’s Story  /  181

 glazed with rain
water

beside the white

chickens.
(Williams 2005: 829–­30)

The meaning of the poem’s sentence—­that much depends on the red wheel-
barrow—­is more than the addition of the particular meanings of words of the
sentence. Rather, it presents a meaningful whole and an overall effect. Wil-
liams breaks up words with his lines (“wheel / barrow”; “rain / water”), so that
qualities of the adjectives stand out as the qualities of the objects and not
merely the addition of attributes. It is as if objects in his world are appre-
hended whole and “glazed” with value.
This analysis, like that of humanistic knowledge more generally, does not
seek a cause or Williams’s particular intention for his poem. We do not need
to ask, “Did Williams intend to break up the words of the poem?” Instead of
explaining this poem in terms of its cause—­that is, instead of attempting to
reduce an effect to its cause—­this kind of analysis seeks to account for phe-
nomena and, like schemas, to account for the experience of phenomena. If
this poem conveys a more or less vague sense of importance and significance,
then we may ask, what about the poem helps us to experience—­which is to
say, to notice and attend to—­that importance? Insofar as the experience of a
room presents itself as the experience of a classroom, attention to the salient
features of the classroom schema that Gureckis and Goldstone present
(2011: 725) can help account for that experience. Similarly, whether or not
this description of the way Williams’s poem decomposes nouns into adjective
plus noun (wheel + barrow; rain + water) presents the cause of the “effect”
of importance or significance, it calls attention to the poem’s exploration of
value in the world (“so much depends”). Even the metaphoric description of
the poem in our discussion—­that objects in the world of this poem are
“‘glazed’ with value”—­offers an example of the descriptive power of meta-
phorical language. Such descriptive power asks us to explicitly notice the
overall affectiveness of the poem—­ something that we might otherwise
vaguely feel or dismiss. In a clinical setting, attention to the manner of pre-
sentation as a whole—­word choice, concern, implicit narrative—­rather than
the presented information allows for a comprehension of the situation not
entirely available solely by means of the analysis of the informational part,
the “two temporalities” of narrative we described in chapter 3.3

182  /  the chief concern of medicine

 Another significant feature of “The Red Wheelbarrow” is that it implies
some kind of narrative, a story with a beginning, middle, and end. The poem
situates itself on a farm after a rainstorm. We can ask of this poem, as we can
of most any poem, why would someone say this? (Again, this is similar to the
classroom that Gureckis and Goldstone describe: we can ask, why would
someone arrange a room this way?) Moreover, we can ask of the poem, what
has happened and is happening so that someone might say “So much de-
pends on a red wheelbarrow glazed with rainwater beside the white chick-
ens”? (This question focuses on the narrative’s beginning.) We can then ask
how to situate this speech in relation to time and tenses; that is, we can ask,
what is happening, what is the “plot” of this implied narrative? (This focuses
on the narrative’s sequence of events, its middle.) Finally, we can ask, what
does this all mean, what is the poem’s chief concern: what, particularly, de-
pends “so much” on the poem’s “action” of observation? (This focus on the
narrative’s “end” reinforces the sense we described in chapter 3 of the over-
determination of a narrative’s end as both its final event and also its overall
purpose, its “point” or “concern” or its “meaningful whole” we have discussed
here.) The same questions we ask of the cryptic language of Williams’s poem
can be asked of the patient’s story. In fact, Dr. Orwig asks these very ques-
tions in his encounter with Mr. Johnson and his daughter: What brings Mr.
Johnson here so that he and his daughter tell his story (what can a witness
learn from this narrative)? What bodily occurrences, pain, and fright—­that
is, what experience that is embodied in this narrative—­bring these people to
the office? How are they related to the way Mr. Johnson talks (how is it ar-
ticulated and received)? What sequence of events—­both recent and long-­
term—­led up to this encounter? Finally, what does it all mean? What, in
other words, is the point or end of what Mr. Johnson and Rosemary are say-
ing in their own narrative language about his medical condition, both his
chief complaint and their chief concern.
Sometimes the triggers for grasping the meaningful whole are easy and
easily (i.e., algorithmically) schematic: a fourteen-­line poem is a sonnet; a
painful tooth is a cavity. But both literature and medicine teach us (as does
the practical reasoning of phronesis) that schemas are provisional rather than
absolute, that there are different ways of configuring the “wholeness” of a
particular set of phenomena. Narrative especially teaches us to take a mo-
ment to attend to—­and deliberate about—­alternative possibilities of mean-
ing. Williams’s “The Red Wheelbarrow” is particularly interesting in this re-
gard because it is about this phenomenon of meaningfulness. “So much
depends” asserts that the arrangement of things—­the arrangement of rural

The Patient’s Story  /  183

items (wheelbarrow and chickens), the quality of their colors, the time of the
observation (right after a rain), the fact that someone takes the trouble to
notice all this—­gathers its elements into the message, namely, that meaning
inhabits our world. (Such a message is over and above the particular ele-
ments of information the poem presents.) Still, the most dangerous and dif-
ficult interpretations often are provoked by “easy” conclusions. Of course, all
fourteen-­line poems are not always sonnets; and all toothaches are not sim-
ple cavities. A problem of premature conclusion—­especially when the evi-
dence points easily to certain interpretations—­is a problem for both inter-
preting literary narrative and diagnosing patients. Quite often, this problem
is a function of assuming, rather than developing, the category or schema
that subsumes the facts, of taking a provisional schema as absolute. As we
saw in chapter 4, classical detective stories are often organized around the
police too-­quickly jumping to conclusions, putting evidence in particular cat-
egories (“murder,” “suicide”) before engaging with the seeming inchoate se-
ries of facts. Narrative knowledge calls for what we describe in chapter 8 as
“pause and reflection,” which often seems difficult in the busy work of the
physician or the police but just as often pays back in saved time. Checklists,
as Atul Gawande suggests, necessitate pause and reflection in the course of
complex and busy work.

Medicine and Detective Fiction

As we saw in chapter 4, the narrative and literary representation of diagnos-

ing detectives—­Dupin and Holmes—­have much to teach health care work-
ers. They do so because an important area in which the kinds of “narrative
evidence” described so far intersects with the “logical, scientific knowledge”
of medicine and Enlightenment science is in the process of hypothesis for-
mation. A special case—­and a strongly practical one—­of hypothesis forma-
tion is the medical diagnosis that we discussed earlier. A hypothesis is both a
formula and a prediction: insofar as it formalizes the evidence it presents, it
participates in the Cartesian analysis of parts; and insofar as it presents an
implicit narrative in its prediction—­that is, in its not-­yet-­completed narra-
tive—­it participates in the apprehension of a narrative whole. In the first
case, it deals with and comprehends facts; in the second, it deals with and
comprehends categories of facts. As we already noted, what is remarkable
about the detective work of Monsieur Dupin in the case of “The Murders in

184  /  the chief concern of medicine

the Rue Morgue” is that he is able to solve the crime by relying largely on the
evidence of listening—­both to his companion’s mutterings as they walked
through Paris and to the voices on the stairs. The solution takes the form of
a categorical difference: the facts—­the women brutally killed, the evidence
of the destruction of the house, even the witnesses’ reports—­remain the
same, but the quality or character of these facts and the manner in which
they are understood have changed. The events in the Rue Morgue fall into
the category of “killings,” rather than “murders,” since the perpetrator of the
killings was an orangutan and since “murder” is a category that is partly de-
fined as involving a human agent. An animal cannot, by definition, be char-
acterized as a “murderer.” In this story, Dupin systematically gathers up and
goes through the factual evidence—­above all, the aural evidence—­to dis-
cover the “character” of the event.
In the same way that Dupin “diagnoses” the evidence to discover that
there is, in fact, no crime but only killing, so another great “deductive” detec-
tive, Arthur Conan Doyle’s Sherlock Holmes, goes about his business. In
“The Resident Patient,” which we already discussed in chapter 4, a young
doctor comes to Sherlock Holmes to report the bizarre behavior of his pa-
tron, a man who has set up his practice in exchange for a percentage of his
earnings and also residency at the doctor’s home-­office. Later, the patron is
found hanging in a locked room, and the police assume it is a suicide. After a
minute inspection of the room—­complete with Holmes’s signature magnify-
ing glass—­the detective discovers, among other things, the remains of vari-
ous kinds of cigars in the room. Rather than a suicide, Holmes discovers what
he calls “a deeply planned and cold-­blooded murder.” In this story, the police
are mistaken because they cannot see what there is to observe. The kind of
mistake the police make is that of clinicians who narrow the differential diag-
nosis too early, failing to account for all the data (both positive and negative)
and to attend to the manner or modality of their own observations.

The History of Present Illness

Throughout all the preceding chapters of The Chief Concern of Medicine, we

have discussed the History of Present Illness (HPI), by which the patient
announces the reason for coming to the physician (the “chief complaint”)
and then narrates the sequence of events and the circumstances surrounding
those events, including other seemingly related facts, the surprises associ-

The Patient’s Story  /  185

ated with them, the feelings they give rise to, their seeming causes, and other
such material. Now, though, let us take a close look at the HPI as a narrative
event in itself. The HPI usually takes its place within an array of information
supplied in the patient’s database, the formal History and Physical Exam.
Starting with the “chief complaint”—­the particular condition that brings the
patient to the doctor—­the database includes the Past Medical History, Social
History, Family History, Review of Systems, and Physical Examination. The
information of these aspects of the database is usually presented as a list of
facts, not narrative, and out of the combination of the HPI and these other
facts comes the physician’s “assessment” and “recommendations” for treat-
ment. As is apparent in the following discussion, the Past Medical History,
Family History, and Review of Systems are, in fact, checklists, species of
Gawande’s read-­do checklist that pilots use.
But even before the verbal “history” that patients narrate, they present
nonverbal evidence—­the evidence of seeing and hearing to which detectives
like Dupin and Holmes attend. In his memoir of practicing in Tennessee
during the beginning of the AIDS epidemic, My Own Country, Dr. Abra-
ham Verghese describes taking a patient’s history that allows us a glimpse of
the physician’s observations from within his point of view.

When Essie left, I began to take Gordon’s history. As I interviewed him, I

instinctively sized him up, trying to pick out as many clues as possible to who
he was and to his condition. The patient encounter is traditionally divided
into the history and physical. But in actual fact, the examination begins the
moment the patient enters the room. . . .
To me, the history and physical are the epitome of the internist’s skill, our
equivalent of the surgeon’s operating room. Like Sherlock Holmes—­a char-
acter based on a superb clinician, Dr. Bell—­the good internist should miss no
clue, and should make the correct inference from the clues provided. (1994:
80)

Apprehending the patient’s story—­even the unspoken part of the patient’s

story—­is a crucial aspect of doctoring.
The patient’s story is presented in a standardized form. Such a form,
however, does not detract from the understanding achieved through the con-
scious pursuit of narrative knowledge. The following is a complete report of
a medical consultation on a case of fever of unknown origin in a young woman
of twenty-­seven.

186  /  the chief concern of medicine

Internal Medicine Consultation
9-­5-­1997
Referring Physician: C—­S—­, MD
Reason for Consultation: Fever of unknown origin

Patient Profile
Patient is a 27 year old single white female. She lives in a rural commu-
nity; however, she has been in the Caribbean Islands for the past 2
years. She works as a bartender.
Chief Complaint: “I feel tired and have fever.”

History of Present Illness

This young woman states that she is usually in excellent health. She was
in good health until approximately 6–­8 months ago. At that time, she
noticed fatigue. She recognized a need to sit down at work, which was
unusual. The fatigue gradually worsened. She is usually full of energy,
and describes herself as tireless. Therefore, this state of fatigue was a
concern to her. At about the same time as the fatigue began, she noticed
some discomfort in the thigh muscles of her legs, which she described as
aching. This aching pain is moderate in severity, estimated as a 6/10. The
leg pain seems to wax and wane, is worse when she is ambulatory, and
better early in the morning. She went to a doctor in the West Indies. He
performed diagnostic blood tests and found mild elevation in the liver
enzymes. This occurred 5 months ago. He informed her that this proba-
bly represented a form of mononucleosis. However, she never had any
high fevers and has had no pharyngitis. The fatigue continued and the
patient decided she had to come home. Upon arrival, she went to her
hometown physician, at which time she was found to have fever, eleva-
tion of the white blood cell count, and mild hypertension. This was 3
months ago. Her doctor unsuccessfully spent 2 months investigating the
cause of her symptoms. She was then referred to Dr. C—­S—­, an infec-
tious disease specialist for consultation. Dr. C—­S—­referred this patient
to me.
Over the past 2 months, she has continued to feel fatigued. She be-
lieves the fatigue is worse and in fact finds it is necessary to rest 2–­3 hours
during the day and sleep at least 10 hours each night. During the past

The Patient’s Story  /  187

 month she has begun having headaches. These respond somewhat to as-
pirin. The headache is present night and day. There is no association with
other symptoms. The headache is described as all over her head. The
pain is 4/10 in severity, and after two aspirin tablets is relieved temporar-
ily.
The patient has also noticed some intermittent abdominal pain. It is
vague, not well localized, and cramping. The pain has been present for
about 3 weeks and is not necessarily getting worse. It is not associated
with nausea, vomiting, diarrhea, or blood in the stools.
When asked specifically, she admitted to fleeting episodes of numb-
ness of various areas of the skin. This has been going on since she became
ill. However, since the numbness always goes away within a day or two
she felt it was not important, so she never told anyone about it.
When asked how she felt about feeling ill for several months without
having a diagnosis, she became teary eyed and expressed sadness, and
fear. She is afraid of having a very serious illness “like cancer.”

Past Medical History

Childhood: Patient reports having all the usual childhood illnesses, no
hospitalizations and no surgeries.
GYN-­OB: Menarche at age 12. Periods have been normal. Duration av-
erages about 5 days.
Pregnancies: One
Therapeutic abortions: One
Medications: Aspirin for headache; birth control pills
Allergies: None known
Surgeries: None
Accidents : None
Adult Chronic Illnesses: None until the HPI

Social History
The patient states that she was raised in an upper middle class home. She
was a good student and attended college for 2 years. She was studying
English. She decided to drop out to work for a while, and that was 7 years
ago. She would like to return to college some day to finish her degree.
She considers herself religious, was raised in the Baptist church, but does
not attend church on a regular basis now. She uses occasional alcohol, but
is not habitual in its use, and does not feel that alcohol is a problem for

188  /  the chief concern of medicine

 her. She has used occasional marijuana over the years but again is not a
habitual user. She states that she injected heroin on one occasion with
her boyfriend 2 years ago. This frightened her so she never did it again.
She is sexually active with her boyfriend. She considers that relationship
monogamous and has been with him for four years.

Family History
Father: Age 54 alive and in good health
Mother: Age 55 alive and has hypertension
Brother: Age 30 alive and in good health
Grandparents: All alive but she doesn’t know any details about their
health

Review of Systems
General: None besides the history of present illness
Head: Headache as mentioned in the HPI. No history of head trauma.
Eyes: Wears contact lens. No double vision, no blurred vision.
Ears: Hears well. No other symptoms.
Neck: Denies any swelling, sore throat, swallowing difficulty
Respiratory: Denies cough, shortness of breath, hemoptysis, and pleu-
ritic pain
Cardiovascular: Denies chest pain, PND, orthopnea, and edema
Gastrointestinal: Complains of abdominal pain as stated in the HPI. She
denies vomiting, diarrhea, hematochezia, melena, and rectal pain.
Genitourinary: Denies dysuria, hematuria, and history of infections. She
was treated on one occasion for gonorrhea. Denies a history of syphi-
lis, and has never been tested for HIV.
Neurological: History of headache, and mononeuritis multiplex type
symptoms. Denies motor problems, continuous sensory deficit, and
denies cognitive impairment.
Psychiatric: Denies depression, history of suicide attempts or any psychi-
atric diagnoses

Physical Examination
Vital Signs: BP: 164/96; Pulse: 92/min; Temp: 100; F Resp. 14/min
General: Patient is a young female, pleasant, and cooperative. She ap-
pears slightly chronically ill, but in no acute distress.
Head: Normocephalic, nontender
Skin: Well tanned, with bathing suit lines. One area of small patch of

The Patient’s Story  /  189

 maculopapular rash over the lateral thigh. Patient states it is non pru-
ritic and has been present for 1 week.
Eyes: Extraoccular muscles intact. Pupils are equal, round, and reactive
to light and accommodation. Fundi are within normal limits. No pap-
iledema, no retinopathy.
Ears: Canals clear. TMs normal. Weber in midline, and Rinne is AC >
BC.
Neck: Supple, no thyromegally, and no bruits. There is no adenopathy.
Lungs: Clear to auscultation and percussion. Both diaphragms move well
to inspiration.
Heart: Regular rate and rhythm. Grade 1/6 soft, nonradiating systolic
murmur. Normal S1 and S2. No gallop and no rub.
Abdomen: Soft with mild tenderness. No guarding or rebound. Bowel
sounds are active and normal. No hepatomegally, and no spleno-
megally.
Rectal: Sphincter tone normal. No masses in rectum. Stool is guaic nega-
tive.
Pelvic: Introitus is within normal limits. No external lesions. Cervix is
normal in appearance, Pap smear is taken. Bimanual examination re-
veals ovaries of normal size, a retroflexed uterus, and no adnexal
masses. There is no tenderness.
Neurological: Sensorium intact. Cranial nerves intact.
Motor: Strength is 5/5 in upper and lower extremities.
Sensory: Intact to pain, cold, graphesthesia, and position sense
Cerebellum: RAM intact bilaterally in fingers and feet
Reflexes: 2–­3+ and equal in biceps, triceps and patellar tendons. Toes
down going.
Laboratory: White blood cell count is elevated. There is a mild anemia,
which appears to be an anemia of chronic disease. Hypokalemia and
mild metabolic alkalosis are present without renal insufficiency. Urine
sediment has been normal on at least two occasions. Thyroid tests
have been reported as normal. CT of abdomen is normal.

Assessment
This is a very difficult case. Patient is young, chronically ill, and has been
thought to have infection. However, she has been evaluated for 10 days
by Dr. C—­S—­, and has had numerous cultures and tests looking for in-
fection. She has a positive test for hepatitis B, but no other evidence of
infectious disease. If one assumes that the entire presentation is due to

190  /  the chief concern of medicine

 one illness, which is reasonable in a person of this age, then one has to
assume that there is disease in the head, the abdomen, the peripheral
nervous system, the skin, and kidneys (hypokalemia with metabolic alka-
losis). If one then assumes the high blood pressure is associated with the
overall illness as well as the decreased K and the alkalosis, one is led to
believe that the problem is with a structure or structures associated with
all the organs mentioned above. The only thing that fits that is blood ves-
sels. Inflammation of blood vessels could present this way. It would look
like an infection, with fever, and elevated white blood cell count. It could
affect all the organs listed, and is known to be associated with a Hep B
infection. Patient serology is positive for Hep B. I suspect she has Polyar-
teritis Nodosa associated with Hep B infection.

Recommendation
I would recommend doing a renal arteriogram. This is the most likely
positive area, given the hypertension, hypokalemia, and metabolic alkalo-
sis. Arteriogram of the head or the abdominal vessels could also be posi-
tive, but I believe I would recommend renal.

The patient’s HPI presents a series of symptoms: fatigue (mentioned four

times in the report); aching thighs; headaches; abdominal pains; and inter-
mittent, remitting numbness. The numbness is particularly noteworthy be-
cause it is a symptom that was only described upon questioning—­a part of the
“history” that was facilitated by the physician by means of a medical checklist,
the Review of Systems. (Like checklists pilots use prior to takeoff, the Review
of Systems prevents physicians from overlooking important symptoms the
patient herself may have overlooked.) In addition, feelings of sadness and
fear were expressed or presented by the patient. All of these symptoms are
conveyed through aural reporting. In addition, visual and physical evi-
dence—­of hand, eye, and laboratory—­are presented or called for.
Along with this evidence, the HPI presents a series of diagnoses of the
patient’s condition. Initially, the patient is diagnosed with mononucleosis,
despite the fact that several symptoms of this condition are not present in the
patient and despite the fact that several symptoms were presented that are
not accounted for by a diagnosis of mononucleosis. Then, two doctors—­the
patient’s hometown doctor, and Dr. C—­S—­ , a specialist in infectious
diseases—­describe her condition as symptoms of “unknown origin,” which
comprise two additional, inconclusive diagnoses. Finally, the patient diagno-
ses herself in general terms, fearing “a very serious illness ‘like cancer,’” hint-

The Patient’s Story  /  191

ing here at her chief concern. In all these instances, as well as the “Internal
Medicine Consultation” as a whole, doctors and patient are attempting to
grasp the combination of symptoms as a meaningful whole, to understand a
large number of phenomena or events as part of a consistent pattern defined
by its putative cause.
These two kinds of misapprehension of symptoms—­drawing a false con-
clusion by ignoring a lack of evidence and by ignoring positive evidence—­are
presented in “The Murders in the Rue Morgue” and “The Resident Patient,”
respectively. In Poe’s story, the police ignore the fact that the “language” of
the putative murderers was not recognized by anyone who understood the
attributed language. “That was the evidence itself,” said Dupin, “but it was
not the peculiarity of the evidence. You have observed nothing distinctive.
Yet there was something to be observed. . . . In regard to the shrill voice, the
peculiarity is—­not that they disagreed—­but that, while an Italian, an Eng-
lishman, a Spaniard, a Hollander, and a Frenchman attempted to describe it,
each one spoke of a foreigner. Each likens it [to a language he did not under-
stand]. . . . No words—­no sounds resembling words—­were by any witness
mentioned as distinguishable” (Poe 1985: 258). In Doyle’s story, the police
ignore the different kinds of cigar butts present at the scene of the putative
suicide. Holmes opened the victim’s cigar case and sees (with his magnifying
glass) that two of the cigars “have been smoked from a holder and two with-
out. . . . Two have been cut by a not very sharp knife, and two have had the
ends bitten off by a set of excellent teeth. This is no suicide, Mr. Lanner. It is
a very deeply planned and cold-­blooded murder” (A. Doyle 1986: 592).
The next sections of this History and Physical Exam gather more evi-
dence, verbal and physical, in the Past Medical History, Social and Family
History, and Review of Systems and Physical Exam. A considerable amount
of this “evidence” is negative, in that it rules out possibilities in order to re-
duce the number of possible causes by which these symptoms can be grasped
as a whole. Negative evidence—­both the patient’s “denials” (as we saw in the
woman with hyponatremia in chapter 4) and the presentation of “nontender”
body parts—­is very important for the physician, as it is for Dupin and
Holmes. As we have already suggested, the very structures of narrative—­its
“salient features”—­ allows nonexistent or “negative” evidence to be dis-
cerned: absent features in a narrative call attention to themselves in ways
that positivist science does not explain. The final sections of this History, As-
sessment and Recommendation, present the consulting physician’s diagno-
sis. In this, the physician gathers positive and negative evidence, makes “rea-

192  /  the chief concern of medicine

sonable” assumptions about this particular case, and creates a hypothesis that
allows the seemingly surprising fact (fleeting numbness or mononeuritis
multiplex) of this young woman’s symptoms to be understood as a matter of
course. As a matter of fact, the inflammation of blood vessels (polyarteritis
nodosa) proved to be the underlying condition producing the patient’s symp-
toms, demonstrated by the renal arteriogram.
The Consultation asserts that one should assume “that the entire presen-
tation is due to one illness, which is reasonable in a person of this age.” It is
a reasonable assumption that multiple serious symptoms in a young person
will be caused by a single illness or condition. In older patients, multiple
symptoms can reasonably be caused by a group of unrelated illnesses and
conditions, since aging makes people susceptible to a larger number of con-
current conditions. Such “reason” is not absolute—­it is more like the provi-
sional “fair guesses” Peirce describes—­but it does point to a likely under-
standing of the meaning of multiple symptoms in a patient, insofar as it
makes a categorical, rather than a factual, generalization. The “likely” is the
first place to look for further testing, which, in this case, proved to discern
the single cause of the patient’s multiple symptoms. But even the “unlikely”
should not be ruled out too early. As M. Dupin says, “It is not our part, as
reasoners, to reject [an explanation] on account of apparent impossibilities.
It is only left for us to prove that these apparent ‘impossibilities’ are, in real-
ity, not such” (Poe 1985: 259).
The History as a whole, then, presents the salient features of narrative.
The sequence of events of this illness, presented in flashback, goes back over
six to eight months of gradually worsening fatigue, aching limbs, headaches,
and retrospectively remembered numbness. (The physician asked about
numbness as part of the “educated guess” that the disparate symptoms might
be tied together by the circulatory system.) The sequence continues with
recognizable agents, including various doctors, who diagnose mononucleo-
sis, confess ignorance, and finally gather together the symptoms into the
“end” of the story, with representations of experience, a teller and a listener,
and a witness who recognizes what is happening in the same way a reader
figures out the plot of a story. As we saw earlier, Dr. Rita Charon notes that
“in a funny way what the doctor does in diagnosis is pretty much what he or
she does in reading for the plot.” She explains,

Listening to the woman with abdominal pain, I’m registering each of many
different events, not all of them told chronologically, and this will include the

The Patient’s Story  /  193

 pain in the belly, the history of appendicitis as a child, the taking care of Aunt
Melinda when she was ill, right? All these different events, and I, as the diag-
nosing doctor, have to somehow register these events, configure them in my
mind so that they make provisional sense. And then, at the end of this listen-
ing activity, I have some notion of what happened in sort of the way at the
end of a novel you have some notion of what happened. The difference, of
course, is I close the novel. I might decide to read more of that author or not,
but I close the novel, no doubt being transformed by having read it. But for
the doctor, that’s just the beginning because here you have, if you will, the
plot of this illness, and you have in your mind some notion of what it might
mean, and then you go about testing it, right? So that at the end of my visit
with this woman, I have what we call the differential diagnosis. (Vannatta,
Schleifer, and Crow 2005: chap. 2, screen 52)

The next step, as we will see in Part 3 of this book, is what Charon calls the
physician’s “duty to act,” a very pragmatic “end” of narrative.
In any case, this relationship or analogy between the HPI and narrative
features emphasizes a very important context in which the HPI is situated,
namely, the social background of the patient. This element of the History is
important not only because it offers biomedical evidence of predispositions
to particular kinds of illnesses and conditions but also because a very signifi-
cant part of the patient’s story is the context from which she comes, the fam-
ily that surrounds the illness and constitutes part of its story. In the case of
the fever of unknown origin—­the case of polyarteritis nodosa—­the patient
offers an extended social as well as medical history. Moreover, in many
cases—­as in Robert Johnson’s story—­a family member as well as the patient
narrates or helps narrate the patient’s story, including the social background.
Thus, as we have seen, Rosemary Johnson is a significant “teller” of her fa-
ther’s story about his stroke. For this reason, it is very important for the phy-
sician to understand that the patient’s story may have multiple narrators.
In his poem “The Couple,” Dr. Rafael Campo describes a joint presenta-
tion of a patient and a family member. This poem conveys social information
about the patient through its presentation of the dramatic interaction of
patient and wife that is analogous to the social information conveyed in the
case of a fever of unknown origin and the family-­presented stroke patient in
the two patient-­doctor interviews presented in this chapter. As an art narra-
tive, this poem powerfully demonstrates how illness affects the family as a
whole, most notably, perhaps, in the image of the patient’s wife “doused” in

194  /  the chief concern of medicine

her husband’s blood. (This is the metaphor Dr. Stone uses to describe his
poem.)

the couple
Releasing his determined grip, he lets
her take the spoon; the cube of cherry Jell-­O
teeters on it, about to drop as if
no precipice were any steeper, no
oblivion more final. Earlier
today, he hemorrhaged, the blood so fast
a torrent that it splattered onto her.
She washed herself, unwillingly it seemed,
perhaps not wanting to remove what was
his ending life from where it stained her skin.
I watch them now, the way they love across
the gap between them that their bodies make:
how cruel our life-­long separation seems.
The ward keeps narrowing itself to that
bright point outside his door—­the muffled screams
along a hallway to the absolute—­
and as I turn away from them it’s not
their privacy, or even my beginning shame
I wish I could escape. It is the light,
the awful light of what we know must come.
(Campo 2002: 70)

What this poem emphasizes, as Dr. Campo has noted, is the way in which
“illness is almost never an isolated experience or individual experience, that
this is a shared experience in the poem between two people who are in love,
and that the end of life, I think, which is visible in the poem, is something
that both people present in the poem must confront.” But it also, suggests, as
he said, that it is “a poem about the mystery of human suffering and how suf-
fering, in a sense, is, perhaps, made more visible by the presence of another”
(Vannatta, Schleifer, and Crow 2005: chap. 2, screen 53). One shared lesson
of medicine and literature is that the pain and suffering that both treat in
very different ways is part of our common—­our shared—­human inheritance.
The poem’s art is its image of such shared experience—­presented more for-
mally than in Stone’s “House Call,” with stricter meter and rhymes—­as the

The Patient’s Story  /  195

patient releases his grip so that his wife can feed him and as the poet-­
physician senses the privacy of this ordinary act.

Story Filters

We began this chapter with an example of an “accidental” impediment to a

coherent narrative: Robert Johnson’s stroke created obstacles to his narra-
tive, which were compounded by his daughter’s emotional response to his
condition. (As we will see shortly, fear has physiological and psychological
consequences that impair or inflect narrative responses, which can be no-
ticed in Rosemary’s speech patterns, facial features, and overall physical ap-
pearance.) To conclude this chapter, we examine what we might call struc-
tural or “schematic” impediments to the creation and transmission of
recognizable narrative, impediments between the teller and the listener (or,
in Greimas’s actantial terms, the Sender and the Receiver). Because these
problems are structural, they lend themselves to systematic schematic un-
derstanding and systematic responses—­or, at least, to the conscious aware-
ness that they do exist, which can allow physicians to systematically prepare
themselves for their occurrence. The background of patients—­their families,
cultures, or subcultures and the assumptions they bring to their illness, which
are sometimes recoverable in relation to their chosen life occupations—­are
part of a larger series of contexts or “filters” that help shape the stories they
bring to their physicians. The patient’s story, the HPI, is told through a series
of filters that are the results of the life experiences of the patient and the as-
sumptions she or he brings to the current experience. Such filters can be
understood in terms of schemas of elements. There are innumerable filters,
often tied to more or less idiosyncratic belief systems—­the story of Mrs.
Jones in chapter 3 is a good example of such a “filter”—­but there are some
that are more predictably important than others in their role in preventing
effective communication in the patient-­physician relationship.

Primary Emotions

Some of the most important filters in the physician-­patient interaction are

the primary emotions exhibited by the patient when the patient presents to
the physician. Scientists—­psychologists, neurologists, and primatologists—­
have isolated six “primary emotions” in humans and, to a lesser extent, in all
primates. They include anger, fear, sadness, disgust, joy, and surprise. (Fear

196  /  the chief concern of medicine

governs Rosemary’s response in the story of Robert Johnson.) These primary
emotions are associated with particular physiological, neurological, and psy-
chological reactions, including involuntary physiological (muscular) re-
sponses in faces. The first three—­anger, fear, and sadness—­are particularly
important in affecting the stories patients tell and their responses to encoun-
ters with physicians.

Anger

Anger is a common human emotion seen in the clinical setting. It has par-
ticular psychophysiological components, facial components, and objective
observable components.

Psychophysiological Manifestations of Anger and Aggression

1. Neurotransmitters: noradrenergic, dopaminergic, and serotonergic
systems play a role.
2. Androgens and aggression are related.
3. Hypothalamus and limbic system are involved.
4. Rise in blood pressure.

Facial Manifestations of Anger

1. frown (corrugator)
2. narrowed eyelid (orbicularis occulae)
3. snarl (orbicularis oris)

Observable Manifestations of Anger

1. Moving forward in the chair
2. Acceleration of the anger in the verbal content
3. Respiratory changes, quickening
4. Distention of the veins of the neck

When patient anger is encountered in the patient-­physician relationship, the

patient’s story can be severely impaired. The patients’ hostility distorts the
stories they are trying to tell. Memory may be impaired, judgment is ad-
versely affected, and hostility tends to shade the facts that comprise the HPI.
Many people in our society are raised in families where anger is not ac-
ceptable: it is not acceptable to express it, and so it is also ignored by the
members of those families. For this reason, anger is often ignored by physi-
cians and medical students. But even though they ignore it in their outward

The Patient’s Story  /  197

behavior, they cannot ignore it emotionally, because human beings are
built—­neurologically—­to recognize these emotions, and we all recognize
them at a very basic level, a deep brain level. Physicians need to acknowledge
anger and recognize it in patients—­and, as we will see in chapter 7, in them-
selves as well. They need to bring it up to the conscious level and say to
themselves, “This patient is really angry,” and then to verbally recognize the
emotion and say to the patient,

“You certainly seem agitated. Is there something bothering you?”

Such a statement often allows the patient to share with them whatever it is
that is making them angry. Moreover, when students and health care workers
learn to do that, they are pleased to find that it disarms the anger most of the
time.

Fear

Fear and anxiety are common human emotions seen in the clinical setting.
They, too, have particular psychophysiological components, facial compo-
nents, and objective observable components.

Psychophysiological Manifestations of Fear and Anxiety

1. Norepinephrine and the locus cereleus: sympathetic outflow domi-
nates the expression of anxiety and is responsible for most of the ob-
jective signs.
2. Gamma-­aminobutyric acid (GABA): inhibits neuronal firing. Benzo-
diazapines work through the GABA receptors.

Facial Manifestations of Fear and Anxiety

1. Tense open lips (risorius-­orbicularis oris)
2. Tense lower lids (orbicularis occulae)
3. Dilated pupils

Observable Manifestations of Fear and Anxiety

1. Tense body muscularity
2. Shortness of breath (speaks at the height of inspiration)
3. Sweating
4. Rapid heart rate
5. Brisk reflexes
6. Gastrointestinal disturbances

198  /  the chief concern of medicine

When fear and anxiety are encountered in the patient-­physician relationship,
the patient’s story can be severely impaired. Patients’ emotions distract at-
tention, so that the stories they are trying to tell may not be well focused.
Memory may be impaired, and a worry tends to shade the facts that comprise
the HPI. The first most common emotion that is seen in the doctor-­patient
relationship is probably acceptance. Most patients who come in and see the
doctor are not particularly sad or angry or anxious but are pretty much in an
acceptance mode. The second most common is probably fear and anxiety,
and again it is necessary to recognize that the patient is anxious through both
verbal and nonverbal cues, to speak to it with such statements as

“This seems to have you upset” or

“This seems to have you worried.”

Such statements allow the patient to express specifically what he is worried

about. The most interesting thing is that guessing what is wrong or guessing
what a patient is anxious about is commonly mistaken: physicians need to ask
patients specifically what they are worried about, because assumptions about
what is worrying them simply waste time. Moreover, when the issue of fear
is explicitly raised in a consultation, the anxiety levels usually fall.

Sadness

A final emotional filter for the patient’s story is sadness, which is commonly
encountered in the medical setting. Again, it has particular psychophysiolog-
ical components, facial components, and objective observable components.

Psychophysiological Manifestations of Sadness

1. Slower gastrointestinal action
2. Decreased hypothalamic drives (i.e., sex and appetite)
3. Sleep disturbances

Facial Manifestations of Sadness

1. Inner corners of eyebrows raised
2. Inner corners of eyelids drawn up
3. Corners of lips drawn down

Observable Manifestations of Sadness

1. Physical withdrawal
2. Quiet or inaudible voice
3. Lower heart rate

The Patient’s Story  /  199

When sadness is encountered in the patient-­physician relationship, the pa-
tient’s story can be severely impaired. The patient has less energy than nor-
mal to put into the story he is trying to tell. Memory may be impaired, and a
negative attitude tends to distort the facts that comprise the HPI. Anger and
anxiety have lots of energy in them. Depression is characterized by a lack of
energy. It provides hardly anything for the physician to work with, so most
physicians find that it creates a more difficult situation. It is necessary to
recognize that there is not much energy going on in a depressed patient and
to try to figure out what the feeling state is, to try to get the patient to name
it. Once again, the physician can and should speak to the emotion:

“This sounds like it makes you very sad.”

If the patient can name the feeling state, the physician can validate it and try
to figure out its cause. As we suggested in chapter 5, the questions and re-
sponses listed in this section are schemas of discursive acts that can and
should be habituated in eliciting the HPI.

Cultural Differences

Besides psychophysiological manifestations of emotion, other factors can in-

flect the patient story to the point where the physician’s ability to discover
narrative evidence is impaired. The most common of these narrative “filters”
encountered in a medical setting are

differences between patient and physician in cultural background and

experience that affect the form and often the content of the patient’s
story;
differences between patient and physician in education and class that af-
fect the clarity and content of the patient’s story;
gender differences between patient and physician that affect the focus
and evaluation of the patient’s story; and
differences between patient and physician in age that affect the organiza-
tion of the patient’s story.

These differences of background, worldview, experience, education, and so-

cioeconomic strata create cultural filters that inflect the patient’s story and,
sometimes (as in the Mrs. Jones story in chapter 3), obstruct the physician’s
listening.

200  /  the chief concern of medicine

 Patients present from a wide variety of cultural backgrounds. Most stu-
dent doctors, residents, and practicing physicians have limited exposure to
cultures other than their own. Literature and its rich narrative descriptions—­
and the possibilities of case-­based reasoning it makes available—­can provide
the physician with an understanding of how the world appears through the
eyes of the other. In chapter 9, we examine, in greater detail, the ability of
narrative (particularly art narrative) to create vicarious experience—­one of
the salient features of narrative we have already discussed. In this section, we
only touch on this in asserting how narrative allows physicians and others to
have seemingly experiential encounters with new schemas of experience.
Encountering such experience is particularly important for physicians, be-
cause the narrative evidence presented by patients from different cultures
and backgrounds often involves assumptions about what a narrative “tells”—­
what constitutes evidence and concern—­and how it is presented that differ
from the narrative experiences of people who grew up in the United States
and other Western countries. Physicians can easily assume that the manifes-
tations of such differences are simply explained as patient recalcitrance, and
in doing so, physicians can thus fail to pursue evidence in their patients’ nar-
ratives.
In The Spirit Catches You and You Fall Down, Anne Fadiman provides
us with a dramatic example of transcultural medicine in which a tragedy oc-
curs in the care of a Hmong child. Lia Lee, the girl in the story, has a seizure
disorder, congenital in nature. The differences in belief systems between the
physicians and the patient and her family make the history almost inaudible
to the physicians. As Lia’s family communicates its understanding of Lia’s
condition, their hopes for her care, and their expectations from the health
care delivery system, they do so in the context of their culture. Therefore, the
story is told through cultural filters. The differences between beliefs that
separate the patient’s family and the physicians include different assump-
tions about the nature of physiology and different assumptions about the
nature of “personhood” of the patient we mentioned earlier. In Fadiman’s
narrative, different assumptions about physiology are captured in the Hmong
conception of the placenta, its place in the narrative of birthing.

Soon after the birth, while the mother and baby were still lying together next
to the fire pit, the father dug a hole at least two feet deep in the dirt floor and
buried the placenta. . . . The placenta was always buried with the smooth
side, the side that had faced the fetus inside the womb, turned upward, since
if it was upside down, the baby might vomit after nursing. . . . In the Hmong

The Patient’s Story  /  201

 language, the word for placenta means “jacket.” It is considered one’s first
and finest garment. When a Hmong dies, his or her soul must travel back
from place to place, retracing the path of its life geography, until it reaches
the burial place of its placental jacket, and puts it on. Only after the soul is
properly dressed in the clothing in which it was born can it continue its dan-
gerous journey . . . where it is reunited with its ancestors and from which it
will someday be sent to be reborn as the soul of a new baby. If the soul cannot
find its jacket, it is condemned to an eternity of wandering, naked and alone.
(1998: 5)

Here are assumptions about the world and about human life that are vastly
different from those most westerners share, especially those trained in the
medical sciences.
Fadiman’s narrative also captures the particular Hmong conception of
personhood, which is vastly different from that of the doctors who treat Lia.

When Lia was about three months old, her older sister Yer slammed the front
door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her
arms jerked over her head, and she fainted. The Lees had little doubt what
had happened. Despite the careful installation of Lia’s soul during the bu plig
ceremony, the noise of the door had been so profoundly frightening that her
soul had fled her body and become lost. They recognized the resulting symp-
toms as qaug dab peg, which means “the spirit catches you and you fall
down.” The spirit referred to in this phrase is a soul-­stealing dab; peg means
to catch or hit; and qaug means to fall over with one’s roots still in the ground,
as grain might be beaten down by wind or rain. (1998: 21)

In this passage, Fadiman’s language—­her metaphors—­capture a sense of the

foreignness of Hmong culture to urban Americans. Hmong understanding
and value—­the very elements and form of their narratives, including the
stories patients tell—­grow out of rural and rustic life experiences of dirt
floors and weathered grain and without Cartesian assumptions of the opposi-
tion of matter and spirit. Moreover, Fadiman’s narrative as a whole—­as the
other narratives we examine here in relation to cultural differences—­suggests
the importance of making the chief concern part of the protocol of the His-
tory and Physical Exam.
In fact, near the end of her narrative, Fadiman quotes “a set of eight
questions designed to elicit a patient’s ‘explanatory model,’ which were de-
veloped by Arthur Kleinman” (1998: 260). The questions function like the

202  /  the chief concern of medicine

checklists described in our introduction to the present book; in fact, the last
of these questions is an explicit version of asking a patient for his chief con-
cern. Although they are designed for what Fadiman calls “cross-­cultural
medicine,” they would be appropriate for many of the cultural filters we are
describing here; they would also be useful in aiding the discernment of the
“point” of the popular and art narratives we touch on in this book, from Mrs.
Jones’s concern with the almanac to Paula’s inability to describe her desper-
ate domestic situation (see chaps. 3 and 5, respectively). Fadiman notes that,
as is true of many checklists, “the first few times I read these questions they
seemed so obvious I hardly noticed them”; after fifty readings, however, she
reports, “I began to think that, like many obvious things, they might actually
be a work of genius” (1998: 260). Here are Kleinman’s questions as cited by
Fadiman:

1. What do you call this problem?

2. What do you think has caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does? How does it work?
5. How severe is the sickness? Will it have a short or long course?
6. What kind of treatment do you think the patient should receive?
What are the most important results you hope she receives from this
treatment?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness? (1998: 260)

The last two questions focus explicitly on the chief complaint and the chief
concern, though most of the others are related to the chief concern: even
question 4, which a westerner might attempt to answer in biomedical terms
(especially in regard to its second part), also entails concern in its focus on
what a sickness does.
Cross-­cultural medicine, so conceived, can be understood in relation to
differences in socioeconomic backgrounds as well: this surely is a factor in
physicians encountering Mrs. Jones or Paula. By definition, student doctors,
residents, and practicing physicians bring to their encounters with patients
high levels of education and the values that have allowed them to complete a
difficult and time-­consuming education. Moreover, those values—­hard work,
deferred gratification, particular kinds of goals and ambitions—­have histori-
cally inhabited the middle class in our culture. A large proportion of medical
students and doctors have been raised in the middle class—­with parents and

The Patient’s Story  /  203

relatives who are salaried workers in the professions or business or have
other such employment. Almost by definition, an even larger proportion of
practicing physicians find themselves members of the middle class. Thus,
they often have limited exposure to people from lower social classes with
significantly different educations. Literature and its narrative descriptions—­
the vicarious experience they create that we examine later—­can provide the
physician with an understanding of how the world appears through the eyes
of the other.
Often, narrative evidence from patients from different educational and
class backgrounds who bring assumptions about what can be said and how a
physician might respond to them is presented in a manner that is different
from the clarity and details that physicians are taught to expect and, more
important, to respect. Physicians can easily assume that the manifestations of
such differences are simply explained as patient ignorance, and in so doing,
physicians can again fail to pursue the evidence of the patient’s history. We
saw one such instance of this in chapter 5, when Paula in The Woman Who
Walked into Doors was dismissed as a drunk in the emergency room. Roddy
Doyle narrates this novel, strikingly, in the voice of a woman and is able to
allow us to do what William Carlos Williams says both literature and a life as
a doctor allowed him to do, to transform “stereotype . . . [into] a moment of
insight” (1967: 359). Doyle accomplishes this by transforming sight to sound,
body parts to voice.

I could see all these people but they couldn’t see me. They could see the
hand that held out the money. . . . They could see the foot that tried on the
shoe. They could see the mouth that spoke the words. They could see the
hair that was being cut. But they couldn’t see me. The woman who wasn’t
there. The woman who had nothing wrong with her. The woman who was
fine. The woman who walked into doors.
They could smell the drink. Aah. They could see the bruises. Aah, now.
They could see the bumps. Aah now, God love her. Their noses led them but
their eyes wouldn’t. (1996: 187)

Doyle presents two ways of seeing: (1) one where parts—­hand, foot, hair—­
add up to all there is and where the whole is the sum of the parts and (2) one
that encompasses the narrative knowledge of the novel as a whole, in which
“the woman who walked into doors,” poor, drunken, abused, becomes a per-
son, Paula, and in which the whole is greater than the sum of the parts.

204  /  the chief concern of medicine

Gender and Age

In addition to the cultural differences of nation and class, patients present in

the context of two significant differences tied—­at least in part—­to their bod-
ies rather than their cultures: gender and age. Gender-­dependent interpreta-
tion is a well-­known phenomenon, and this is important in medicine because
the interpretation implicit in the patient’s narrative presentation makes a
large difference in the doctor’s evaluation and, consequently, in the final dif-
ferential diagnosis. Therefore, training in attending to different narrative
strategies—­the focus and implicit evaluations articulated in narrative—­in
relation to these differences is important. In relation to gender and sexual
orientation, such different narrative strategies are not “natural”—­they are
not defining elements of gender difference—­but are culturally determined
factors that can inflect and “filter” patients’ stories in our culture at this par-
ticular historical moment. Thus the gender and gender orientation of the
patient who tells the story should not be ignored in understanding the pa-
tient’s story. In this category as in the others, literature and its vicarious nar-
rative descriptions can provide the physician with an understanding of how
the world appears through the eyes of the other.
The HPI from a patient of a different gender or sexual orientation from
the physician is often inflected in narrative strategies differently from the
way that biomedical information is presented in textbooks, lectures, and im-
personal reports. This can be discerned in a comparison of two versions of a
story about an adulterous love affair, “The Lady with the Pet Dog,” written
by Anton Chekhov in the late nineteenth century and rewritten under the
same title by Joyce Carol Oates in the late twentieth century. This is a story
of a love affair between two married individuals. When the two versions of
the story are read together, different narrative strategies associated with gen-
der differences become apparent. Chekhov’s narrative presentation, written
from the point of view of the male protagonist, is very different from Oates’s,
written from the female point of view.
In Chekhov’s story, Dmitri Gurov, the protagonist, begins the affair with
an insincere approach to yet another woman who he can conquer sexually.
Anna, who is considerably younger than Gurov, is self-­reproaching, con-
stantly asking Gurov if he loves her, demanding that he say he does not re-
spect her. Immediately following the consummation of the affair, Anna tells
Gurov that she believes she is a fallen woman, and she begs Gurov to admit
that he does not respect her any longer. “‘It isn’t right,’ she said. ‘You will

The Patient’s Story  /  205

never respect me anymore.’ On the table was a watermelon. Gurov cut him-
self a slice from it and began slowly eating it. At least half an hour passed in
silence” (Chekhov 1979: 225). Like the “loaded rifle” that Chekhov mentions
needs to fire in a successful play (see chap. 3 in the present book), this aes-
thetic narrative detail gathers up the meaning of the older man’s impatience
and ironic detachment from his affair: it is a sign of his understanding, born
of experience, that his lover’s guilt is momentary. In the story, which pro-
gresses chronologically with no—­or few—­interruptions to the sequence of
narrative events, Chekhov depicts Gurov as traveling from this attitude of
ironic insincerity, to heartfelt compassion for his lover, and finally to a sin-
cere, mature love for Anna in the end. Toward the middle of the story, Chek-
hov notes,

He was moved and sad, and felt a slight remorse. After all, this young woman
whom he would never again see had not been really happy with him. He had
been friendly and affectionate with her, but in his whole behaviour, in the
tones of his voice, in his very caresses, there had been a shade of irony, the
insulting indulgence of the fortunate male, who was, moreover, almost twice
her age. She had insisted in calling him good, remarkable, high-­minded.
Evidently, he had appeared to her different from his real self, in a word he
had involuntarily deceived her. (1979: 227–­28)

At the end, however, after he notices his own gray hair in a mirror, Gurov
discovers a “profound pity” for Anna and desires to be sincere and tender.
He thinks, “He and Anna Sergeyevna loved one another as people who are
very close and intimate, as husband and wife, as dear friends love one an-
other. . . . They forgave one another all that they were ashamed of in the past,
in their present, and felt that this love of theirs had changed them both”
(234–­35). Chekhov’s narrative strategy is that of intelligent, detached irony
pursuing a chronological story to a revelation, irony transformed to compas-
sion.
Oates’s story, written from the point of view of her female protagonist,
pursues a different narrative trajectory, even though—­in large ways—­the
events of these stories are basically the “same.” (We noted in chapter 2 that
one feature of narrative is that narratives are subject to retelling and sum-
mary.) Anna is initially enmeshed in relationships, both the failed or failing
relationship with her husband and her relationship with her lover, in which
she cannot think of herself without him. She begins her story with a scene
from the middle of her relationship (as it was in the middle of Chekhov’s

206  /  the chief concern of medicine

story), in which Anna encounters her lover at a play she is attending with her
husband. In Oates’s telling the scene is repeated four times in the course of
the narrative, not with the intelligent detachment of Chekhov’s watermelon,
but with the pulsating power of narrative interruptions. Each time, Oates
depicts Anna’s panic and the failure of physical love with her husband. Thus,
unlike Chekhov’s story, Oates’s narrative does not follow chronology: it be-
gins in the middle and repeatedly returns to that “middle”—­to a moment
that insists it is Anna’s chief concern—­so that, unlike Chekhov, the sequence
of events of the narrative middle and its “end” confuse themselves.
Oates depicts Anna not as “traveler” like Gurov, learning from experi-
ence, but as a person confronting a revelation about the world and about
herself. Near the beginning of the affair, she tells her lover about all the
“people I believed in, but it turned out wrong. Now I believe in you. . . . I
can’t think of myself without you” (Oates 1993: 290). By the end of the
story—­after panic, attempted suicide, despair—­she catches her lover’s re-
flection in the mirror (in Chekhov Gurov sees his own reflection) and

she realized that he existed in a dimension apart from her, a mysterious be-
ing. And suddenly, joyfully, she felt a miraculous calm. This man was her
husband, truly—­they were truly married here in this room—­they had been
married haphazardly and accidentally for a long time. . . . This man, whom
she loved above any other person in the world, above even her own self-­
pitying sorrow and her own life, was her truest lover, her destiny. And she did
not hate him, she did not hate herself any longer; she did not wish to die; she
was flooded with a strange certainty, a sense of gratitude, of pure selfless
energy. It was obvious to her that she had, all along, been behaving correctly;
out of instinct. (300–­301)

These two stories are “gendered” differently—­one from the point of view of
a man, the second from that of a woman—­and each organizes the same
events with a different focus, narrative progression, and presentation of emo-
tion. Reading these stories together does not teach some putative general
differences between men and women. Read together, however, they do teach
how a medical student or physician listening to a patient’s story can and
should attend to different modalities of storytelling in relation to the gender
and sexual orientation of the teller. Throughout this chapter, we have fo-
cused on the modalities of narrative discourse—­the different ways the tellers
of a story and their “temporalities” of storytelling more generally inflect nar-
rative meaning and narrative knowledge in relation to emotional, cultural,

The Patient’s Story  /  207

and other differences, but here, when men and women, young and old, give
the superficial impression that they come from the “same” world and lifestyle
of the physician and that there are no palpable differences of class, dress,
education, (foreign) language, and so on, it is particularly important to attend
to differences that could be easily missed.
A final filter for the patient’s story is age. The nature and understanding
of the patient’s story can be inflected by the age of the patient. In one study
in developmental psychology, for instance, storytelling skills were assessed
across age-­groups (Mergler, Faust, and Goldstein 1985). The experiment
analyzed young adults’ assessments and recall of vocal recordings of narrative
and descriptive prose passages presented in young, middle-­aged, and elderly
voices. It discovered that while more positive listener assessments were elic-
ited when young voices transmitted the descriptive passage than when older
voices relayed the same information—­ such as recognizable characters
(agents) and setting—­listeners recalled other aspects of narrative more ac-
curately when narrative prose was narrated by older people. More particu-
larly, it was reported that “highly-­structured prose with an explicit moral—­
the discourse of narrative cognition—­ resulted in a measurably greater
amount of transmitted information when it came from an old person”
­(Schleifer, Davis, and Mergler 1992: 118; see also Mergler and Goldstein
1983: 85–­86). Under the category of “the discourse of narrative cognition” in
this passage, the researchers are describing three of the salient features of
narrative: the sequence of events, the end of the story, and the witness who
learns. Thus differences in age—­like differences in culture, socioeconomic
background, and gender—­ often produce narrative filters, the effects of
which are measurable. These differences inflect and transform the organiza-
tion of a patient’s story and can interfere with the recovery of narrative evi-
dence. For this reason, the narrative evidence from a patient of an age sig-
nificantly different from that of the physician—­very much older or very
much younger—­often presents itself within a different organization of narra-
tive. (See the discussions of Williams’s story “The Use of Force” and the at-
titude of “paternalism” more generally in chapter 5 for examinations of phy-
sicians’ relations with children.)
The strangeness of old age is its essential ambiguity, its essential ambiva-
lence. Most people find aging ambiguous and impure. What characterizes
the elderly is not simply the loss of power but the situation of simultaneously
possessing a sense of self and a sense of otherness about oneself. Thomas
Hardy captures this wonderfully in a short poem, “I Look into My Glass.”

208  /  the chief concern of medicine

 I look into my glass,
And view my wasting skin,
And say, “Would God it came to pass
My heart had shrunk as thin!”

For then, I, undistrest

By hearts grown cold to me,
Could lonely wait my endless rest
With equanimity.

But Time, to make me grieve,

Part steals, lets part abide;
And shakes this fragile frame at eve
With throbbings of noontide.
(1976: 81)

The ambiguity of the loss and maintenance of power and emotion is the bur-
den of Hardy’s poem, and it is the burden of old age as well. Moreover, this
ambiguity often leads to inappropriate assertions of power, taking the form of
very much talk. Thus an eighty-­four-­year-­old man told Ronald Blythe in The
View in Winter, a book of interviews with the very old,

Old age doesn’t necessarily mean that one is entirely old—­all old, if you fol-
low me. It doesn’t mean that for many people, which is why it is so very dif-
ficult. It is complicated by the retention of a lot of one’s youth in an old body.
I tend to look upon other old men as old men—­and not include myself. It is
not vanity; it is just that it is still natural for me to be young in some respects.
What is generally assumed to have happened to a man in his eighties has not
happened to me. . . . Yet I resent it all in some ways, this being very old, yes,
I resent it. (1979: 185)

Aging combines one’s ideal sense of oneself with the inevitable and pressing
fact of one’s own bodily life, a life of “parts.” Thus the old man Blythe is in-
terviewing goes on to say, “King Lear said, ‘When the mind’s free the body’s
delicate,’ and that is true. . . . I feel so alive, but my muscles tell me other-
wise” (186).
Old age also affects storytelling, the patient’s story. Blythe records a
seventy-­nine-­year-­old speaker as saying,

The Patient’s Story  /  209

 Well, Father’d set beside me evenins-­like and he’d whittle away at things. . . .
It was a pleasure to see it. So there he’d set, in his ol’ chair—­Father’s chair,
we called it. That wouldn’t dew to let him ketch you with your arse in it, that
wouldn’t! I would love to know where that chair is this minute, that I
would! . . . Silly fule, I give it away years agoo. The chair Father made. I see
him makin’ it, an’ I give it away! Pity. Father’s chair—­fancy me a-­thinkin’ o’
that now! But that’s how it is when you’re an old un, it all kind-­a starts up
agin, the long agoo. As plain as lookin’ out that winder. So this ol’ chair. . . .
That was Father’s [work]bench, that chair. Snares, he’d make. I lay there on
the couch larnin’ the carvin’ and the snares, a-­pickin’ it all up, gittin’ like
Father, gittin’ Father’s skill. (46)

His father’s chair sums up this speaker’s life, and it also implies the moral of
not giving anything away: it is a narrative event that is like Chekhov’s water-
melon and his loaded rifle. In the end, this old man says of the things he
makes, “at furst I’d make ’em and give ’em away, but now I keep every-
thing. . . . I don’t copy anything, I make what I remember.” Such is the plot-
ted prose with an explicit moral—­the sequence of events, the end, the wit-
ness who learns—­that experimenters describe as the discourse of old people.
It is garrulous and sometimes seemingly pointless, yet it is governed by a
chief concern, and in it—­as in narrative and patients’ stories more gener-
ally—­a whole can be discovered that is more than its parts.
In this chapter, we have focused on practical encounters with patient nar-
ratives in ways that instantiate the more abstract features of narrative we
discussed in Part 1; more particularly, we have focused on the formal ele-
ments of the History and Physical Exam and the History of Present Illness
that patients bring to doctors. In chapter 7, we examine such less formal
narrative interactions between patients and physicians from a different point
of view, from the vantage of the physician’s engagement and response to pa-
tient narratives. The chapters of Part 2 examine the situation of the patient
narrative—­the scene of telling and listening—­and the narrative itself, in all
its richness, complexity, and concern. In the next chapter, we turn to the
work of narrative in the ways it engages action in the world.

210  /  the chief concern of medicine

7
doctors listening and attending
to patients
Response and Engagement with Acts of Narration

When I think back to some of those early patients it is that first impression that lingers:
what they wore, what words they used to tell their story, who was with them, the scent of
the room, how the enlarged spleen felt rebounding off my fingers, how the smooth but
distended liver slid under my hand. The writer Milan Kundera says that the first ten
minutes between a man and woman are the most important in their subsequent history, a
predictor of things to come. So it was with me: the first ten minutes were a determinant
of how I would color that patient in my memory.
—­dr. abraham verghese, My Own Country (1995: 111)

Listening to patients and the illness story is one of the most important skills
(technē) a physician uses during a lifetime of practice. Because the patient
history is the most important diagnostic information, listening carefully is of
enormous importance. Patients commonly complain that their doctor does
not listen. But when patients are heard, they report that their doctor was
empathetic. Listening carefully helps build rapport, increases diagnostic ac-
curacy, and improves patient satisfaction. If a doctor has a broad and deep
enough knowledge base, has the skills to listen carefully to what the patient
has to say, and gets the information from the patient in very detailed fashion,
he has a really good chance to develop a broad, differential diagnosis. Before
any physical exam, before any diagnostic testing or any technological supple-
ments, skillful listening by a physician—­which includes skillfully facilitating
her patient’s story—­will help clarify and insure well-­focused attention to di-
agnosis and care.

/  211  /
Attentive Listening

Apprehending the Whole

Listening is a skill different from the attention to details and facts of analysis
called for by logico-­scientific understanding. Listening is a constituent part
of narrative and narrative knowledge: a narrative, as we noted, is both articu-
lated and received. Moreover, both listening and narrative are interactive
and often deal with the interaction of different languages or vocabularies and
concerns as well as the different temporalities of narrative, the time of the
telling and the time of the events described. Good listening attends to the
patient’s story as a whole, to the details of the storytelling—­both narrative
fact and telling emotions—­as they contribute to the whole, and it, as we sug-
gested in the preceding chapters, acknowledges and facilitates the patient’s
story explicitly through paraphrase and response. Thus good listening at-
tends both to direct evidence—­explicit details and explicit patient explana-
tions of their motives in calling the doctor—­and to circumstantial evidence,
including the style of what is presented to the listener, what is left unsaid,
and the degree to which the speaker is reliable.
Listening carefully and finding new methods of attending to the patient
are skills that can and should be taught to physicians. The well-­known
twentieth-­century linguist Roman Jakobson defined literature as a special
kind of attending. (He even identified a particular aspect of language he
called “literariness.”) Part of the delight readers take in Sherlock Holmes’s
stories is the fact that Holmes’s seemingly supernatural ability to see into
things is often shown to be explained by his careful attention to what he hears
and sees. In a story we have already discussed, “The Resident Patient,” Wat-
son and Holmes are visited by a young doctor with a strange narrative con-
cerning his practice, including a break-­in at the residence where he sees pa-
tients. Holmes arrives at the residence in question and discusses a break-­in
with the “resident patient,” Mr. Blessington, a rich man who set up the physi-
cian’s practice under the condition that he reside there with the constant
availability of the doctor’s care.

“Who are these two men, Mr. Blessington,” Holmes asks, “and why do they
wish to molest you?”
“Well, well,” said the resident patient in a nervous fashion, “of course it is
hard to say that. You can hardly expect me to answer that Mr. Holmes.”

212  /  the chief concern of medicine

 “Do you mean that you don’t know? I can not possibly advise you if you try
to deceive me,” said he.
“But I have told you everything.”
Holmes turned on his heel with a gesture of disgust. “Goodnight, Dr. Trev-
elyan,” said he.
“And no advice for me?” cried Blessington in a breaking voice.
“My advice to you, sir, is to speak the truth.” (A. Doyle 1986: 589)

The story that Sherlock Holmes has heard from Dr. Trevelyan (analogous for
the detective to the patient’s History of Present Illness), the evidence in the
room, and the primary emotion of anxiety demonstrated by Mr. Blessington’s
words, tone, and action all convince Holmes that Mr. Blessington is lying.
Holmes’s “diagnostic listening” takes in the story as a whole.
This story, “The Resident Patient,” demonstrates the power of narrative
and narrative knowledge in relation to diagnosis. Holmes has the advantage
of listening to the whole story that the young doctor shares with him, this
being analogous to the doctor who listens well enough to get the entire story
from his patient, including psychosocial issues. As in many of Dr. Arthur
Conan Doyle’s Sherlock Holmes stories, the discussion of the “method” of
detection and the presentation of the client’s narrative explaining the consul-
tation with Holmes occupy approximately 65 percent of this story—­we have
already touched on this in chapter 4—­while the final solution to the problem
and the conclusion comprise another 35 percent. The considerable focus on
narrative knowledge—­ for this is what Holmes’s “method” deals with—­
underscores our contention, as we have noted repeatedly, that the History of
Present Illness is the most important portion of the patient’s database, with
all the rest—­Past Medical History and Family History, Review of Systems,
Physical Examination, and Diagnostic Tests, including technologically so-
phisticated tests—­playing a lesser role. In Doyle’s story, the police, who get
called after the break-­in, have access only to a very short version of the nar-
rative and then misinterpret the signs they discover by focusing almost solely
on isolated facts rather than on the story and its circumstances as a whole.
With their dependence almost solely on physical evidence, they do not fa-
cilitate narrative telling by the victim (or victims) of the crime. Moreover, the
police do not attend carefully to the evidence of cigars at the scene of Bless-
ington’s death, and they therefore erroneously conclude that Blessington
smoked heavily during the night. Holmes discovered that Blessington
smoked Havanas and that the four cigars found in the room were from the

Doctors Listening and Attending to Patients  /  213

Dutch East Indies. This ratifies our earlier suggestion that the better diag-
nostician is the one who has a broader knowledge base, attends better to the
narrative and to physical evidence (especially in relation to the narrative),
and keeps his diagnostic options open longer.

Attending to the Parts

As well as listening to the story as a whole, both detective and physician can
be attentive to the details of the client’s (patient’s) story. As discussed in the
preceding chapter, Edgar Allan Poe’s story “The Murders in the Rue Morgue”
organizes itself around the detective’s ability to “hear” anomalous details
within the story of the crime. That story’s detective, Auguste Dupin, one of
the models for Doyle’s Holmes, is a very widely read and learned man. We
examined the language of this story in chapter 6, but Poe’s story, like Doyle’s,
is instructive on many levels that are analogous to the process used by the
physician to make a diagnosis. Dupin, like a good doctor, keeps his diagnostic
conclusion open long enough to collect the clues necessary to arrive at a re-
sult that is logical and coherent given all the data. In this story, the police
reach an erroneous conclusion because they take details of the narrative on
face value rather than being curious enough about the auditory evidence of
the six witnesses. Dupin’s listening is informed by the surprising fact—­he
calls it a “curious” fact—­that no witness was able to understand the so-­called
language that was heard, and his judgment is informed by his in-­depth knowl-
edge of the navy, orangutans, and the Parisian port.
The doctor’s listening with special attention to both the whole of a pa-
tient’s story and to the details (or parts) that make up that whole is even more
important in these days of limited time with each patient. Special attention
in this context has several meanings. First, the patient made the appointment
and, therefore, has an agenda; that is, first of all, there are both a “chief con-
cern” and a meaningful whole to the patient’s story that may or may not be
fully congruent with the details he presents. If the physician can learn to
listen to the patient’s agenda early in the encounter rather than to turn the
patient’s attention to the doctor’s own agenda, the time will be spent more
efficiently. Just as the police in Doyle and Poe bring their own agendas to the
events they encounter—­in Poe, they begin with the notion that there must
be a crime here; in Doyle, they begin with the assumption that there cannot
be a crime here—­so physicians often make their professional (and some-
times personal) agenda (or concerns) the governing framework of the
patient-­physician interview. The fact that the doctor is pursuing his own

214  /  the chief concern of medicine

agenda—­whether or not it reaches the level of conscious awareness—­might
account for the fact that physicians are sometimes faced with patients who,
after the initial interview, say as they are leaving the office, “But doctor, what
about this problem I’m having with my knee (or back, or headache)?”
As the physician is listening for the patient’s agenda, special attention
must also be paid to the emotional state of the patient. Often, such emotional
detail can be discerned in the patient’s tone, just as Dupin attends to the
sounds of the “languages” reported by the witnesses in “The Murders in the
Rue Morgue.” If this primary emotional state is anything other than
“acceptance”—­if it is angry, anxious, or sad—­the physician needs to address
the emotional state early in the encounter. This will provide the patient with
more clarity of thought so that the story the patient tells is as clear, detailed,
and coherent as possible, unencumbered with the stress of the primary emo-
tions, such as fear, sadness, or anger. Moreover, addressing the primary emo-
tion might also uncover the patient’s chief concern as it shifts the dialogue
from symptoms to caring. In any case, the achievement of narrative compe-
tence, as we have suggested throughout this book, can be taught and prac-
ticed through encounters with art narratives that, in the contexts of their
complexity and the rewarding pleasure and understanding they provoke,
help to develop and to habituate this special attending to the patient.

The Act of Communication

A useful way literature helps us to pay special attention to narrative is the fact
that it allows us to focus on the ways language works more generally. To have
a successful communication, Jakobson has argued that six elements are neces-
sary. (It is notable that in class, when asked, students always will come up with
the elements of Jakobson’s analysis. This is another example of the fact that
speakers seem to have an intuitive sense of the structures of sentences, narra-
tives, and speech acts even if they are not fully conscious of them.) First of all,
of course, an act of communication requires a speaker, somebody who’s talk-
ing—­in narrative, the teller of the story. A listener is also required. As we have
seen, A. J. Greimas notes in his actantial description of narrative that these
roles are performed by the Sender and Receiver. Moreover, this act of com-
munication always has a historical context, a moment when and a context in
which it takes place. Then there is a message that is being communicated
between the speaker and the listener. In addition, a language or vocabulary in
which to convey that message is required; Jakobson calls this the “code.” (This
is ideally a shared vocabulary, but one of the inherent problems in the patient-­

Doctors Listening and Attending to Patients  /  215

physician relationship is that the professional vocabulary of the physician is
notably different from the “ordinary language” of the patient.) Finally, some
kind of contact or medium between the listener and the speaker—­language,
gestures, ink, motion pictures, but also the tone of voice, as we already men-
tioned—­ is also necessary. In relation to doctor-­ patient relationships and
doctor-­ patient communication, this catalog is particularly interesting. In
doctor-­patient situations, the patient is a speaker or the teller, and the doctor
is a listener. The first thing that the doctor listens for is the message, whatever
it might be (e.g., “My head hurts”). But the other aspects of the act of
communication—­the context, code, and medium—­always play a part in this
communicative event, and doctors can pay more or less attention to them.

C ontext

M essage

a ddr esser ------------------------------------------------------------- a ddr essee

C ontaCt

C ode ----------------------- (1987b: 66)

Fig. 7.1. Roman Jakobson’s analysis of speech communication

Jakobson has diagrammed this catalog as depicted in figure 7.1. Jakob-

son’s six components are useful in describing the components of the special
communication that occur between a doctor and a patient; they create a
schema—­a list of the elements—­of communicative language that calls for
special attention. This schema is different from the salient features of the
narrative itself we describe in chapter 3, insofar as they describe not the ex-
perience of narrative but the act of speech communication. It should be
clear, however, that although we are distinguishing these elements from the
salient features of narrative, an act of narrative always participates in these
elements as well: it is implicit in the telling of narrative embodied in the sa-
lient feature of a teller and a listener. In chapter 3, we describe elements or
features of narrative residing, so to speak, within the “temporality” of the
story itself (i.e., what happens to the characters); here, Jakobson is describing
the “temporality” of the telling (i.e., the situation of the telling rather than of
the events described, implicit in the fact that narrative is articulated and re-
ceived). Skillful listening requires attention to both aspects of narrative, but

216  /  the chief concern of medicine

many people—­especially those trained to attend to the “facts” of positive
science described in chapter 1—­attend less habitually to the situation of tell-
ing than to the facts of the story.
Nevertheless, it should be noted that people attend to these things more
or less automatically in ordinary conversation: note how good we all are—­
even young children—­at understanding and responding to the tone of voice
as well as what is said.1 Here is a description, in Jakobson’s terms, of the act
of communication at the scene of narration in the patient-­physician encoun-
ter. Our description itself is a small narrative.

The Speaker (patient) has a Message (History of Present Illness), and the
Listener (physician) listens to the story. The story-­message is told in a Con-
text (both the situation of the visit to the doctor’s office and the larger psycho-
social milieu of the patient herself). The language is Coded, so that when the
patient is speaking, the code is that of the patient’s language, common speech
with its idioms, colloquialisms, slang, dialects. When the physician is speak-
ing, the code is likely that of professional language (jargon), the univocal
(usually Latinate) language of biomedicine that is one result of medical edu-
cation. Contact is a more difficult concept, but in a patient-­physician encoun-
ter, it may be as simple as touching, standing (vs. sitting on a bed), sitting
behind a desk rather than next to the patient, and so on.

This narrative of the teller and the listener, like all narrative in its events and
agents, presents, more or less explicitly, its end (or chief concern) to a witness
who learns; and when it is fully engaged, it provides experience as well as
information, particularly the experience of the act of communication we are
describing here. This last observation is of particular importance because it
allows physicians to reconceive their daily and often seemingly routinized
activity as an engaged and often enriching experience.
In any case, we can align this narrative description of Jakobson’s analysis
of the action of experience with the salient features of narrative. Literary
narrative—­perhaps most clearly delineated in a dramatic conception of
narrative—­might be viewed as communicating with the reader using the
same system. The Speaker (writer) sends a Message (the story, including rec-
ognizable characters, a sequence of events, and its end or “point”) to the
Listener (reader), with the goal of creating a witness who learns by means of
both the information conveyed and the experience provoked. The story-­
message is presented in a Context, the historical moment of the writing,
which usually includes reasonable assumptions about what a reader will

Doctors Listening and Attending to Patients  /  217

know (hence the many footnotes to “lost” information in older literary works)
and also, we are emphasizing here, the historical moment of the experience
of reading. The Contact can be understood as the medium of the narrative
(the prose fiction of novels, the patterned language of poetry, the visual ac-
tions of film, theatrical staging, etc.). The language of narrative is Coded,
both in terms of the diction—­the “embellished speech” and “ornamental
language” Aristotle describes in tragedy—­and also in the same manner as
verbal communication between individuals, including dialect, professional
jargon, colloquialisms, and slang.
Any communication always has all six of these elements, but different
literary works—­and, more generally, different discursive acts (e.g., a prom-
ise, a description, a joke)—­ask us to attend to different aspects or different
particulars of these elements. For instance, as we have seen, Dr. John Stone
ends his poem “He Makes a House Call” with the line “when you bled in my
hands like a saint.” The connection that line of poetry makes between saintli-
ness and the position of Stone’s patient ask us to pay special attention to the
message and to how the parts of the message relate to one another. It also
asks us to pay special attention to language or vocabulary (the code): what is
it that encourages a physician to use theological language when writing about
his patient? William Carlos Williams’s stories (e.g., “The Use of Force”), usu-
ally written in the first person, ask their readers to attend to the speaker.
Even the typography in his stories—­the lack of quotation marks—­blurs the
distinction between events and the speaker of events. Flannery O’Connor’s
stories, such as “The Lame Shall Enter First” or “The Artificial Nigger,” or-
ganize themselves in such a way that readers are forced to attend to their
own reactions: these stories emphasize attending to the “listener.” As we
have seen, at the end of “The Artificial Nigger,” sensitive readers suddenly
realize that Mr. Head, this hillbilly than whom they think they are so much
smarter, is capable of being saved and that readers are no “better” than he is.
In other words, O’Connor positions her readers in relation to her characters
in ways that force readers to attend to the response of the listener. Other
literary works emphasize other aspects of Jakobson’s model. For instance,
some literary texts ask us to focus on the context. In one novel we have dis-
cussed, The Woman Who Walked into Doors, Paula’s ongoing life story—­the
context of marital abuse—­that brings her to the emergency room physicians
is known to readers but not to the physicians themselves, and part of what
happens in that novel is that readers are shocked by the fact that the physi-
cians who encounter Paula are not able to see or hear the signs of the context
that the novel emphasizes in the extended narrative of Paula’s life.

218  /  the chief concern of medicine

 Jakobson’s final category is medium or contact. As suggested before,
there is experimental evidence that when physicians on rounds stop and just
put their hand on a patient’s arm, they get a different response than when
they stand and talk to a patient. Sitting down on the bed and touching, as
opposed to standing or sitting behind a desk, are what Jakobson means by
contact. This is very important for a narrative: this is why Brian Boyd empha-
sizes the “telling events” of narrative, which he describes as “an effortful pro-
cess we undertake only to direct the attention of others to events real or
imagined” (2009: 382). Our chief examples in this book have been literary
narratives, but there are other forms of narrative. For instance, films, a dif-
ferent medium from discursive literary narrative, can allow us to see the
power of contact, perhaps more than discursive narrative. In the film Phila-
delphia, for example, Tom Hanks plays lawyer Andy Beckett, who is stricken
by AIDS and fired from his job. In one remarkable scene between him and
his lawyer—­another “scene of narration”—­his lawyer visits him to take a de-
position after a costume party, and Beckett is dressed in costume and plays a
recording of an opera as they talk. As the soprano sings, Beckett translates
the Italian into English while the camera moves around him, so that it almost
seems as if he is dancing. All the different media in the scene—­dance, music,
words, interpersonal relations between Beckett and his lawyer—­are experi-
enced together as “media” of contact and create an emotional effect that is
probably the high point of that movie, when the lawyer suddenly realizes the
humanity he shares with this AIDS victim. It is a remarkable moment in the
movie, effected by the contact of the communicative act.
In any case, narrative, especially art narrative, asks us to attend to these
various things more intensely than we do in ordinary language. When people
talk in ordinary language, the aim is to communicate meaning, and once it is
communicated, the conversation is over. When a patient comes in to a doc-
tor, sometimes the conversation is over when the explicit meaning is com-
municated, but quite often all these other things—­the very acts of narration—­
need to be taken into account in order to get as much useful information as
possible from that encounter with the patient. Moreover, the act of narration
leads to what Rita Charon describes as focused action.
In fact, besides communicating information, another result of “special
attending” in the context of the patient-­physician interaction is patient satis-
faction. When the physician begins the encounter with the patient’s agenda,
or chief concern, listens carefully to the details of the story, and ends the
encounter by summarizing the story to the patient, the patient knows for
sure that the doctor listened and heard her story. This knowing is a form of

Doctors Listening and Attending to Patients  /  219

understanding—­or at least a form of contact—­between the doctor and pa-
tient, a cognitive and affective form of empathy. This feeling of being under-
stood leads directly to confidence in the physician and satisfaction with the
encounter. Literary narrative, as we have said, works to enhance the “special
attending.” As students read and discuss stories from literature—­as they dis-
cuss the message of a literary work, its context, its form of contact, its code,
and, above all, the interaction between writer and reader (speaker and lis-
tener) and the interactions between the characters within the stories
themselves—­they learn to expect interesting stories and often surprise end-
ings. As physicians become more competent at attending to literary narra-
tives, they become more competent at attending to the everyday narratives
of their patients’ stories, and they become able to use that competence to act
on the patient’s behalf. As they become more attentive, they also display—­
and often actually feel—­more respect for their patients. Both of these issues
will be taken up in chapter 9, when we examine ethical responsibilities of
physicians. Finally, in attentive listening, many physicians rediscover the mo-
tives that drew them to medicine and health care in the first place, the won-
derful and moving experience in the encounter with the patient and his story
where, as William Carlos Williams says, “under the language to which we
have been listening all our lives a new, a more profound language underlying
all the dialects offers itself” in an act of hearing and engaging realized narra-
tive (1967: 361).

Failing to Listen to Patients

Failing to listen to the patient with special attention is not uncommon but
has significant consequences. Paramount among those consequences is miss-
ing the diagnosis. Since the History of Present Illness (HPI) presents power-
ful diagnostic information, failing to listen well enough to “get it right” runs
a high risk of “getting it wrong.” Such failure can take the form of limitations
on listening or more positive “barriers” to listening that are somewhat paral-
lel to the story filters inflecting the patient’s story, described in the preceding
chapter. We will call these two phenomena “the failure to listen” and “the
inability to hear.”
One common cause for a failure of listening in terms of an inability—­or
at least a limitation—­of hearing is related to medical specialties. A specialist
is necessarily trained to possess well-­focused knowledge and experience—­in
a word, “attention”—­for the particular schemas of his specialty. This is a

220  /  the chief concern of medicine

powerful tool in the care and cure of patients, but it also creates the danger
of a physician’s not being able to translate what the patient presents in her
story into general, rather than specialized, medical understanding. This is
demonstrated in the following clinical account, which begins with an en-
counter between a patient and her gynecologist.

“Hi, I am Dr. Karen Peters.”

“Hello.”
“What can I do for you today?”
“I have a pain right here.” The patient points directly over her femoral
area on the right side.
“So, what is this pain like?”
“It begins as sharp pain and then it starts to ache. It stays there until I
change position.”
“Is it associated with your periods? Is it made worse by intercourse?”
“Uh, not really.”
Following the physical examination, with special attention to the pelvic
exam, the gynecologist reports, “Your physical examination is normal; I find
nothing wrong with you. You will be scheduled for an ultrasound to check
on your ovaries.” Following the ultrasound, she advises, “Well, I’ve done an
examination and an ultrasound, and I do not find anything wrong. I want
you to see a gastroenterologist.”
After the patient has a similar encounter with a gastroenterologist, an
upper endoscopy, and a colonoscopy, the GI consultant says, “I find nothing
wrong. No disease.” Frustrated by the fact that she has had two
consultations, two examinations, and three expensive procedures, with no
diagnosis, the patient consults a third physician, a generalist, who retakes
the history.
“Hi, I am Dr. Sarah Smith. What can I do for you today?”
“I have a pain right here.” The patient points directly over her femoral
area on the right side.
“So, tell me about the pain?”
“It begins as sharp and then it starts to ache. It stays there until I
change position.”
“Explain what you mean by ‘change position.’”
“When I sit, the pain begins immediately. The longer I sit there, the
longer it hurts. If I stand up, it begins immediately to subside, and if I lay
down, it gets a little better. But sitting is so painful that I had to quit my job
as an accountant.”

Doctors Listening and Attending to Patients  /  221

 “That must be a significant loss.”
“Yes it is; thank you for recognizing that.”
“Let’s do an examination and see what we find.”
Following the examination, Dr. Smith says, “The examination is normal,
but the pain is real, and I know it is badly affecting your life, not to mention
making you miserable from a pain standpoint. The pain is always in the very
same place and is affected by position. I want you to see a general surgeon,
because there is a very good chance that you have a femoral hernia and that
something is trapped in the femoral canal. Sometimes, when a person has
one of these hernias, the physical examination is normal, and the diagnosis
can only be made by doing surgery and looking.”
Following an examination by the general surgeon and an exploratory
surgery, the femoral hernia was identified, with a piece of omentum
trapped in the canal. Surgery completely relieved the patient’s pain.

In the preceding vignette, the first two doctors missed the diagnosis by
not listening carefully enough to the description of the pain in the patient’s
story. The first two doctors (specialists) followed the patient’s initial state-
ment (chief complaint) with directed questions investigating the systems of
their specialties. These questions investigated categories dictated by the spe-
cialties of the doctors rather than by the story of the patient. This error leads
to narrowing the differential diagnosis too early—­the same mistake made by
the police in the detective stories “The Resident Patient” and “The Murders
in the Rue Morgue.” Dr. Smith allows the patient’s story to do the work. Af-
ter the chief complaint, the doctor follows with an open-­ended question
about the pain. The patient’s story leads the way. In fact, at this point, the
patient’s information becomes a story, with a teller and a listener (indicated
by the doctor’s questions), a recognizable agent (the patient in pain), a se-
quence of events (pain, changing positions, moments of less pain), a point or
chief concern (loss of job as well as ongoing pain), a witness who learns (the
doctor’s assessment of a possible hernia), and even experience (the patient’s
gratitude for the doctor’s listening). Because the patient is allowed to stay
with her agenda—­the story that brought her in—­the description of the pain
is more complete. How the pain changes in response to position is the nar-
rated information that leads to the correct diagnosis. Dr. Smith is not biased
by special categories of disease in trying to understand the patient’s pain. In
this vignette, we can see that making the chief concern a formal aspect of the
HPI—­in this case, making the particular experience of the patient’s pain
explicit—­helps to realize it as a narrative that calls for deliberate listening.

222  /  the chief concern of medicine

 The clinical encounter just narrated has its counterpart in the Sherlock
Holmes story “The Resident Patient.” In that story, the police officer, Mr.
Lanner, notes that Mr. Blessington “has been driven out of his senses by
fright. The bed has been well slept in, you see. There’s his impression, deep
enough. It’s about five in the morning, you know, that suicides are most com-
mon. That would be about his time for hanging himself. It seems to have
been a very deliberate affair” (A. Doyle 1986: 591). As specialists, like the
gynecologist and the gastroenterologist, the police—­knowing, as they do,
that suicides are early-­morning affairs—­focus on particular parts of the evi-
dence without listening (or, in this case, watching) for all the evidence and
attending to the story as a whole. Doyle’s story allows us to see, so to speak,
the failure to listen on the part of the police.
Another cause of the failure to listen occurs when the physician “person-
alizes” the patient-­physician encounter so that patient emotion—­anger, sad-
ness, fear—­calls forth a personal, rather than professional, response. As we
have already suggested, human beings recognize and respond to emotion on
what we might call a very basic level, a deep brain level. If handled inappro-
priately, such an emotional response prevents the kind of attentive listening
that allows a physician to gather up the information of the patient’s story. In
chapter 5, we saw such “emotional” responses from physicians in William
Carlos Williams’s “The Use of Force” and Richard Selzer’s “Brute.” In both
stories, the physicians become enraged and abandon all decorum of profes-
sional response: “‘I have sewn your ears to the stretcher,’ [Selzer’s doctor
says]. ‘Move and you’ll rip ’em off.’ I do more; I wipe the gelatinous clots
from his eyes so that he can see. And I lean over him from the head of the
table, so that my face is directly above his, upside down and I grin. It is the
cruelest grin of my life. Torturers must grin like that, beheaders and opera-
tors of racks” (1982: 62). In Selzer’s story, the physician gets so caught up in
the emotion of the encounter that he forgets the context (the patient is
drunk), the message (“do no harm”), the contact (it is a patient-­physician
encounter), and the code (professional conduct). Above all, he forgets that
this is a relationship between two people (the silent speaker of the patient
and the physician listener), that of physician and patient rather than torturer
and victim. Yet while the character in the story is unmindful of all of this, the
story itself, in all its details, emphasizes these elements of narrative attention
for its readers.
The reader of this powerful short story is invited not only into the world
of medicine at its most base but also into the consciousness and actions of a
tired and frustrated physician. The reader witnesses the physician choose a

Doctors Listening and Attending to Patients  /  223

violent, dehumanizing act, rather than some alternative—­possibly insisting
on waiting until the patient is no longer intoxicated prior to suturing his fore-
head. This dehumanizing violence stems directly from taking the patient’s
words and actions personally. This “personalizing “of the words and actions,
rather than “professionalizing” them, results from responding to the patient,
his circumstance, and his story as a stereotype, rather than reflectively at-
tending to the patient’s story. The doctor’s actions, then, stem from the mean-
ings this stereotype holds in his mind. As William Carlos Williams tells us in
his Autobiography, “the difficulty is to catch the evasive life of the thing, to
phrase the words in such a way that stereotype will yield a moment of in-
sight” (1967: 359).
Another cause of the failure to listen is a failure of will—­a failure of or a
failure in the process by which one deliberately chooses one’s behavior. An
example of a failure of will is the physician who listens to the patient’s story
and fails to determine and take appropriate professional action—­the physi-
cian who fails to decide from competing choices that some action is required
in this particular clinical situation. There are many causes of a failure of will,
from sociopathic personalities, to drug and alcohol addiction, to depression
and other psychiatric diseases or simply time pressures that physicians labor
under. (While the physician in “Brute” has no failure of will but, rather, the
brutality of mindless willfulness, he still labors under terrible time pres-
sures.) Sometimes the failure of will is simply that the physician is too tired
to listen or succumbs to the competing needs of his personal life. In Atul
Gawande’s “case-­based” narrative presentation “When Good Doctors Go
Bad,” he describes a Dr. Goodman, an excellent orthopedic surgeon, who
over a few months’ time became careless and seemingly callous to patients’
concerns. Once, when confronted with a hot, swollen, tender postoperative
knee, Dr. Goodman ordered oral antibiotics instead of examining the patient
and performing the procedure that he knew to be indicated, arthrocentesis
(the insertion of a needle into the knee joint for the purpose of culturing the
joint fluid for infection) (Gawande 2002: 88–­106). This short narrative de-
scribes several instances where Dr. Goodman and others like him fail to re-
spond to the details of their patients’ stories—­their acts of narration—­in a
meaningful way. Worse, they miss the meaningful whole of the story and,
therefore, act in a manner totally inappropriate to the situation. This narra-
tive about good doctors who have gone bad itself creates a vicarious experi-
ence of failure for both physician and nonphysician readers—­allowing them
to reflect on their own behavior as listeners, professionals, and patients and

224  /  the chief concern of medicine

to situate themselves as witnesses who learn and ask the question about what
is missing in this behavior.
Listening to patients is a skill usually taught in earnest in the first two
years of medical school. However, studies have shown that by the time stu-
dents are in their final year of education in medical school, many of the skills
are worse than they were at the end of the second year. This most likely has
multiple explanations. Among them is the role modeling by resident physi-
cians in teaching hospitals, some of whom display some of the impediments
already described—­residents who are too busy, too routinized, too sure their
knowledge is far more important than the patient’s. (Note the behavior of the
resident, intern, and medical student in the story of the woman with ab-
dominal pain in this book’s introduction.) For all these reasons, they rush to
get just the pertinent information. The student often observes the resident
or attending physician ignoring much of the patient agenda, psychosocial
information, and details of presentation in order to hurry straight to the bio-
medical information that the doctor believes to be the goal of the exercise. In
addition, medical students find that they are too busy when working in the
clinics and in the hospital wards. The culture within which they are working
does not support the idea that taking the time to listen carefully pays divi-
dends. The rigors of their formal education do not provide sufficient time in
support of the idea that a patient’s knowledge—­often “narrative knowledge”—­
powerfully supplements their scientific biomedical knowledge. An explana-
tion of the decline in listening skills closely related to this is the fact that
medical students are exposed an increasing percentage of time to subspecial-
ists who approach the patient with the bias of their specialties. Examples of
this are seen in the previous case of femoral pain, where the gynecologist
looked for a gynecological disease and where the gastroenterologist looked
for a gastrointestinal disease. The problem here is that the epistemology of
medicine has developed along these specialty lines and not along the lines of
presentation by the patient. In other words, the patient does not “bundle”
the information in the same way that a specialist is listening for it. The stu-
dent, observing the behavior of the specialists they work with, learns to listen
for the information in specialty format and learns from her superiors that a
vast amount of the information that the patient feels is important simply is
not important and can be ignored.
As well as failures to listen, physicians often simply labor under an “in-
ability” to hear, as we already mentioned. (These observations of the ways in
which training decreases the ability to listen stand between our two catego-

Doctors Listening and Attending to Patients  /  225

ries.) Listening effectively requires being conscious of and taking into ac-
count the idiosyncrasies through which the patient is telling the story (see
“Story Filters” in the preceding chapter) and the biases that the doctor may
have while listening. Young physicians often have difficulty relating to elderly
patients. They find it difficult to understand the special circumstances in
which old people find themselves, such as limitation of physical activity, dif-
ficulty hearing, poor eyesight, and poor memory. The average medical
learner is twenty-­two to thirty-­two years old, while the patient population is
aging every year. It is logical that the medical student, resident, or young
physician will have difficulty understanding and, indeed, empathizing with
the older patient. The elderly patient is often a much slower historian than
the younger patient, and so the young doctor is ready to listen to the patient’s
history at a much more rapid rate than the patient is ready to tell it. This
leads to many mistakes in the listening process. These mistakes include cut-
ting the patient off, the use of leading questions, and ignoring many of the
psychosocial issues that are important to the patient. One important function
of narrative, as we have suggested, is that it presents a meaningful whole.
This may be most apparent in novels that trace characters’ lives over a long
period of time. A novel like Love in the Time of Cholera by Gabriel Garcia
Márquez, which covers lived life into the old age of its characters, is a good
case in point. If ever the vicarious experience afforded by literature is effec-
tive—­in chapter 9, we examine the ways in which literature creates vicarious
experience—­surely it is in teaching the young what age will force them to
acknowledge, what a lifespan looks like.
A final inability physicians constantly complain about is that there is sim-
ply not enough time to engage the rambling narratives of patients, especially
those of elderly patients. But to understand the usefulness of narrative and
narrative knowledge, as the story of Karen Peters indicates, suggests that
much wasted time can be saved with careful attention to the patient’s story.
The art narratives we have been discussing teach a species of respect for the
patient’s story: literary narrative—­even a short poem—­takes time, and narra-
tive in general requires both pause and reflection in order to gather up its
meaning. The pause narrative provokes is its patience and its promise that at
the heart of narrative, its disparate elements will constitute a meaningful
whole. Its reflection is the respect it demands of the story, for the storyteller,
the narrative’s concern, and the witness who learns. The physicians in “When
Good Doctors Go Bad” and in The Woman Who Walked into Doors were
men who had little time for their patients. These physicians neither paused

226  /  the chief concern of medicine

over their patients nor reflected on the context that brought them to their
respective patient-­physician encounters. They failed to listen and attend.
In the case of The Woman Who Walked into Doors, the physicians take
no account of the fact that Paula’s husband hovers nearby during the inter-
view and examination. In any case, Roddy Doyle represents Paula’s internal
dialogue as vastly different from anything the physicians hear from the pa-
tient. The physicians do not spend time facilitating Paula’s story, attending to
her person, and understanding the meaningful whole of her narrative. In
fact, the physicians she encounters—­like the gynecologist Karen Peters
encounters—­fail to encourage narrative altogether: they take no trouble to
get at her agenda that, the novel shows us, lurks just below the surface.
By means of its first-­person narrative—­remarkably rendered by a male
writer—­Doyle’s novel presents Paula’s below-­the-­surface concern and thus
suggests that it can be attended to. Internally, Paula is saying,

He pushed me back into the corner. I felt hair coming away; skin fighting it.
And a sharper pain when his shoe bit into my arm, like the cut of a knife. He
grunted. He leaned against the wall, over me. I heard the next kick coming;
my fingers exploded. Another grunt and my head was thrown back. My head
hit the wall. My chin was split. I felt blood on my neck. Again. Again. I curled
away to block the kicks. I closed my eyes. He kicked my back. Again. My
back. My back. My back. The same spot again and again. He was breaking
through my back.
The doctor never looked at me. He studied parts of me but he never
looked at my eyes. He never looked at me when he spoke. He never saw me.
Drink, he said to himself. I could see his nose twitching, taking in the smell,
and deciding. None of the doctors looked at me. (R. Doyle 1997: 185)

If, as we suggested, O’Connor creates a world in which the narrator’s lan-

guage and that of her characters do not coincide—­a disjunction of Jakobson’s
code—­then Roddy Doyle does the opposite: his main character provides a
shared language with the reader, and the inability of her physicians to elicit
her language, to even imagine she has a voice, creates the disjunction in his
novel between the two temporalities of narrative discourse, the time of the
narrated events and the time of the narration’s telling. The act of narration
that is plain to the reader is nonexistent for these physicians. Here is another
instance in which understanding the way narrative organizes itself and
experience—­even a shorthand understanding provided by the outlines of

Doctors Listening and Attending to Patients  /  227

schematic elements—­can help physicians attend to “nonpositive” evidence
of what is not said.
In some ways, the inability to hear is a function of the gender and class
filters we described in chapter 6, but physicians are also sometimes con-
fronted with a patient who represents, either in real terms or symbolically, a
disease process or situation to which they are personally or professionally
“blind” and “deaf,” as are the police in the detective stories or Abraham Ver-
ghese in his memoir The Tennis Partner. In The Tennis Partner, Dr. Verghese
befriends a senior medical student who has a past history of drug abuse and
is under watchful supervision for this addiction. The student becomes a ten-
nis partner and tennis instructor for Dr. Verghese. When the medical stu-
dent, David, begins to use drugs again, Dr. Verghese either does not see or is
“blind” to the drug use for a while. Even after learning of it, the doctor waits
twenty-­four hours before turning the student into the authorities at the
school. What is meant by “blind” in this instance is a form of denial. Some-
where in his past, the physician has had an experience that creates in him a
need to not see or hear meaningful aspects of the patient before him or of the
narrative he tells. This need may relate to an individual issue, such as Dr.
Verghese’s admirable need to believe in his friend, or a more widely social
issue, such as a disease with metaphorical significance (meaning beyond the
strict biomedical condition), like cancer. It may even relate to an aspect of
personal history, such as when a patient reminds the doctor of one of her fam-
ily members. This inability to access or recognize certain categories of illness
in the search for a diagnosis—­where certain categories are denied or blocked
because of selective memory—­is subtle but can create powerful bias. The
following vignette offers an example of one such denial by a physician.

Two medical students, in the context of a course on History and

Physical Examination were assigned a forty-­five-­year-­old man with “foot
drop,” a condition in which the nerve that causes the foot to flex upward
when one walks does not work properly, so that those muscles are
paralyzed. When the patient walks, his foot “drops,” and he appears to be
dragging it. The attending physician had already evaluated the patient and
knew him to be an alcoholic attorney who worked hard all day but drank
martinis every evening while sitting in a recliner with his legs crossed just
below the knee. He commonly passed out and spent several hours in the
same position. The attending physician knew this to be peroneal
neuropathy from pressure. The medical students, after finishing the

228  /  the chief concern of medicine

evaluation, which included a history and physical examination, returned to
the attending’s office to discuss the case. They had ascertained that
sometime over the past week, this man had noticed his foot had quit
working correctly and had come to the doctor to seek a solution. They had
duly noted that he was a forty-­five-­year-­old man who worked hard every day
as an attorney. Pressure neuropathy was not in their differential diagnosis,
nor was the possibility that he was an alcoholic. After some discussion with
the students, the attending was able to ascertain that both students were
twenty-­four years old and had fathers in their midforties, both of whom
were attorneys.

It is probably not coincidence or ignorance that led the two medical students
in the preceding vignette to fail at obtaining the important information con-
cerning the patient’s drinking habits. The patient’s similarity to both of their
fathers led to a need in each of them to ignore certain categories of disease
among the possible causes of the patient’s condition. Moreover, they also ig-
nored their own narratives, parallel as they were to the situation of the pa-
tient they encountered. Here, the failure to listen is created by the inability
to recognize that something was not being said by the patient and by the fact
that the category of alcoholism was not being considered. This form of denial
by a health care provider illuminates the need for the physician or any other
provider to attend to her own family stories. Denial is different from simple
ignorance, and the difference is that denial—­not seeing or hearing—­is the
goal or concern of its own unspoken narrative. As one reflects on the stories
of one’s own family of origin, important information is learned. (In checklist
1, “Self-­Appraisal Schema,” in appendix 2, we offer a procedure that focuses
on a closely related problem.)
In a manner similar to the process of gaining narrative knowledge through
reading, insight can be gained into the potential blind spots one might have
in dealing with others. These blind spots function through the process of
denial. The Tennis Partner presents the narrative of Dr. Verghese’s failing
marriage and, more obliquely, the need he feels for close friendship during
this trying time. This personal story contributes, at least in part, to his blind-
ness to David’s drug use, so that, in a manner, he cannot see or register the
suggestions of David’s drug-­related behavior. The “art” of art narrative, as we
have already suggested, multiplies patterns of events so that meanings arise
that might otherwise remain unnoticed. For this reason, The Tennis Partner
is a valuable text in exploring this issue of denial. Not only does the friend

Doctors Listening and Attending to Patients  /  229

and attending physician—­Dr. Verghese—­face the issue of denial of David’s
drug use, but David himself, the struggling medical student, as is usually the
case, participates in denial as a part of his illness.
Possibly no disease in the past half century has provoked more fear,
stress, and bias among physicians than HIV-­AIDS. The fear among the gen-
eral population has been palpable, the discrimination legion. In the early
portion of the epidemic, the mid-­1980s, physicians were alarmed and feared
infection by droplet, and thus many tried desperately to isolate themselves
from these patients. Not only did physicians and other health care workers
attempt, in effect, to quarantine themselves and their practices from these
patients, but they behaved reprehensively toward physicians who were car-
ing for them. Verghese narrates this experience in another memoir, My Own
Country. Of a hemophiliac patient who had contracted AIDS and was admit-
ted to the hospital in 1985, early in the epidemic, Verghese writes,

He was weak and ill, but food services would bring him his tray and leave it
near the door. There was no way that he could go and get it so it would just
sit there. And if he threw up, it wouldn’t get cleaned up. People would just
walk right past. Well, I knew it wasn’t right. I said something. I kind of got
into it with a few people.
To me, he was an old friend. I had to take care of him. There was no way I
was going to walk away from him. So I did. I took complete care of him and
it could not have made some of the other nurses happier. What I saw in them
disturbed me. I had considered them my friends, I respected them as nurses.
And I saw a side of them that I would never have seen in a million years, but
for AIDS. (1994: 105)

By making this behavior the focus (in part) of his narrative memoir, Verghese
is able to discuss action that is performed with the expectation that it would
not be noticed or discussed.
HIV-­AIDS can create a feeling of isolation for the patients being cared
for and for the physicians caring for them. When a team of physicians are
providing the care, as occurs at a teaching hospital, one commonly observes
the young physician caregivers isolating themselves from these patients,
spending less time with them than with other patients under their care. This
may also occur in the outpatient setting with any physician caring for patients
with AIDS. Many reasons explain these occurrences, among them the leg-
ends, myths, and—­encompassing these—­the metaphors that have developed
around this illness. Regardless of the reasons, the isolation is miserable for

230  /  the chief concern of medicine

the patients as well as for the physicians: it is an enforced silence, the erasure
of listening. It is the physicians’ responsibility to rectify this intolerable situ-
ation. The problem can be addressed head-­on, with discussion about the
patients and why we are avoiding them. It can be approached as a logico-­
scientific problem, with a trip to the computer to explore medical literature
on the subject, in search of an explanation. Or one can try a narrative ap-
proach to this primarily psychosocial issue.
Such isolation is often the result of stereotype, and one strategy to ad-
dress the isolation being felt by caregivers and patients alike is to have all
those involved in the care of the patients engage with an art narrative that
transforms, as Williams says, stereotype into insight. One such art narrative
is Raphael Campo’s poem “Manuel.” This poem provides the reader with
images of actions, concepts, motivations, desires—­a schema—­that are used
to reflect on a fictional patient. This reflection hopefully leads to insights that
are useful to a physician in dealing with his own patient.

manuel
In trauma 1 a gay Latino kid—­
I think he’s 17—­Is getting tubed
For respiratory failure. “Sleeping pills
And Tylenol,” I translated for him
As he was wheeled in. His novio
Explained that when he told his folks about
It all, they threw him out like trash. They lived
Together underneath the overpass
Of highway 101 for seven Weeks,
The stars obstructed from their view. For cash,
They sucked off older men in Cadillacs;
A viejita from the neighborhood
Brought tacos to them secretly. Last night,
With 18-­wheelers roaring overhead,
He whispered that he’d lost the will to live.
He pawned his crucifix to get the pills.
(Campo 1996: 67)

This poem provides the reader with a stereotype—­“a gay Latino kid”—­
whose life is narrated in images and narrative. The result is that the poet can
listen to and “hear” the patient even when he does not speak: the poem’s final
image of selling his crucifix to commit suicide gathers together elements of

Doctors Listening and Attending to Patients  /  231

this young man’s life to make it whole, a stereotype transformed into insight.
The religious imagery—­like that in Dr. Stone’s poem “He Makes a House
Call”—­gathers a whole person from within the miscellaneous facts presented
here. The gay Latino kid is stereotyped by his parents—­and, to some degree,
by himself—­as “trash,” while the poet transforms what the parents see as
trash into a whole that creates within the reader a type of empathy for this
young Latino boy who has decided not to live. This strategy of seeing the
person beyond the stereotype is precisely what health care workers failed to
employ in Verghese’s memoir and, in fact in the 1980s and later confronted
with the stereotype of AIDS.

Listening Strategies

Good listening is a skill—­a technē—­that can be taught and acquired. Multi-

ple techniques have been developed in many professional fields to enhance
listening skills. These include behavioral techniques, observation by experts
with detailed feedback to the learner. Others include attention to silence;
attention to particular words that, in the context of a patient-­physician en-
counter, carry more weight than their simple meaning; and attention to miss-
ing “characters” of a story—­as in the young patient’s history recounted in our
introduction, which mentions mother and siblings but no father. In addition,
active listening—­namely, repeating back the patient’s story to the patient—­
“re-­stories” the patient’s story, which Kathryn Montgomery Hunter describes
in her book Doctors’ Stories as “the third narrative act of healing . . . the
physician’s return of the story to the patient” (1991: 141). All of these
techniques—­detailed feedback, attention to silence and to words, filling in
“slots” of the narrative schema or pattern, and summarizing or retelling a
story—­are strategies that employ a conscious or unconscious sense that nar-
rative discourse is organized around particular recognizable schemas. En-
gagement with narrative is a strategy we will explore in some detail in this
section of this chapter. The encounter with and study of art narrative works
in several ways to make physicians better listeners, sensitizing them to the
concern of the patient, enhancing empathy, teaching special attention to dis-
cursive (“salient”) narrative features in patients’ stories. An important aspect
of good listening is the possession of what Rita Charon calls narrative com-
petence. This competence includes the ability to critically engage narrative
schemas and discern the themes and concerns, plots, time sequences, mul-
tiple perspectives, and attributes of character in narrative more generally.

232  /  the chief concern of medicine

Narrative Plots

Stories—­particularly patient stories—­frequently present the plot in a non-

chronological sequence. Thus Rita Charon and Maura Spiegel argue that

narratives that emerge from suffering differ from those born elsewhere (un-
less one argues that all of the business of existing is, to some extent, suffer-
ing). Not restricted to the linear, the orderly, the emplotted, or the clean,
these narratives that come from the ill contain unruly fragments, silences,
bodily processes rendered in code. The language is deputized to point to
things not ordinarily admitted into prose or poetry or text of other kinds—­
shameful, painful, prelingual limitations, absences, breath-­ taking fears.
(2005: vi)

In fact, such nonchronological sequencing has led to the discussion of the

two temporalities of narrative we have discussed, what literary scholarship
has sometimes formulated as the distinction between “story,” what happens,
and “discourse,” the manner and sequence in which what happens is pre-
sented. The discursive telling of the narrative in backward, unruly order and
in nonlinear sequences, with “prelingual limitations,” is often disorienting.
This is particularly true for the “linear,” Cartesian thinker. (One distinction
between the versions of “The Lady with the Pet Dog” by Anton Chekhov and
Joyce Carol Oates, discussed in the preceding chapter, is that Chekhov’s ver-
sion is presented chronologically and Oates’s is not.) Understanding such
disorienting stories requires special attention to time sequences, reordering
the events, and re-­creating the story in the reader’s mind in order to clearly
understand the concern, plots, and consequences of the actions of the char-
acters. Patient stories are always told in retrospect, given that the symptoms
have already been experienced before the patient tells his or her story to the
doctor. Often, as Charon and Spiegel note, patients do not present their sto-
ries chronologically—­they often get the sequence of events wrong—­because
of faulty memory, a heightened emotional state at the time of the telling,
anxiety or pain, or other reasons. It is the task of the listener to question the
patient, review carefully what she has heard, and ensure that the message
sent was the message received. This task requires careful listening that en-
compasses anticipation that the narrator may make mistakes, may misre-
member the details, and is occasionally disoriented in time.
Since the time of Aristotle and his Poetics, we have understood the plot
of a story to mean the actions within the narrative that determine conse-

Doctors Listening and Attending to Patients  /  233

quences and that illuminate the theme of the story and its meanings. The
plotting of stories presents or suggests causal relationships among the parts.
In modern narratives, much the same is true. Although the plots are most
commonly obvious, they are sometimes hidden, multiple, and complex. Pa-
tient stories present with symptoms, events. These are shaded by meanings
that the narrator (patient) has already attached to them. These narrations can
and often do misinterpret cause and effect, and they are commonly, as we
have seen, out of temporal order. The physician’s task is to listen carefully
enough to know all the actions but also to recognize, when the possibility ex-
ists, that a hidden plot is embedded in the story. Becoming competent at this
skill—­of attending or listening—­is the same skill of attending to what is con-
veyed in the language, how the words work. In Charlotte Perkins Gilman’s
“The Yellow Wallpaper,” the narration gives the reader information about
the patient’s rapidly deteriorating mental state, demonstrated in the projec-
tion of illusions onto experience and in the breakdown of her language
(shorter and shorter paragraphs). This plot in the story, the one that appears
to be on the surface, is obvious to all who read it: it is the plot of progressive
disorientation and delusion expressed (but not comprehended) by the narra-
tor. However, the issue of gender, the “trapped” feeling of the patient, is of-
ten interpreted as a hidden plot, that of a woman living in and oppressed by
a paternalistic marriage and society.

Widening Experience

One of the ways studying literature creates a more effective physician lis-
tener is by confronting him with issues that otherwise might not have yet
been experienced in his life, that, for this reason, have presented themselves
but were not otherwise attended to (in the way Dr. Watson sees but does not
apprehend the same things Holmes apprehends). The physician gains
experiences—­that is, “cases”—­that provide emotional responses to circum-
stances, events, and concepts that he otherwise would not have had. These
literary experiences can serve to sensitize the reader. The reader with these
experiences might be more aware of the events in narrative and their mean-
ings, might gain insight into social or personal phenomena, or might develop
empathy for certain situations or characters. This new awareness, insight,
and empathy may be available to the reader (physician)—­this is what Thomas
Nickles means by the “memory store” of cases and schemas (1998: 79)—­
when confronted by a character (patient) with a similar theme, plot, or cir-
cumstance in a patient’s story (HPI). As we have already suggested, there is

234  /  the chief concern of medicine

neurophysiological evidence—­the “mirror neurons” we mentioned (see Ia-
coboni 2009)—­that most humans are built to respond to other people’s pain
and suffering and that reading stories that contain pain and suffering sensi-
tizes readers, lowering the threshold for recognizing and, if you will, experi-
encing empathy for that pain; that is, there is a connection between having
read about the misery of the old man who has lost his son recently in Chek-
hov’s story “Misery,” empathizing with him in the story, and then seeing a
patient the next day in the clinic who has recently lost a loved one.
The functioning of the vicarious experience that literature provides—­
how it seems to work and how it is useful in terms of the practice of medi-
cine—­is very important. In chapters 3 and 5, we discussed some possible
neurological evidence for a species-­related sense of empathy and, by exten-
sion, vicarious experience. In any case, when people go to a comedy, they
laugh; if a person goes to a comedy by herself, there is much less laughter
than if there is a roomful of people, and neurology suggests, as a matter of
fact, that laughter is a communal kind of response (Deacon 1998: 419–­20).
One of the reasons that the earliest literary works were theatrical is because
communal responses feed on one another. But by the end of the eighteenth
century, the central literary forms were not communal but private, with peo-
ple reading novels and short stories and reading, rather than listening to,
poetry. Even in those circumstances, readers respond. Literature, through
the medium of language, provokes empathetic experiences. As we noted in
chapter 2, Marco Iacoboni cites a study that demonstrates that “areas in the
brain known to control the movements of particular body parts (i.e., the hand
or the mouth) were activated not only when subjects watched the movement
on video but also when subjects read sentences about the movement” (2009:
94). In relation to the practices of medicine, what does this mean? It means
that literature can afford people in general and physicians specifically at least
the illusion of experiences that they have not gone through and have not paid
for. One medical student we have taught said of The Spirit Catches You and
You Fall Down, “I have a sense of dealing with the Hmong people that I
didn’t have before I read this book,” and she went on to say, “I didn’t have to
spend two months in the hospital acquiring it.” In chapter 9 we analyze more
fully how narrative gives rise to vicarious experience.

Schemas of Language

Special attunement to the patient’s story helps the physician attend to the
psychosocial as well as the biomedical portions of the patient narrative. As the

Doctors Listening and Attending to Patients  /  235

physician hears certain words or the use of special language—­in fact, sche-
matic words and phrases—­she learns that some words have more “meaning”
or carry more affect than others. As we have seen in Jakobson’s system of
communication, these words with special meaning form a “code” of the mes-
sage between physician and patient. These words receive their meaning from
the emotional context or content connected to them in the mind of the pa-
tient. Each patient is unique. They bring to the encounter their own life lived,
their own catalog of experiences. Yet the categories of experience that consti-
tute these seemingly unique catalogs are based on what Raymond Williams
has called “the felt sense of the quality of life at a particular place and time: a
sense of the ways in which the particular activities [of life] combined into a
way of thinking and feeling,” what he repeatedly describes as a “structure of
feeling” (1961: 63) and what we might define as particular historically in-
flected schemas that condition as well as understand experience. In these
terms, this life experience, which is both unique and communal, creates the
context of each particular patient, which determines the emotional content
associated with words in the patient narrative. While personal experience
feels unique, the organizational forms of life—­the structure of social rela-
tions, the vocabularies of emotional experience, the horizon of what can be
thought and known—­are general rather than unique, and they can be classi-
fied into the more general schemas we have been discussing. In fact, such
structures and vocabularies and even the horizon of possible experience
come close to the definitions of schemas we presented in the introduction and
in the three categories of schemas outlined there and in appendix 3—­schemas
(1) for narrative knowledge, (2) for the medical interview, and (3) for action
and ethics. In the medical interview, such schematic vocabularies govern the
import of a small class of words that recur in patient stories. The physician
will make errors if he assumes the ordinary meaning of these words is all he
needs to attend to; therefore, he must ask patients to share their particular
meanings with him. (This responsive questioning is a particular case of con-
tact.) This set of words (or codes) embedded in a patient’s message—­which
experienced physicians have learned through experience and which, we are
arguing, less experienced physicians can learn through schemas—­possess
high emotional content; they are closely connected to patients’ chief con-
cerns. This special attention to the meaning behind certain words in a pa-
tient’s story can be learned by practice, observation, and feedback.
A common source of concern for patients is marriage and other long-­
term partnerships. Thus, in a patient’s narrative, words like marriage, wife,
husband, partner, and their equivalents are “hot words,” or schematic code

236  /  the chief concern of medicine

words, not only because these relationships are so important in our society,
but also because problems within these relationships are so common. Marital
and other long-­term relationships touch on an area of the patient’s psychoso-
cial life for which the physician may have difficulty listening. Difficulty may
come because of “blind spots” we have discussed—­perhaps marital problems
were prevalent in the physician’s family of origin or are present in her current
family—­or because the physician is uncomfortable discussing problems in
this domain of private, seemingly “personal” life. In these situations, the phy-
sician is unable to apprehend and respond to such schematic code words.
Also, so many types of discord can occur in a marriage that the physician
cannot be expected to have experienced many of them; therefore, he may
not feel comfortable with the discussion or may simply miss the cues. Finally,
in some narratives, as we saw in the account of the young woman with ab-
dominal pain in the introduction, the absence of such terms (in the young
woman’s case, father) must also be “heard” in order to fully comprehend the
patient’s story, and this fact further complicates the skill of listening.
Narrative cases and schemas—­the “stored memory” of cases and the
“slots” of schemas—­once again can fill the experience gap of those who feel
a need to be more competent in this area. Literature is replete with stories of
marriages with discord, dysfunctional families, even explicit violence. A spe-
cific example already mentioned, The Woman Who Walked into Doors by
Roddy Doyle, portrays a marriage between Paula, a poor, uneducated
woman, and Charlo, a poor, uneducated man who abuses Paula physically
and psychologically. Approximately 75 percent of this short novel is used to
develop the setting, the psychological state of the two main characters, Paula
and Charlo, and their families of origin—­in essence, the context. The main
plot of the novel erupts in the last quarter of the text. At this point, Doyle
develops the action in such a way that readers must witness the abuse—­
horrendous physical beatings—­as if they were present. The first-­person nar-
rator, Paula, screams her message for help in the novel’s portrayal of her in-
ner thoughts even when she does not speak. Moreover, in Doyle’s skillful
narrative language, the message filters through a fog of alcoholism. The mes-
sage is confusing, not least because Paula never mentions her marriage to the
health care workers she encounters. The reader is invited to reflect on the
question, why does this woman have no voice that can be heard? But even in
less violent and dramatic marital relationships—­those of Chekhov’s and
Oates’s versions of “The Lady with the Pet Dog,” Gabriel Garcia Márquez’s
Love in the Time of Cholera, or Gilman’s “The Yellow Wallpaper”—­a central
concern of the protagonists revolves around marriage.

Doctors Listening and Attending to Patients  /  237

 Another common concern of patients is their jobs. Problems with rela-
tionships at work can be devastating to people’s lives. A patient presenting
for an office visit who is experiencing difficulties in the workplace may tell a
story in which the employment situation is the most important plot in the
HPI. Whether it be injury on the job, interpersonal problems with a superior,
or coping with the inevitable workplace politics, the employment issue can
be the context of the communication between the physician and the patient
during a particular office visit. In this situation, the patient story may be plot-
ted around the work situation, or it may simply be focused on a biomedical
problem. Regardless, to avoid missing the issue altogether, the listener needs
sensitivity to the “hot words”—­schematic code words referring to the work-
place, fellow workers, and professional stress—­as they are expressed in the
patient narrative. The context of gender surfaces in relation to this situation
as well. Male patients are more likely than female patients to tell a story in
which employment difficulty is a hidden concern or an unspoken sequence
of events. In these instances, the “hot words” are unsaid and only hinted at,
and the hints are isolated words (boss or its equivalent, office, deadline, proj-
ect, etc.). A narratively skilled physician will likely anticipate the meaning of
such terms and be attuned to information that is unspoken yet implicit in the
patient’s story and its structure.
Another context within which a patient story can be told is that of the
patient’s finances. The schematic words associated with this are money, debt,
and other related terms. Money, the lack of it, and the issues of debt and lack
of resources are common sources of stress and concern in our society. Sensi-
tivity to these issues, like those of spousal difficulty or employment, is impor-
tant if the issue is to surface in the patient-­physician interchange. It is all too
easy for the physician to ignore the patient’s mention of financial concerns,
the fact that they do not have enough money, or that their family is making
serious choices about the use of resources, medical care among them. (The
central concern of the narrative vignette revolving around Beloved in chapter
5 is about money.) Making it difficult to ignore these psychosocial issues—­
these contexts, in Jakobson’s analysis—­that are part and parcel of the pa-
tient’s story is an important practical aspect of the work of narrative compe-
tence in medicine. The physician, as listener, can either receive the message
and respond to it or not. The narratively competent, empathic listener will
recognize the message as important—­as not simply auxiliary to the main,
biomedical message but an integral part of the patient’s situation and
concern—­and will respond appropriately. A good narrative example of this
issue—­embodying it as a case and suggesting the schema of its narrative

238  /  the chief concern of medicine

presentation—­is portrayed in a narrative we have already mentioned, Ferrol
Sams’s “Epiphany.”
The emotional “filters” we mentioned earlier and the three areas of the
patient’s personal emotional and family relationships, his daily work respon-
sibilities, and his general sense of financial insecurity are often aspects of the
patient’s chief concern, and a good listener should be alert to their explicit or
implicit presence within the HPI. But there is an additional, more general
category of schematic words that should trigger the attention of a careful
listener, that of metaphors, figurative language, and even euphemisms that
are used to describe events, objects, people, and situations. Diseases have
had metaphorical meanings in all recorded history in the West. The ancients
explained pestilences as magical, using the fable of Pandora’s box. The Judeo-­
Christian tradition explains suffering, illness, and disease as a part of the
original sin narrated in the story of the Garden of Eden. In recent history,
tuberculosis and cancer are two diseases whose relationship to humans have
been defined, to a large extent, by the metaphors our society has developed
about them. Susan Sontag, in her book Illness and Metaphor, describes tu-
berculosis as the illness of love.

The most striking similarity between the myths of TB and of cancer is that
both are, or were, understood as diseases of passion. Fever in TB was a sign
of an inward burning: the tubercular in someone “consumed” by ardor, that
ardor leading to the dissolution of the body. The use of metaphors drawn
from TB to describe love—­the image of a “diseased” love, of a passion that
“consumes”—­long antedates the Romantic movement.
[Moreover,] cancer is generally thought an inappropriate disease for a ro-
mantic character, in contrast to tuberculosis, perhaps because unromantic
depression has supplanted the romantic notion of melancholy. “A fitful strain
of melancholy,” Poe wrote, “will ever be found inseparable from the perfec-
tion of the beautiful.” Depression is melancholy minus its charms—­the ani-
mation, the fits. (1988: 20)

In that book and elsewhere, Sontag argues that metaphors create new reali-
ties that lead to new ways of comprehending the entities for which the meta-
phors stand. Thus there is a social code, shared by a particular generation—­
this is an aspect of Williams’s “structure of feeling” mentioned earlier—­that
often conveys concern in language that seems simply purely descriptive.
A schematic metaphor that both patients and physicians of our time use
to describe illness is the metaphor of war, in which diseases invade the body

Doctors Listening and Attending to Patients  /  239

and destroy its defenses. Such a metaphor creates a sense of “reality”—­a
negative version of the functional reality described in chapter 1—­in the mind
of the public, patients, and even physicians. This functional reality allows for
expenditures without limits, for that is our response to war. It creates a “real-
ity” in the minds of many that suggests victims of cancer have no good reason
to fight, because the enemy is too ominous and the battle too difficult to suf-
fer through. It also creates a sense that any palliative care at the end of life is
a form of surrender. Finally, it might suggest that the physician is the warrior-­
hero and that the patient is the passive homeland the physician defends.
These new realities are created not only for the patient with cancer but also
for the patient’s family and even for the physician caring for the patient. On
the one hand, the war metaphor has led to the situation where the cancerous
enemy should be fought against all odds, even when rational, informed deci-
sion making would suggest no treatment but, rather, a dignified death. On
the other hand, in the mind of some physicians, any patient with cancer is
someone to be avoided, since cancer represents the likelihood of a lost battle,
which the physician, the warrior-­hero, loses. In the situation where a physi-
cian avoids certain kinds of patients, the avoidance has been motivated, in
effect, by the code meaning developed around metaphors associated with
the term cancer. In a similar fashion, the term plague developed into a com-
mon metaphor early in the AIDS epidemic. Sontag writes, “Plague is the
principal metaphor by which the AIDS epidemic is understood. And be-
cause of AIDS, the popular misidentification of cancer as an epidemic, even
a plague, seems to be receding: AIDS has banalized cancer” (1988: 132).
Moreover, the term plague takes on political as well as social and religious
meanings. These metaphorical meanings develop faster in society than sci-
ence can provide explanations, creating misunderstandings and miscommu-
nications. In the case of the early AIDS epidemic, the codes through which
the epidemic was communicated to the public and within the medical pro-
fession contained words such as gay cancer, gay plague, death, and retribu-
tion from God. These metaphors delivered a message about this disease in its
early days that was very harmful to the patients and health care providers
alike.
As we have suggested, the metaphors for diseases—­the Jakobsonian code
by which meaning is conveyed—­are also important for the physician. How
the physician thinks and feels about the disease at hand determines, in part,
how he will treat a patient with that disease, how he will treat the suffering
of the patient with that disease. It has been suggested that the technical,
univocal language of medical education has a tendency to cause the practi­

240  /  the chief concern of medicine

tioner of medicine to lose the capacity to imagine the patient’s suffering. In
this case, the code of the communication between teacher and learner is so
logico-­scientific and technical that the student is unable to remember the
suffering of the patient. (This is a version of the fallacy of misplaced con-
creteness.) The language itself creates a distance between the physician and
his patient. The emotional connection to the suffering fellow human is cam-
ouflaged by the language of science. Not only have patients suffered because
of the illness and its metaphors, but physicians have suffered as well. Some
physicians have felt isolation from their peers for agreeing to care for these
patients, while other physicians are isolated from their patients because of
the meaning attached to the disease itself. The latter—­the separation of the
physician from his patient—­is a special kind of inability in listening. Listen-
ing, or attending, is impaired because the meaning created by the metaphor
justifies not attending; it justifies a kind of lack of caring. This justification,
which was “epidemic” in medicine early in the AIDS epidemic, is less of a
problem now but nonetheless still exists. (In hearing this sentence, a careful
listener might ask us, “Why are you using a medical term epidemic to de-
scribe a social situation? To what degree do you find it appropriate to de-
scribe social behavior in terms of biological disease? Why are you presenting
a moral judgment as if it were a simple—­albeit metaphorical—­description?”)
When used by patients, physicians, or society in general, metaphors cre-
ate a “new” reality by means of the ways they structure and organize experi-
ence and understanding. Metaphors are capable of doing this because they
serve as a kind of “code” in the metacommunication system of a society as a
whole. The flooding of society by a message consisting of terms like gay
plague, gay cancer, and retribution and verbs such as invaded, contracted,
and polluted paint a picture of this illness that is different from the scientific
picture of the infection. This message tells a narrative about the illness that
may have little basis in fact. In the case of AIDS, this new reality has religious
connotations, portraying the gay plague as retribution for sins. In Western
society, this happens when an illness is transmitted by sexual activity. As Su-
san Sontag has said, “plagues are invariably regarded as judgments on soci-
ety, and the metaphoric inflation of AIDS into such a judgment also accus-
toms people to the inevitability of global spread. This is a traditional use of
sexually transmitted diseases: to be described as punishments not just of in-
dividuals but of a group (‘general licentiousness’)” (1988: 142).
Finally, patients use more local metaphors in their histories as well, fig-
ures of speech that often function to hide or de-­emphasize a concern that
can be embarrassing, revealing matters that patients want no one—­not even

Doctors Listening and Attending to Patients  /  241

their physicians—­to know. As we have seen in chapter 3, Eric Cassell calls
this the “secret life” that is part of personhood and, possibly, a patient’s chief
concern (1991: 160). The areas of concern we have been describing here—­
long-­term relationships, employment, finance, emotional states, and even a
patient’s own evaluation of the illness suffered—­might themselves be ex-
pressed in such coded metaphorical language. In the face of the suggestions
or hints of concern and meaning expressed indirectly through metaphor, a
good listener will make what is implicit explicit with simple questions and
comments based on the figurative language a patient uses, such as

“What do you mean by that?”

“Can you describe that in other words?”
“Why do you describe your illness as a site of warfare?”
“It sounds like your job performance is creating stress.”
“It sounds like you feel guilty about your illness.”

Such questions and comments can make the patient’s chief concern explicit,
and they can help the physician understand the patient’s sense of what she
wants. Thus, for instance, a warfare metaphor, especially if it is explicitly
discussed as part of the HPI, can reveal that a patient wants to go to all
lengths in the face of illness; a plague metaphor can give rise to discussions
of a patient’s shame in the face of illness. In other words, through attention
to metaphors and “hot words,” the HPI can be transformed from a simple list
of biomedical information into a deliberative narrative event—­including not
only biomedical information but also a sense, between the patient and physi-
cian, of a shared response to the narrative in the service of health care.
One of the functions of art and literature is to make explicit both personal
and societal assumptions, mores, and ideas that are implicit determinants of
action and belief. As American society developed a judgmental view of the
AIDS epidemic, literature and film attempted to portray these judgments in
relation to other, cultural values. We already talked about Philadelphia, a
movie released early in that epidemic, that challenged the view of the disease
as being someone’s fault—­retribution. In another narrative, the first chapter
of Dr. Jerome Groopman’s Anatomy of Hope, entitled “Unprepared,” he nar-
rates his own experience of encountering a patient with breast cancer who
thinks the disease is retribution from God because of an adulterous affair. As
a fourth-­year medical student, Groopman assumes that the implicit meta-
phor that the patient conveys to him in this situation, that of a clergyman
dealing with a parishioner, should govern his action in relation to this patient.

242  /  the chief concern of medicine

A fellow Jew, the patient tells the medical student, “My cancer is a punish-
ment from God,” and the young student thinks, “Knowing her secret made
me feel complicit in her other life” (Groopman 1995: 12, 15). What Groop-
man failed to do as a young student was to understand the narrative situation
of this patient’s illness, the fact that what he calls the failure of hope ex-
pressed in her metaphor of punishment takes its place in a story, different
from that of adultery, that this patient cannot tell but does suggest. Toward
the end of this narrative, he says, “Brimming with new knowledge, I thought
I was fully ready to assume the care of people. I mistook information for in-
sight. While I was well prepared for the science, I was pitifully unprepared
for the soul” (23). In this particular case, the student has the responsibility to
share the patient’s story with her physician, his teacher. In fact, her physician,
Dr. Foster, did convince her to undergo chemotherapy, but the student
never knows how he was able to do so. One strategy that might have allowed
him to do so, which we are suggesting here, is to transform the “science” of
the biomedical information of the HPI into a narrative of concern that can be
deliberated explicitly in the context of his medical education.
As we have repeatedly noted, the patient story has positive information,
that which the patient utters, and negative information, that which the pa-
tient does not say. A narrative skill that is important for the physician-­listener
to possess, as it is for the literary reader, is to know when important informa-
tion is missing, when silence is used to convey meaning (rather than simply
being the absence of meaning) or when metaphors and incompletely struc-
tured narratives are used to suggest implicit meaning. The clues for these
implied concerns are nonverbal, emotional, indirect hints that reveal them-
selves in the explicit understanding of schemas of experience. Sometimes
patients use silence as the medium of interaction. This is the narrative begin-
ning of Williams’s “The Use of Force,” where the doctor is faced with a young
girl who literally will not open her mouth to be examined. In fact, she will not
open her mouth to speak, for fear her “secret” will be discovered. This is an
unusual, dramatic example of the use of silence by the patient. The patient is
not saying anything—­in the uses of metaphor and euphemism, he is saying
something else—­while the doctor is attempting to make a diagnosis. Listen-
ing in these instances encompasses all the senses and special attention.
If features of narrative—­character, sequence of events, two temporali-
ties, concern—­are important to listening, so are elements of poetry, espe-
cially the encounter with metaphors that poetry almost always occasions. The
condensed language of lyric poetry produces different frameworks or con-
texts in which the doctor’s listening can be understood. Dr. Raphael Campo

Doctors Listening and Attending to Patients  /  243

believes that teaching medical students, residents, and practicing physicians
poetry makes them better listeners. His experience is that teaching poetry
helps physicians and students create new and different categories of ques-
tions that they might want to ask a patient, thus creating a more attentive and
effective listener. In “The Couple,” a poem cited and discussed in the pre-
ceding chapter, Dr. Campo’s narration of the physician attending to both his
dying, hemorrhaging patient and his patient’s wife seems to take special no-
tice of the love between these people. “I watch them now, the way they love
across / the gap between them that their bodies make” is a line that poi-
gnantly presents the opposition between our physical lives and our relation-
ships, our sense of self, of “spirit”—­as Dr. Groopman says, “soul”; as Dr.
Cassell says, “personhood.” Biomedicine necessarily focuses on our bodily
lives, but it does so in the context/frame of the value of life more generally.
Attention to that context can easily be lost in the anxious need to heal the
body. What Dr. Campo’s poem does—­as does powerful literature more gen-
erally—­is to allow us and indeed sometimes force us to attend to that other,
less palpable side of medicine: love that maintains itself despite bodily de-
crepitude.
Good listening makes physicians better diagnosticians and promotes bet-
ter patient satisfaction. When physicians listen poorly or not at all, they run
the risk of missing the diagnosis, both of the illness and of what their patients
want. When interacting with patients with whom they cannot relate because
of some bias or lack of experience, they risk a poor-­quality history and a lack
of rapport and commonly lose the chance of developing empathy for the
patient’s suffering. The narratives and schematic strategies of narrative
meanings discussed here, distinguishable in short stories, novels, and poetry,
can help engender in the developing medical student and in the practicing
physician as well—­but also, as Robert Coles has noted, in the “law student,
or business school student, [in] every man or woman studying at a graduate
school of education or learning to be an architect” (1989: 159)—­the ability to
hear and discern within another person’s story their chief concern.

244  /  the chief concern of medicine

 part 3
Schema-­Based Medicine
8
narrative and medicine
Schemas of Narration

How shall I comprehend the life that is in me and around me? To do so, stories were
constructed—­and told, and remembered, and handed down over time, over the
generations. Some stories—­of persons, of places, of events—­were called factual. Some
stories were called “imaginative” or “fictional”: in them, words were assembled in such a
way that readers were treated to a narration of events and introduced to individuals
whose words and deeds—­well, struck home, or, as some of my students with studied
understatement have put it, made an impression that lasts “longer than a few hours.”
“Longer” for [one of my students] Richard turned out to be longer than he had dared
hope possible. Survival did not diminish his interest in the characters he’d met—­
[Thomas Hardy’s] Jude and [Ernest Hemingway’s] “old man” and Ivan Ilych and [Tillie]
Olsen’s elderly couple [in Tell Me a Riddle]. On the contrary, their presence changed the
shape of his life, prompted him . . . to keep certain texts at his side, stories that helped
him as he (in his middle twenties) went through his own story with growing hope.
—­robert coles, The Call of Stories (1989: 189)

Throughout Part 2 of this book, we were concerned with storytelling and

narrative—­with the patient-­physician relationship growing out of the en-
counter of storytelling, the patient’s narrative itself, and a doctor’s ability in
listening to narrative. Many experienced physicians develop types of
understanding—­phronesis, narrative knowledge, and logic of diagnosis—­
that, in their functional engagements with narrative and reality, are different
from and complementary to the biomedical knowledge of scientific explana-
tion. Such engagements with narrative are at the heart of humanistic under-
standing. This chapter reexamines the importance of narrative in the prac-
tice of medicine from the point of view of the ways in which the narrative
knowledge we examined in Part 1 informs that practice. It then offers an
account of everyday narrative and literary narrative that suggests, more fully
than we did in chapter 3, how the development of systematic guidelines that
grow out of an analysis of narrative focused on the agents and actions of nar-
rative discourse can help physicians and other health care workers serve

/  247  /
their patients and profession with greater care and, perhaps, more fully dis-
cover on a daily basis the rewards of their engagement with patients.

Practices of Medicine and Narrative

As we have argued throughout The Chief Concern of Medicine, the particu-

lar information obtainable through narrative is of direct, practical usefulness
to the physician. As many studies have shown and we have repeatedly men-
tioned, the History of Present Illness (HPI) is the most powerful diagnostic
information for the physician, and the ability to attend to the narrative infor-
mation presented in the HPI is of great practical use in the treatment of pa-
tients. Dr. Rita Charon nicely describes this in terms of “honoring” a narra-
tive in an interview.

This interest we [medical educators pursuing “narrative medicine”] have in

narrative knowledge and narrative methods is not an abstract, scholarly inter-
est alone. It’s a very practical interest. There is a very concrete, direct rela-
tionship between narrative knowledge and clinical action. Indeed, we are
interested in helping our students and doctors understand things for their
own purposes. We’re even interested in helping them reflect on their experi-
ence and feel better for it. I’m happy when my students or the doctors who
study with us feel better by virtue of their narrative training, but that’s not
enough. My goal in giving them narrative training is to enable them to act
more effectively with their patients. So, the increase in the narrative skills of
recognizing there’s a story to be heard, eliciting it, being curious about what’s
unsaid, putting it together in some way, trying provisional hypotheses to see
“Did I get this right?,” and being moved oneself by what’s heard, all of these
things culminate in the doctor then being able to act on the patient’s behalf
with more vigor, with more purpose, with more investment than they other-
wise would.
I talk sometimes about how we have to honor the narratives we hear, and
this is a very active thing. People tell us very private, frightening things about
themselves, and we, because we have skill and also because we have power,
are privileged to hear these things. Sometimes they are things we don’t want
to know about, like child abuse; nonetheless, we hear about these things. We
have duties toward these things we hear, and for doctors, I think there are
twin duties. One duty is to honor what’s been said, which is to say, not to
trivialize it, not to dismiss it, not to forget it; and then we have the duty to act.

248  /  the chief concern of medicine

 By virtue of knowing what I now know, what must I do? I think this is where
narrative training increases the professionalism of doctors, yes? (Vannatta,
Schleifer, and Crow 2005: chap. 4, screen 8)

In her experience as a practicing physician—­as in the professional expe-

riences of many seasoned physicians—­Dr. Charon has found that the effec-
tiveness of her work in medicine is significantly increased by the possession
of particular skills (technē) related to narrative. Specifically, she notes par-
ticular abilities in relation to narrative that can serve the patient-­physician
relationship and the practice of medicine:

the ability to recognize a story (which includes the ability to elicit it);
the ability to identify unspoken parts of a story—­that is, parts of a story
that the general organizational schemas of narratives require even
when a narrator fails to make them explicit;
the ability to arrange or rearrange the elements of a story in order to “put
them together” and suggest a hypothesis that grows out of their reor-
ganization;
the ability to “be moved” by the story that leads both to respect for the
patient and (closely related to what we mean by “respect”) to the felt
necessity to pause and reflect on the story/person apprehended as a
whole;
and, finally, the ability to initiate focused action on behalf of the patient
based on the apprehension of the possible (“hypothetical”) wholeness
of his or her condition and the actual wholeness of the patient as a
person.

All of these abilities are related to the defining fact of narrative: namely, that
narrative allows the apprehension of complex wholeness of phenomena—­of
events, situations, and even personhood and identity—­in terms of the rela-
tion between parts and whole. As Paul Ricoeur has noted in his magisterial
Time and Narrative, narratives allow us the “apprehension of wholeness so
that circumstances, ends and means, reversals of fortune, and unintended
consequences come together to seem complete and whole” (1984: x). This is
particularly true for literature, in which, for instance, the tragedy of Oedipus
is whole in that the circumstances, initiatives, and reversals of that dramatic
narrative come together to provoke pity for the human sufferer, terror at the
state of affairs that creates or allows such suffering, and recognition borne of
the purging of these feelings or their purification or the clarification of the

Narrative and Medicine  /  249

incidents and situations that give rise to them. It is also true for the narration
of events in history, the organization of conceptual knowledge in philosophy,
and other modes of humanistic understanding. In addition, it is true for med-
icine, in which, as Dr. Charon implies, events, circumstances, and complica-
tions can be apprehended as the meaningful whole of a particular disease or
biomedical condition.
Implicit in the apprehension of the meaningful whole of storytelling is
the first element of narrative Dr. Charon discusses, its recognition. This is
closely tied to a salient feature of narrative we have already described, that
narrative gives rise to a witness who learns. Later in this chapter, we return
to Aristotle’s early systematic accounts of narrative, his discussion of tragedy
in The Poetics, which examines the “recognition” that accompanies the best
tragedies, the manner in which the tragic hero (e.g., Oedipus) suddenly rec-
ognizes the sequence of events that befalls him as a single, concrete complex
of relations—­as a meaningful whole. The Greek term for recognition, often
used in The Poetics, is anagnorisis. Later writers, such as James Joyce, sug-
gest that the recognition can be the reader’s along with or instead of the
character’s. Joyce used a liturgical figure to describe this recognition: he
called it an “epiphany.” As we noted in chapter 5, recognition is a central ele-
ment in the development of empathy.
The second element of narrative Dr. Charon notes is the way in which
narrative teaches us to attend to what is unsaid and unspoken in the patient’s
story. It does so because the experience of narrative is conditioned by sche-
mas; that is, narrative has a recognizable structure that governs recognizable
features so that, in a manner very different from positive science, we notice
what is not there along with what is there. We have already seen how Dupin,
talking to the narrator, and Holmes, talking to Watson, pride themselves on
their apperception of what is unsaid and how a writer like Flannery O’Connor
is able to provoke a gut feeling that something is missing. O’Connor is able
to do so by creating a story where some expectation—­a narrative expecta-
tion, conditioned by narrative schemas—­is left unfulfilled. It might be that
one of the narrative features we described in chapter 3 is not fully articu-
lated. It might be that one of the six elements of communication Jakobson
describes is not adequately functioning. It might be that the provisional ge-
neric resolution determined by the end of narrative we discuss in this chap-
ter is not fulfilled. In any case, at the end of “The Lame Shall Enter First,”
for instance, Mr. Sheppard comes to the realization—­satisfying for readers
who have identified with him—­that he has learned from his experience, that
he will become a better father. The communication has been “successful”:

250  /  the chief concern of medicine

the protagonist has listened to his experience; there has been closure. When
readers learn, after this “false” ending, that Mr. Sheppard’s son has killed
himself, the shock is created by both the inadequacy of the listening and the
missing of the plot resolution called for by a story such as this—­the sche-
matic or generic structure of a narrative of “recognition and redemption.”
Later in this chapter, we look more closely at how narrative organization and
structure create particular kinds of expectations and how a schematic outline
of such organization can tutor busy doctors to apprehend the unsaid.
Narrative lends itself to the third ability of great practical use to physi-
cians that Dr. Charon describes, hypothesis formation—­the attempt to for-
mulate a theoretical whole that can account for all of the parts. When a phy-
sician attempts systematically to figure out the underlying condition or
conditions giving rise to a patient’s ailment, she is participating in hypothesis
formation, the logic of abduction we examined earlier. Such figuring is im-
plicit in literary narrative and is often made the explicit organizing principle
of narrative, as in detective fiction. It is also present in the attempt to formu-
late the particular genre of a story. It is the nature of narrative to suggest one
or more comprehensive understandings—­one or more provisional wholes—­
that are implicit in the parts collected together. Thus we can always ask of a
narrative whether it is a tragedy, a melodrama, a comedy, or even a narrative
that leaves us with a sense that it can be understood in a limited number of
different ways. Earlier chapters have touched on the relation between hu-
manistic understanding and encounters with ambiguity. Later in this chapter,
the systematic ambiguity that narrative presents and helps us to understand
is examined. That discussion suggests that the hypothetical generic whole of
a story can be understood in relation to the actors in a narrative as well as its
action and that, in either case, it often leads to the discovery of a thematic
formulation for discovering the chief concern of the narrative and the narra-
tor in ways that can help physicians determine what all the symptoms that a
patient presents mean and, at least equally important, what form the focused
action in response to this illness should take. In this way, hypothesis forma-
tion is an example of a powerful link between medicine and narrative.
The skills or abilities that narrative fosters—­the technē associated with
narrative—­that can contribute to the effectiveness of the physician focus on
the chief concern of the patient’s story: they involve recognition of the story,
attention to its unspoken as well as its spoken elements, and the creation of
hypotheses concerning its whole meaning. The next quality of the storytell-
ing encounter between patient and physician—­and, more generally, between
teller and listener (the Sender and Receiver of a message, to use more tech-

Narrative and Medicine  /  251

nical language)—­helps define the relationship that arises between them.
This aspect of narrative understanding—­an aspect of narrative that comes
with experience and training—­is the important skill that narrative fosters in
interpersonal relationships (e.g., that between physician and patient), creat-
ing achievements in attention, recognition, and honor—­the skill of reflection.
Such reflection—­the ability to grasp retrospectively a meaningful whole of a
situation or a series of events by pausing to bring our own experiences (in-
cluding “experiences” tutored by case-­based schemas) to that situation—­is
the achievement of the phronimos, a person who has achieved the practical
reasoning and practical wisdom of phronesis. This might well be one of the
most important effects that narrative teaches or fosters in physicians. It is
certainly the skill that the necessarily intense hurry of the practice of medi-
cine most militates against.1 Stories, Dr. Robert Coles repeatedly says, “give
us pause.” Coles tells the story of “a hitherto quiet student” speaking up
about a short story by Flannery O’Connor: “His student tells the class that
just to mention that Flannery O’Connor” shows us as we read “that we can
be as smug and blind as the characters in her stories—­[just to mention this]
is to take a step. I don’t think we can stop there, though. ‘Look at us, what we
are doing in this class, the way we’re talking and confronting ourselves!’ . . .
He stopped there, [Coles goes on,] leaving all of us also stopped—­in our
tracks” (1989: 127).
Dr. Coles repeatedly returns to the pause of reflection that encountering
narrative—­especially literary narrative—­encourages. Throughout The Call
of Stories, Coles tries to analyze narrative, describe its effects, and articulate
its goals in terms of the reflection it enforces.

After a long silence, we gradually mustered a willingness to take chances. We

pointed out to one another that a story is not an idea, though there most
certainly are ideas in stories; that reading a story is not like memorizing facts.
We talked of the mind’s capacity to analyze. This capacity—­to abstract, to
absorb elements of knowledge, and to relinquish them in statements, verbal
or written—­is an important part of what we are: creatures of language, of
symbols galore. But we need not use ourselves, so to speak, in only that way.
We have memories; we have feelings. We reach out to others. We have the
responsiveness that one sees in preliterate infants who cry when others cry,
smile when others smile, frown when others frown. . . . That side of ourselves
is not set apart from our intellect. In order to respond, one remembers, one
notices, then one makes connections—­engaging the thinking mind as well as
what is called one’s emotional side.

252  /  the chief concern of medicine

 How to encompass in our minds the complexity of some lived moments in
a life? How to embody in language the mix of heightened awareness and felt
experience which reading a story can end up offering to the reader? (1989:
127–­28)

The meaningful whole of narrative—­the encompassed complexity of some

lived moments in a life—­occasions a reflective pause in which incidents and
events are gathered together to account for an emotional response, to under-
stand ongoing experience, to motivate subsequent action. (These are the ele-
ments of attention, recognition, and honor that narrative fosters.) “The whole
point of stories,” Coles says, “is not ‘solutions’ or ‘resolutions’ but a broaden-
ing and even a heightening of our struggles” (1989: 129).
The experience of narrative—­with its salient features, its particular kind
of knowledge, its structures, its forms (genres), its ambiguities, its surprises—­
calls for and teaches certain modes of attention. Thus Coles’s teacher, Dr.
Alfred Ludwig, pointed out to him that

our questioning . . . had its own unacknowledged story to tell—­about the way
we looked at lives, which matters we chose to emphasize, which details we
considered important, the imagery we used as we made our interpretations.
If our job was to help our patients understand what they had experienced by
getting them to tell their stories, our job was also to realize that as active lis-
teners we give shape to what we hear, make over their stories into something
of our own. (Coles 1989: 19)

Here, Coles is describing “reflective attention” that, above all, attends to the
interpersonal aspect of the patient-­physician relationship that arises in the
scene of narration. When we listen to stories, we listen both to the speaker
and also to the elements of narrative we have discussed; we listen to the two
temporalities of narrative. For this reason, stories are able to shape experi-
ence and, as Coles says, to be shared in their retelling.
It should be clear from this account of narrative that puts recognition
and reflection at its center—­an account we have pursued throughout this
book—­that narrative is particularly structured to provoke empathetic un-
derstanding. A corollary of the recognition that narrative occasions is that
when it is most powerful, it becomes so by being “earned” by the author and
the audience. Certainly, this work is a significant part of what Dr. Ludwig
means by “active listening.” Thus Coles reports being told by one of his
students,

Narrative and Medicine  /  253

 “I’ve read [Agee’s] Death in the Family; I’ve read a lot of Dostoevsky—­Crime
and Punishment and The Brothers Karamazov, both for the second time. I
keep reading and keep thinking about what those writers have to tell me
about life and death. I think of the old fisherman [in Hemingway’s The Old
Man and the Sea], trying to get one more big one, and fighting it out with the
sharks, pulling on it [the marlin] and taking it in, finally, even though his skiff
is half destroyed and the fish mostly eaten by the sharks, and coming into
port with it. I wonder whether I’ll win my big struggle with ‘it’! I’m trying to
rope ‘it’ in; I’m trying to prevail, and I might just not be able to win; but I
have no choice but to keep trying. I get preachy with myself, as you can see.
I wish I could talk—­talk to myself—­like a good storyteller: no sentimentality,
only emotion that I’ve earned, that my life has earned. I feel really inade-
quate, compared to that ‘old man’ of Hemingway’s, or to Jamie [in Walker
Percy’s The Last Gentleman]. Jamie and I are about the same age—­two
young men who’ve got cancer. He died of leukemia, I think. ‘A powerful
death bed-­scene.’ That’s the kind of talk I used to love! Now—­well, I think of
Jamie, and I picture the sweat on his forehead, and I feel it on my own, and
I can see him lying there, stoic and decent, and I hope to God I’ll have some
of that silence, that acceptance, in me when the time comes, and it could be
sooner than I want to think.” (1989: 187)

For this young man, Richard, part of his recognition and empathy is that the
stories he encounters are not adequately accounted for by cliché (“A power-
ful death bed-­scene”). “A powerful death bed-­scene” is a thematic sum-
mary, comparable to a cliché like “Have a nice day!” but also to the stereo-
types of class that William Carlos Williams describes or to the labels used in
such expressions as “He’s a hypochondriac” or “the polyarteritis nodosa in
room 5.” Clichés, stereotypes, and labels describe narrative meaning with-
out a strong sense of what James Joyce calls “whatsoever is grave and con-
stant in human suffering” (1966: 204), which narrative helps us to see and
comprehend.
Still, the label “the polyarteritis nodosa,” like the “sweat” on Walker’s
character’s forehead, might well also mark a powerful, empathetic recogni-
tion insofar as the term functions as a particular role in narrative—­the role,
we mentioned in chapter 3 and shall discuss more fully here, of the “oppo-
nent” with whom the patient, with the physician’s help, struggles. Jamie’s is a
powerful death bed-­scene, but simply labeling it, rather than actively engag-
ing his situation, easily functions to dismiss his suffering. Narrative cliché is
a stark example of the ambiguity that life stories—­including patient stories—­

254  /  the chief concern of medicine

present: cliché can be (and often is) dismissive, but it can also command re-
flective thoughtfulness that allows us to see the authentic human situation
that we share with others to be “unpacked” from cliché. After all, we do want
the strangers we encounter to wish us well—­to wish us a nice day—­though
we do not want those wishes to be automatic and thoughtlessly indiscrimi-
nate. Narrative creates the possibility of making labels authentic by embed-
ding them within the details of the narrative drama we share. This is why
William Carlos Williams profoundly notes that his writing and doctoring to-
gether helped him to transform “stereotype . . . [into] a moment of insight”
(1967: 359).
The final ability arising from narrative that Dr. Charon describes is fo-
cused action: storytelling and story listening culminate, as she says, in “the
doctor then being able to act on the patient’s behalf with more vigor, with
more purpose, with more investment than they otherwise would.” Focused
action responds to the patient’s story: it must recognize the story as story,
supply the unsaid as well as the said, put it together as a hypothetical medical
story, and pause and reflect on the human suffering that we all share in,
sooner or later, and that is always part of patients’ stories and doctors’ stories.
Such action also has to acknowledge the dynamic nature of disease, healing,
and caring. Illnesses have beginnings, middles, and ends, and focused action
can give the “narrative” of disease an ending different from what it might
otherwise have, whether it be the new end of the restoration of health (as in
the following case of thrombotic thromocytopenic purpura), the reorganiza-
tion of living (as in many of Oliver Sacks’s case histories), or palliative care (as
in Ivan Ilych’s realizations about himself as he dies). Most important, as
Charon notes, the patient’s story is a telling that, most explicitly of all narra-
tive telling, demands action as well as understanding.
The following vignette presents the case history of a patient with throm-
botic thromocytopenic purpura and the case history of the physician who
treats her.

A young internist picks up the telephone to call his older colleague,

really his mentor. He is thrilled to present the story of the most exciting
patient he has seen in his young practice. She’s a forty-­eight-­year-­old
woman, presenting to the emergency room since she doesn’t have a primary
care provider. Her chief complaint is that she’s “really tired, doesn’t have
any energy.” The young internist, just eighteen months out of residency, is
eager to take on a diagnostic and therapeutic challenge. The emergency
room doctor has told him she needs admission to the hospital because her

Narrative and Medicine  /  255

hemoglobin (red blood cell) count is very low (at 6 grams per deciliter).
Severe anemia—­this is a wonderful problem for a young internist, who has
just finished learning every cause in every category of the anemia for his
exams. He’s excited. He will uncover the secrets of this suffering; he will be
the hero of this little story; he will shine before his mentor. After a brief
discussion, it is decided that the elder hematologist will see the patient that
afternoon and talk over the case with the young doctor.
The patient was pleasant and smart and gave an excellent history. She
said that she has felt fatigued over the past three or four weeks. She also
noticed a few bruises on her skin she hadn’t seen before. Along with her
anemia, the tests showed that her kidneys were functioning at only about 30
percent of their normal capacity: she was also in acute renal failure. The
young doctor put these findings all together into a disease pattern and knew
that he had to view the blood cells himself. In the lab, he saw the telltale
red blood cells smashed and broken into pieces. This can only be caused by
an artificial heart valve, clumsily pumping the blood, or by small clots
formed in the tiniest of capillaries throughout the circulatory system. He is
so excited at these rare findings, it is hard for him to remember the patient.
How does he convey the seriousness of the disease and hide his elation at
being on this case? In the library, he reviewed the differential diagnosis of
“schistocytes” (red blood cell fragments). He had remembered it right:
artificial heart valve and microangiopathic hemolytic anemia. She doesn’t
have a heart valve: it’s the microangiopathy. And the kidneys are clearly
involved, especially if he can prove that her kidneys were normal prior to
several weeks ago. The bruising is a result of the fact that the platelets are
clotting in the capillaries faster than the bones can make new ones.
This must be thrombotic thromocytopenic purpura, a disease
characterized by a group of five findings. They are (1) microangiopathic
hemolytic anemia, (2) thrombocytopenia, (3) renal disease, (4) neurological
involvement, (5) fever. The young doctor knows that the patient had the
first three. But what can be done about the lack of neurological
involvement and fever? Back in the emergency room, he couldn’t tell her
that he thinks but isn’t quite sure that she has a potentially very serious
disease. She only has three of the criteria. He repeated the neurological
examination, and it was totally normal. She wasn’t febrile at the moment,
and she wasn’t sure if she has had fever in the last few weeks or not. He’s
not sure. He told his patient he is going to consult a hematologist, one of
the smartest doctors he knows.

256  /  the chief concern of medicine

 “What do you think the diagnosis is?” the older man asks. The internist
hesitates. “I’d like to call it TTP. But there’s no fever and no neurological
symptoms. Williams’s Hematology reminds me that TTP is a syndrome with
five characteristics. This patient only has three for sure, so I can’t say for
sure it’s TTP. It could be other things. Hemolytic uremic syndrome looks a
lot like it, but that’s almost always in children and usually simply gets better.
With TTP, there’s an 80 percent mortality rate without aggressive
treatment.”
The longer the internist tells the story to his mentor, the less sure he is
about the diagnosis. He goes back to the library. He will see his mentor
again tomorrow. He learns more about the proper treatment of TTP but is
no surer that this is a case of TTP. The next day, the senior mentor and the
young internist find the patient with a fever of 100 degrees and feeling very
poor. In the hall outside her room, the mentor asks, “What do you think is
going on?” The young doctor says, “Well, she is clearly hemolyzing her red
cells and consuming her platelets. Her kidneys are involved, and I’m going
to have to begin therapy for acute renal failure. But I’m afraid to begin
aggressive therapy for the TTP until she satisfies all five of the diagnostic
criteria.” The senior physician looks at the young doctor knowingly. “Wait
another day or two,” he says, “and she’ll be so sick that she’ll probably
satisfy all five: she’ll be sick enough to die, so she’ll have that criterion as
well.” The young doctor is horrified. He has just learned that illness tells a
story too.

Just as Paul Valéry’s definition of poetry asserts that “the sole purpose of
the poem is to prepare the reader for its climax,” so the physician must be
attentive in his or her focused action on the dynamic nature of illness—­the
fact that it is a sequence of events, exhibits recognizable features, and moves
toward an end. The preceding case history of thrombotic thrombocytpenic
purpura narrates that dynamism in the education of the young physician.
More particularly, it contrasts the narrative dynamism of clinical practice to
the analytic understanding of textbook understanding—­the narrative and
analytic knowledges we have discussed in various chapters. Clinicians learn
the trajectories and histories of illnesses as part and parcel of their experi-
ence: they learn what we have described as the clinical knowledge of phro-
nesis. In fact, the “focused action” as an end (or aim) of narrative that occurs
at its end is best understood, as Aristotle understood it, as an ethical category
of behavior in the world.

Narrative and Medicine  /  257

 The negative side of the dynamic nature of medical practice is another
function of the ethical implications of narrative, namely, the ways in which
narrative allows attention to be focused on errors so that they might be rec-
ognized as having a significant role in medical practice and medical educa-
tion. Just as narratives allow us to apprehend what is missing—­to recognize
and attend to missing information—­so narratives allow us to recognize the
importance of error in medicine. The definition of narrative we have
presented—­namely, the mode of humanistic understanding that “allows the
apprehension of wholeness so that the circumstances, ends and means, re-
versals of fortune, unintended consequences come together to seem com-
plete and whole” (Ricoeur 1984: x)—­implicitly includes the assumption that
the mistakes in medicine discussed in chapter 9 should not simply be dis-
missed under the label “error.” Medical errors are clearly “unintended con-
sequences” and “reversals of fortune”; but more important, they are woven
into the fabric of the meaningful whole of narrative and must be understood
in relation to that whole. This, too, is a skill narrative teaches.

Aristotle, Narrative, and Medicine

In chapter 3, we noted that narrative—­storytelling—­is ubiquitous to human

cultures and that, although particular narratives are innumerable, the number
of kinds of narrative is relatively small. Moreover, we suggested that knowl-
edge about the kinds of narrative is particularly helpful in recognizing and
comprehending narrative knowledge. In our culture, there has always been a
close link between narrative and medicine—­the oldest and among the most
revered narratives in the Western culture are the ancient Greek tragedies that
focused, like medicine, on human suffering. A sense of how narratives are
organized and how they work can aid and enrich clinical encounters.
The ubiquity of narrative and storytelling—­like music, but also like walk-
ing and social organization—­takes place across the lifespan as well as across
social organizations. As we mentioned earlier, young children—­as young as
four or five—­can identify ill-­constructed narratives in a manner that is similar
to their ability to recognize ungrammatical sentences. Moreover, children can
recognize different narratives as the “same.” In relation to “The Three Pigs,”
for instance, they will recognize that the story is the “same” even if the char-
acters are changed from animals to people, the medium is changed from spo-
ken paragraphs to video images, and the plot of the narrative—­the order in

258  /  the chief concern of medicine

which events are presented—­is altered. Often, though, such alteration of
plot—­for example, having the wolf fail to blow down the brick house first—­
will register as an ill-­constructed narrative. Similarly, readers have no problem
identifying Anton Chekhov’s and Joyce Carol Oates’s versions of “The Lady
with the Pet Dog” as telling the “same” story even though the central charac-
ters (Gurov [unnamed in Oates’s story] vs. Anna), location and time frame
(1890s Russia vs. 1970s United States), order of narrative events, and particu-
lar narrative events themselves differ from one another in these versions. (We
noted in chapter 2 the likely evolutionary and neurological bases for such
recognition of narration and for narrative comprehension in general.)
Perhaps the earliest systematic treatment of narrative in the Western tra-
dition is presented in Aristotle’s Poetics in the fourth century BCE. As we
suggested in the introduction, one of the most striking facts in the Poetics is
that when Aristotle attempts to define classical tragedy in terms of its narra-
tive form, virtually the first gesture he makes is to turn to medicine to de-
velop a vocabulary for the new systematic study of literature. As we noted
earlier, perhaps the central term in Aristotle’s discussion of the dramatic nar-
rative of tragedy is katharsis, a term he adopts from classical medicine. It is
as if the crucial categories of “health,” “well-­being,” and “care” brought to-
gether the practice of medicine and the experience of literature from the
very beginning of the study of literature and narrative understanding. (Even
the Ayurveda, the ancient Indian science of medicine, a tradition very differ-
ent from that of the West, asserted that a perfectly structured couplet could
clean the air and heal the sick.) Moreover, though Aristotle wrote a study of
comedy as well as tragedy, history has preserved for us his study of tragedy in
the Poetics, which shares medicine’s central concern with human suffering.
In the Poetics, Aristotle defines tragedy in terms of its narrative form: it
is a serious, complete, and significant (“weighty”) action, possessing a begin-
ning, middle, and end, and it may lead to recognition (or anagnorisis) on the
part of the tragic hero and provokes katharsis in the audience. Katharsis, as
we saw, has been variously translated into English as “to purge,” “to purify,”
or “to clarify.” Whatever the dispute about these translations, there is no
dispute over the fact that Aristotle defines literary narrative—­really dramatic
narrative—­in a term that also defines health, well-­being, and care. He de-
fines narrative in terms of its wholeness and describes it in terms that are
literally or figuratively connected to healing. In relation to this, we should
note that the English word health “derives from an old Germanic root mean-
ing wholeness” (Boyd 2000: 13).

Narrative and Medicine  /  259

 Here we elaborate on our discussion of the Poetics in the introduction.
Three translations of Aristotle’s ancient Greek definition of tragic drama and
tragic action in the Poetics follow.

1. Tragedy, then, is an imitation of an action that is serious, complete, and of

a certain magnitude; in language embellished with each kind of artistic orna-
ment, the several kinds being found in separate parts of the play; in the form
of action, not of narrative; through pity and fear effecting the proper purga-
tion of these emotions. . . .

***

Now, according to our definition, Tragedy is an imitation of an action that is

complete, and whole, and of a certain magnitude; for there may be a whole
that is wanting in magnitude. A whole is that which has a beginning, a mid-
dle, and an end. A beginning is that which does not itself follow anything by
causal necessity, but after which something naturally is or comes to be. An
end, on the contrary, is that which itself naturally follows some other thing,
either by necessity, or as a rule, but has nothing following it. A middle is that
which follows something as some other thing follows it. A well constructed
plot, therefore, must neither begin nor end at haphazard, but conform to
these principles.
(trans. Butcher 2000: 10, 12)

2. Tragedy is a representation of a serious, complete action which has magni-

tude, in embellished speech, with each of its elements [used] separately in
the [various] parts [of the play]; [represented] by people acting and not by
narration; accomplishing by means of pity and terror the catharsis of such
emotions.
(trans. Janko 2001: 95)

3. Tragedy is, then, an imitation of a noble and complete action, having the
proper magnitude; it employs language that has been artistically enhanced by
each of the kinds of linguistic adornment, applied separately in the various
parts of the play; it is presented in dramatic, not narrative form, and achieves,
through the representation of pitiable and fearful incidents, the catharsis of
such pitiable and fearful incidents.
(trans. Golden 1968: 11)

These three translations offer three different ideas of what tragedy accom-
plishes, and they offer the three definitions of katharsis we describe in the

260  /  the chief concern of medicine

introduction: katharsis as “purgation,” expelling feelings of pity and terror;
katharsis as “purification,” purifying emotion in general—­not simply pity
and terror, but any “such emotions”—­so that the audience can understand
and experience it in its “purest” state; and katharsis as “clarification,” clarify-
ing not the emotional responses provoked by the narrative but the narrative
action itself (comprised of “incidents”), so that the experience allows us to
see in “pitiable and fearful incidents” events that are part and parcel of every
person’s life. This was Joyce’s definition of the pity and terror provoked by
tragedy, and we suspect that in Aristotle’s mind, it was the definition pro-
voked by illness as well. “Pity,” Joyce writes,

is the feeling which arrests the mind in the presence of whatsoever is grave
and constant in human sufferings and unites it with the human sufferer. Ter-
ror is the feeling which arrests the mind in the presence of whatsoever is
grave and constant in human sufferings and unites it with the secret cause.
(1966: 204)

All three definitions of katharsis, we noted earlier, are closely related to med-
icine—­to its practices of healing; its objective, scientific understandings; and
its global enterprise of confronting suffering in the person of its human suf-
ferer with pity and empathy and confronting suffering in its various causes
with science and care.
Besides katharsis, Aristotle’s definition articulates the limits and scope of
a narrative, its beginning and end. These elements are marked in several dif-
ferent ways. As Peter Brooks notes, “When we ‘tell a story’ there tends to be
a shift in the register of our voices, enclosing and setting off the narrative
almost in the manner of the traditional ‘once upon a time’ and ‘there lived
happily ever after’: narrative demarcates, encloses, establishes limits, orders”
(1984: 7). The traditional formulaic openings and endings Brooks describes
are clear examples of the beginning and end. Aristotle notes that the tragic
chorus—­singing at the beginning and end of the tragedy—­presents a lan-
guage of “linguistic adornment” that distinguishes it from other parts of the
drama. In medicine, these limits are equally well marked. If the beginning—­
the “once upon a time” of medicine, embodied in the chief complaint—­is
powerfully recognizable for its energy and focus, then the narrative “end” is
also particularly powerful. This is implicit in Aristotle’s emphasis on both nar-
rative recognition (anagnorisis) and narrative effect (katharsis); more gener-
ally, it is implicit in the ways that the end of a narrative defines, retrospec-
tively, the meaning of the whole, its chief concern; that is, the combination of

Narrative and Medicine  /  261

recognition and effect most usually takes place at the end of the story. (We
say “most usually” because the schemas of narrative are, like the humanistic
schemas we present throughout this book, provisional.)
The middle of a story—­its sequence of events—­is more difficult to define
formally, because, as Aristotle says, there always is something before the
middle and something after it. We all live in the middle, so to speak—­
between birth and death. But it may well be that the quality of this middling
life is defined in relation to the definitions of health we assume, so that each
definition—­the absence of disease, the presence of well-­being, and abilities
to cope with ongoing life—­can be seen variously as the beginning of a story,
its middle, or its end. What most characterizes the “middle” of narrative is
the relation among its salient features, the “plot” of a narrative. In his short
book written in 1927, Aspects of the Novel, novelist E. M. Forster notes that
the formula “The king died and then the queen died” presents a series of
events, while the formula “The king died, and then the queen died of grief”
offers a plot. He means that, above all, plot presents events graspable as a
whole. In chapter 6, the assessment in the patient profile of the case of poly-
artiritis nodosa presents the “reasonable assumption” that “multiple serious
symptoms in a young person will be caused by a single illness or condition”;
implicit in this assumption is the further assumption that there was a single
“plot” to be discovered in the patient’s symptoms (rather than multiple, un-
connected “plots” or diseases, as might be found in older people). In any
case, the narrative middle—­the plot or sequence of events of a story—­is the
organization of the story’s events that suggests the wholeness of its meaning
growing out of the interrelatedness of its parts, the events themselves. Such
“plotting” is usually pursued through the process of the physician developing
a differential diagnosis on the basis of the History and Physical Exam (the
HPI plus exam findings) and laboratory findings. Earlier in this chapter, the
young doctor investigating the case of thrombotic thromocytopenic purpura
discovered the dynamic plot of a narrative middle of his patient’s illness.

The Drama of Medical Practice

If a focus on narrative events—­and how narrative organizes events into

plots—­is instructive for understanding the mechanisms of the differential
diagnosis, then the focus on narrative actors that we touched on in chapter 3
is instructive in understanding the mechanisms of the drama of medical
practice, the relationship between patient and physician and the roles par-

262  /  the chief concern of medicine

ticipants assume in the practice of medicine. The life events of the epony-
mous character in William Carlos Williams’s story “Old Doc Rivers” com-
prise a narrative plot that can be grasped as a whole in an evaluation of his
professional life and in the conception of doctoring that ties it together (see
chap. 9). The relationship between Patsy and her physician, Dr. Nicholas, in
Jean Stafford’s “The Interior Castle” comprises a dramatic narrative that can
be grasped as a whole in its representation of the connection between the
patient’s pain and the physician’s arrogance. The unspoken relationship be-
tween the narrator-­patient and her father that remains unsaid in the narra-
tion of the young mother with abdominal pain in our introduction can be
grasped within the not-­yet-­completed whole of her story.
As we argued in chapter 3, the focus on the actors (or actants) in narra-
tive allows for an analysis of the relationships among the actors of a narrative
that is analogous to the grammatical and syntactical analysis of the relation-
ships among the parts of a sentence. That different people—­across differ-
ences in age, gender, and culture—­make similar judgments of well-­formed
and ill-­formed narratives suggests as much. A focus on actors makes dramatic
interaction a defining feature of narrative, just as a focus on events makes
plotting a defining feature of narrative. Understanding, even in a schematic
way, a structural account of narrative analogous to the analysis of sentences
in relation to their syntactical structure is important to physicians and medi-
cal students. Such a “structural” understanding is a schematic understanding
of the necessary but not sufficient elements of narrative that allows people to
see more clearly relationships embedded in narrative situations: it allows
them more readily to recognize narrative, hear the unspoken, form hypoth-
eses, pause and reflect on the human suffering they encounter, and develop
focused action by means of pragmatic working guidelines that can focus at-
tention. It does so because it suggests that the number of dramatic situations
is limited and, as Joyce says, “constant” in human affairs.
In chapter 3, we outlined the model of A. J. Greimas that, focusing on the
actors within narrative, suggests that there are a limited number of narrative
roles corresponding to the limited number of parts of speech in a sentence
and that, as in a sentence, there is a “grammar” defining the relationships
between and among parts in narrative, much as there is a grammar for sen-
tences. In this model,

the hero of a story corresponds to the subject of a sentence;

the object of desire (often, in traditional narratives, a “heroine”) corre-
sponds to the object of a sentence;

Narrative and Medicine  /  263

 the hero’s helper and the hero’s antagonist or opponent (“villain”) corre-
spond to adverbs modifying the activity of narrative in positive and
negative ways; and
the action or plot corresponds to the verb of the sentence.

Narrative actors do not have to be animate: in some traditional narratives,

the helper is the hero’s “magical ring,” the opponent a mountain range or
disease, the object of desire a “magical ring” (not here helping the hero with
its powers, but simply something the hero wants or needs to possess). Quite
often in detective fiction—­ as we have seen with Dupin and Sherlock
Holmes—­the identification of actor and role marks the ultimate success of
the detective. The following chart describes these paradigmatic actors and
roles:

Narrative Sentence Medical Roles

hero subject patient (“hero”)
desired object object health (“desired object/condition”)
action verb to purge (to remove the disease)
to purify (to achieve well-­being)
to clarify (to figure out whatever works)
helper adverb physician (“helper”)
opponent adverb illness (“opponent”)

In addition to these roles, the narrative roles of teller and listener correspond
to the sender and receiver of the message as a whole. Often in art or even
popular narrative, the narrator—­whether or not he or she is a character in
the narrative—­is the sender as well. In many traditional narratives, the king
will send the hero on a quest. (Often, as we already mentioned, the same ac-
tor can assume more than one of these narrative roles.) Similarly, the re-
ceiver might be a character in a narrative to whom a story is told—­one won-
ders, for instance, to whom Paula is speaking in The Woman Who Walked
into Doors: might it be a physician of some kind or herself (or even an Alco-
holics Anonymous meeting)? In any case, as we noted earlier and examine
more closely in the discussion of “systematic genres” in this chapter, the re-
ceiver of the sought-­for good at the end of a narrative helps determine the
particular genre of a narrative.
The narrator of a story is often also a character in the story itself; this is
almost always true in the patient story, even when it is narrated by a family
member or friend. The person telling the story—­its sender—­can also be the

264  /  the chief concern of medicine

story’s hero, as in The Woman Who Walked into Doors, or its villain or op-
ponent, as in “The Use of Force.” Such a coalescence of roles—­the “syncre-
tism” of different narrative roles performed by a single actor in the manner
that the queen in chess combines the “roles” (i.e., the actions) of the rook
and the bishop—­is quite common in narratives. This fact has allowed literary
scholars to develop the descriptive category of the “unreliable narrator,” a
storyteller who may not be trusted because she or he is both narrator (seem-
ingly objectively and impersonally presenting the story) and a character (dis-
playing personal motives of one sort or another that readers can discern) in
the two temporalities of narrative. (The woman with hyponatremia we saw in
chapter 4 was such an unreliable narrator.) Even when the narrator is not a
character as such in a narrative, the narrator can function as a helper to the
hero or even an opponent. The Victorian novelist George Eliot narrates her
novels under that male name—­the pseudonym of Marianne Evans—­with
such sympathy for her characters that the narrator often functions as the
characters’ helper.2 In contrast, Edgar Allan Poe often narrates his stories,
especially his tales of horror, with such little sympathy for his characters—­
and, indeed, for his readers, whom he is always trying to frighten (in his hor-
ror stories), to outsmart (in his detective stories), or to fool (in his lesser-­
known magazine stories described as “hoaxes”)—­that the narrator might
reasonably join other characters in the role of opponent.
Syncretic roles in which one actor fulfills two or more roles in a narrative
(e.g., a ring functioning both to help the hero and to exist also as his object of
desire) should not be confused with an actor assuming alternative roles in a
dramatic narrative. Thus, in “The Interior Castle,” Dr. Nicholas imagines
himself the hero of the medical drama in which he finds himself, while Patsy
thinks of herself as the drama’s hero and of Dr. Nicholas as the opponent (or
“villain”), since he refuses his proper role as helper. The conflict of this story
resides in the struggle over dramatic roles. A similar conflict can be discerned
in The Spirit Catches You and You Fall Down, in which Lia’s doctors situate
themselves as the drama’s hero, while Lia’s parents think of Lia herself—­or
at least her soul—­as the hero of this narrative. These conflicts can also be
understood as alternative definitions of the object of desire (the “sought-­for
good”): namely, health as the “absence of disease,” in which case the physi-
cian is the hero, banishing the opponent “disease”; or health as “well-­being,”
in which case Patsy and Lia are heroes, attempting to achieve the sought-­for
good. In the case of Lia, her parents can be understood as the syncretism of
the sender and the joint hero, insofar as they are seeking a version of health
as “whatever works / and for as long” in the attempts to cure and comfort Lia

Narrative and Medicine  /  265

with Western medicine and Hmong medicine simultaneously. In any case,
the schema (or “grammatical paradigm,” as we noted in the introduction) of
a sentence-­style “grammar” for narrative can make the roles and actions of
narrative—­and the alternatives among them—­more readily discernible, par-
ticularly to busy physicians. It can also help clarify the dynamics of the
patient-­physician relationship.
Even a schematic, working awareness of the structure of narrative allows
medical practitioners to glean more information than they might otherwise
obtain. The development of a systematic syntactical or grammatical account
of narrative can help us understand what it means to be skilled in narrative,
to possess a narrative technē. It helps us understand what knowledge and
skill allow readers/listeners to notice the ways that narratives often assign and
switch roles, as well as how these more or less standardized roles help ac-
count for the moral or “point” of a story and the chief concern of its teller.
Thus, in “He Makes a House Call,” Dr. Stone narrates a story in which, by
means of its flashback to the hospital, there are two heroes (two “people in
charge,” as we said in chapter 6): the doctor in the hospital, whose object of
desire is his patient’s restoration of health (or at least the ability to carry on)
and who faces opponents in the “pressure” of her condition and his youthful
ignorance; and the patient at home, whose object of desire is to welcome her
doctor with her

 . . . leathery smile

which insists that I see inside
the house: someone named Bill I’m supposed

to know; the royal plastic soldier

whose body fills with whiskey
and marches on a music box

How Dry I Am;

the illuminated 3-­D Christ who turns
into Mary from different angles;

the watery basement,

the pills you take, the ivy
that may grow around the ceiling
if it must.
(1980: 4–­5)

266  /  the chief concern of medicine

All these household items—­her husband, her bric-­a-­brac, her medicine,
even her smile itself—­fulfill this patient’s role of helper in her activity of wel-
come, just as, in the poem’s final image of a saint, the doctor filled the role of
helper to the patient’s hero in the hospital itself so long ago. To be skilled in
narrative—­which means not necessarily to know the analogy between narra-
tive syntax and the grammar of a sentence but just to be attentive to the
complex of relationships that narratives present and to know that no particu-
lar role is absolutely tied to a particular actor—­allows the physician to grasp
information and its tacit meaning that she might otherwise miss.
The schematic analogy between narrative structure and sentence gram-
mar accounts for the striking fact that people who are narratively skilled will
often notice oddnesses of role assignment or even missing information in a
story. Thus, in Jean Stafford’s “The Interior Castle,” the arrogance of the
physician can be understood as created or represented by the fact that Dr.
Nicholas assumes throughout the narrative that he is the hero of the story,
even though Stafford presents Patsy as the hero. In fact, we believe that the
ability to recognize role switching, as Dr. Stone does in “He Makes a House
Call,” is a teachable skill and a learnable talent (technē) that can help develop
empathy. Certainly, the neurological basis of empathy in mirror neurons,
which we examined in earlier chapters, describes phenomena that enables
the recognition—­or at least the experience—­of role switching as we notably
cringe when we see a child fall off a bike (activating mirror neurons). In a
similar fashion, the analogy between narrative structure and sentence gram-
mar can help people encountering narratives notice what is missing. Thus,
many aspects of Charlotte Perkins Gilman’s story “The Yellow Wallpaper”—­
the husband-­doctor’s inability or unwillingness to function as a physician-­
helper by asking medical questions; the wife-­patient’s inability to assert her-
self as an artist-­hero or to allow herself anger; the narrator-­sender’s inability
to explicitly represent the breakdown of her own (the hero’s) cognitive func-
tion (she is only able to present it through the progressive disorganization of
the writing)—­will be more noticeable and more pronounced to readers who
are aware of the schema of narrative structure. Noticing such things seems
more or less intuitive to the seasoned physician encountering the young
mother with abdominal pain in our introduction.
A final feature of narrative that partly accounts for the uncertainty and
ambiguities it sometimes presents—­ along with the sequence of events
(“plot”), actors, and emotion Aristotle describes and the ways these elements
are organized—­is the fact that narrative presents itself in “ordinary” lan-
guage as opposed to the technical language of scientific analysis. Thus the

Narrative and Medicine  /  267

martial metaphors for illness transform a diseased condition into a story
(much to Susan Sontag’s dismay) that describes viruses “attacking” the body
in one way or another, “replicating” themselves, “infiltrating” defenses, and
so on. This transformation changes the scientific language of biomedicine
into the ordinary language of narrative. Moreover, in this narrative, the virus
(as the chief actor) is the hero, infiltration is the action, and replication is the
object of desire. (Needless to say, if the “fighting” patient is discussed, these
roles transform themselves, with the body as the hero, defense as the action,
and vanquishing the replicating opponent as the object of desire.) Similarly,
in “The Use of Force,” William Carlos Williams presents in one paragraph
the language of the scientific description of “cases” of diphtheria and narra-
tive action of battle.

The child’s mouth was already bleeding. Her tongue was cut and she was
screaming in wild hysterical shrieks. Perhaps I should have desisted and
come back in an hour or more. No doubt that would have been better. But I
have seen at least two children lying dead in bed of neglect in such cases, and
feeling that I must get a diagnosis now or never I went at it again. But the
worst of it was that I too had got beyond reason. I could have torn the child
apart in my own fury and enjoyed it. It was a pleasure to attack her. My face
was burning with it. (1984: 60)

In one case, the patient is the hero, the doctor the helper; in the other, the
doctor is the hero, the patient the opponent (or “villain”). Moreover, the
copresence of these two schematic understandings allows us to account for
the ambivalent judgments this story occasions. Whether narratives present
themselves in the ambiguities of ordinary language or whether the ubiqui-
tous “ordinariness” of narrative makes the language of storytelling ordinary,
narrative presents a different kind of vocabulary from that of science and
scientific medicine. This difference too often encourages physicians to dis-
miss narrative rather than to attend to it. With a sense of how narrative sche-
mas work, physicians can notice and use the ordinary language of narrative—­
and the knowledge it conveys—­rather than dismiss it.
Related to the eclectic and ambiguous language of narrative are the am-
biguities of narrative forms or “genres.” Earlier, genre was mentioned in
relation to the meaningful whole of narrative. Genres, like other aspects of
narrative, participate in the ambiguity of the relationship between the whole
and its parts. If we know or assume a narrative whole is tragedy, we attend

268  /  the chief concern of medicine

to particular aspects of the narrative—­its seriousness and magnitude, the
recognition of the tragic hero, its presentation of suffering. If we suspect the
narrative is a comedy, we notice that its hero confronts events without rec-
ognition, that suffering occasions laughter, that what might be taken for a
hero is really an object of desire. (Later in this chapter, we present schema
guidelines for recognizing a narrative’s genre.) In the detective story, the
detective is a melodramatic hero, the solution of the crime (like the discov-
ery of a disease) is the object of desire, and the criminal is an extreme
opponent—­quite literally the “villain.” In a tragedy, the villain is not so clear:
is Oedipus’s antagonist Creon or his own pride? Is Hamlet’s opponent
Claudius, Laertes, or his own pusillanimousness? Is Grace Paley’s narrator
her father’s helper or his opponent? In comedy, the opponent is more often
the hero’s rival than his absolute enemy. In these large narrative genres—­
the melodrama, tragedy, comedy, and ironic narratives we already men-
tioned and examine more closely here—­the whole is determined by the
concrete complex of relations among the parts, and the ambiguity of narra-
tive is often a function of that complexity. These narrative genres are small
in number, and they can be systematically analyzed in ways that help de-
velop narrative skills.
As we already mentioned, the small number of narrator roles (performed
by varying “actors”) has suggested that there is a specific method (technē) for
determining the global genre of a particular narrative, for determining
whether it is best understood as a melodrama, tragedy, comedy, or ironic nar-
rative. This method focuses on which actor in a narrative is left with the
sought-­for goods (the object of desire) at the end of the story; it focuses on
the actor in a narrative that assumes the additional (“syncretic”) role of re-
ceiver. This syncreticization of a narrative actant (or actor) signals the end of
a narrative and helps us to understand that the “end” is both the narrative’s
conclusion and the values it encompasses (the moral or “point” of the tale).
Chekhov’s story “Misery” organizes its tragically inflected plot around the
sender-­receiver relationship: the hero is also the sender, telling anyone and
no one of the death of his son, and the story ends, ironically, when he tells his
story to his horse. This story is “tragically inflected” because the hero’s
“helper”—­his faithful horse—­receives the sought-­for good, Iona’s story. But
it is essentially ironic because a horse is not a proper receiver for a story. The
pathos of this narrative—­Chekhov’s chief concern, or, in the language of
Charon, the story’s “desire” (2006a: 124)—­is the fact that underlying its irony
is the palpable suffering of its (“tragic”) hero.

Narrative and Medicine  /  269

Kinds of Narrative and the Comprehension of Medical Practices

As we noted in chapter 3, in traditional narratives, the determination of

genre is relatively clear. In heroic melodrama (or epic), the hero is syncreti-
cally the receiver; he gains the kingdom and the princess. In tragedy, the
hero’s friend, his helper, is left with the hero’s estate, often remaining to tell
the tragic tale. In comedy, the heroine obtains the sought-­for goods; she
gains a union with the hero. In ironic narrative, the opponent can be seen to
obtain whatever is left of the “goods” sought for, though these are often am-
biguous. Here, though, we can see more closely how these “schematic”
genres can help us understand the action of medical practice conceived of as
a drama.3

Heroic Narrative

At the end of the narrative in a melodrama or heroic tale (“epic” is the adjec-
tive for “heroic”), the hero is the receiver of the sought-­for good. A melodra-
matic narrative has very distinct characters inhabiting narrative roles that
are most clearly delineated: the opponent is clearly a villain, the hero stereo-
typically virtuous. In the Odyssey, Odysseus gets his kingdom, Ithaca, and
his wife, Penelope. In “The Artificial Nigger”—­as in many religious narra-
tives—­Mr. Head achieves salvation and reconciliation with his grandson. In
all the Sherlock Holmes stories, Holmes is clearly the hero, with almost su-
perhuman powers, and Watson, as his helper, is almost superfluous. The
crime’s solution (Holmes’s private goal) and the restoration of public order
(his public goal) are obtained by the hero himself.4 Shakespeare’s Henry V is
a classic example of melodrama, pitting the noble Henry and the brave Eng-
lish against the boastful Dauphin and the despicable French. The show-
down at Agincourt is the classic climax of melodrama, where the hero gets
the princess and the kingdom. This narrative form is particularly useful in
what we are calling the dramatic narrative of medical practice (itself a kind
of schema or, as we present here, a series of four schemas). In medicine, a
situation is quite often conceived as melodrama: the physician assumes the
role of melodramatic hero, conquering the opponent of disease and restor-
ing the sought-­for good of health (conceived as the purgation of disease).
Success or failure is starkly defined in melodrama, and triumph is the gov-
erning emotion. Much of physician arrogance and paternalism that arises
within medical practice can be understood in relation to the features of this
narrative genre: as already noted, this is how Dr. Nicholas conceives of him-

270  /  the chief concern of medicine

self in “The Interior Castle”; and this is how the arrogant Mr. Head sees
himself in O’Connor’s story.

Tragic Narrative

At the end of a tragedy, the hero is usually dead or exiled; the heroine, as
object of desire, is often also dead or exiled; and the sought-­for good—­now
the state rather than a combination of public and personal goods—­is in the
hands of the hero’s helper. At the conclusion of Hamlet, Hamlet, Ophelia,
Claudius, and Gertrude are all dead, and Horatio, Hamlet’s friend, is left in
charge of the community, with the need to tell the story. In tragedy, the hero
himself, as Aristotle says, is a “man who is not eminently good and just, yet
whose misfortune is brought about not by vice or depravity, but by some er-
ror or frailty” (Aristotle 2000: 17). Similarly, the hero’s opponent is not so
villainous as the melodramatic hero’s opponent (e.g., Holmes’s arch-­enemy
Moriarity); and in the end, he is usually also dead. This description of tragedy
based on narrative roles nicely fits Hamlet and Oedipus (at the end of which
Creon is revealed as Oedipus’s helper rather than opponent), and it also
helps us grasp the narrative organization and understanding of historical
events such as the assassination of President Kennedy, as we have suggested
in chapter 4. The increasing ambiguity of roles in tragedy (as compared with
melodrama) helps account for interpretative controversies. Thus the degree
to which readers understand F. Scott Fitzgerald’s Tender Is the Night as a
tragedy (in which, it has been argued, Dr. Dick Diver ends as a tragic hero in
exile while his patient-­helper, Nicole, is left with the goods) or as thoroughly
ironic (with Dick understood to be subject to the “vice or depravity” of his
drinking and his need to be loved) can be systematically measured in terms
of the judgment of what precise provisional schematic genre this narrative
suggests. In the dramatic narrative of medical practice, when the narrative
events are conceived as tragedy, the patient assumes the role of tragic hero,
and suffering (rather than melodramatic triumph) is the governing emotion:
tragedy often begins in the state of ill health (“Something’s rotten in the state
of Denmark,” Hamlet says at the beginning of the play).

Comic Narrative

At the end of a comedy, the hero usually obtains the object of desire, but the
sought-­for good—­most often in the form of an actual or symbolic mar-
riage—­is most fully received by the heroine. However, the narrative end

Narrative and Medicine  /  271

marked by this reception is often actualized in the form of a union, the com-
bination of hero and heroine—­or, in the dramatic narrative of medicine, the
combination of hero (patient) and object of desire (health), aided by the nar-
rative helper (the physician). The narrative plot of comedy was established in
the New Comedy of late classical Greece in the fourth century BCE (over-
lapping with Aristotle’s lifetime). In it, a boy wants a girl but cannot achieve
his desire because of some obstacle, usually parental disapproval. By intrigue
or luck, the lovers overcome the obstacle and eventually live together. In this
plot, the villainy of the opponent is softened even further than in tragedy.
This role is usually assumed by a “blocking” parent who tries to prevent the
marriage, and in the end, the opponent is welcomed back into the family.
Thus comedy “domesticates” the conflicts of narrative. Shakespeare uses this
formula in The Taming of the Shrew and Much Ado about Nothing, and he
inflects it somewhat darkly in Merchant of Venice. Even Neil Simon uses this
formula, as do many television sit-­coms. A hallmark of comedy is the roughly
equal status of the characters. In melodrama and tragedy, the hero towers
over the other characters; in comedy, the hero and heroine are a pair. A
poem like Dr. John Stone’s “Gaudeamus Igitur” (Stone and Reynolds 2001:
282–­85)—­celebrating the “day of joy” of the medical student’s graduation,
which is at least analogous to the joyful day of marriage and being accepted
into a community—­focuses on the particular moment of comedy, the rejoic-
ing that extinguishes the relationships and conflicts of narrative roles.
In the dramatic narrative of medical practice, when a situation is con-
ceived as comedy, the comic action is quite often a simultaneous discovery by
patient and physician, syncretized together in receiving the good news of
health (which seems analogous to the good news of marriage or of joining a
profession on graduation), in which health is conceived as well-­ being.
Happiness—­health as well-­being—­is the governing emotion. In a poem like
Derek Mahon’s “Everything Is Going to Be All Right,” profound comedy
seems to resonate in the title, which has the patient-­speaker apparently re-
peating the physician’s words in the reflective pause of the poem as a whole.

How should I not be glad to contemplate

the clouds clearing beyond the dormer window
and a high tide reflected on the ceiling?
There will be dying, there will be dying,
but there is no need to go into that.
The poems flow from the hand unbidden
and the hidden source is the watchful heart.
The sun rises in spite of everything

272  /  the chief concern of medicine

 and the far cities are beautiful and bright.
I lie here in a riot of sunlight
watching the day break and the clouds flying.
Everything is going to be all right.
(Stone and Reynolds 2001: 316)

These words—­“Everything is going to be all right”—­are fully shared by phy-

sician and patient: they are what both want to say, what both want to hear.
Their utterance signals the joy of caretaking, as does this wonderful poem. In
an interview, Dr. John Stone (who includes this poem in his anthology On
Doctoring) notes that this is a poem, as he says, “that I can carry with me in
my back pocket against any adversity that might come across my pathway”
(Vannatta, Schleifer, and Crow 2005: chap. 5, screen 50).

Ironic Narrative

At the end of an ironic narrative, all the clarity of narrative roles seems to
dissipate in ambiguity (which is very different from the syncretizing of roles
in comic rejoicing). Usually, the opponent is the receiver of the sought-­for
goods, but it is unclear to what degree the opponent is not a helper. (In
Chekhov’s “Misery,” Iona’s horse is his helper but is dumb to his owner’s nar-
rative of grief.) Because of this, ironic narratives undermine the absolute-
ness of the distinction among schematic roles that determine the generic
whole of narratives. Instead, such narratives emphasize what we might de-
scribe as the systematic ambiguity of narrative. For instance, the signifi-
cance of Dick Diver in Tender Is the Night is largely a function of whether
readers apprehend him as a tragic hero (as suggested earlier) or a weak and
undisciplined man. To a significant degree, this judgment is a function of the
understanding of his role with Nicole as his patient-­wife, who is also a mem-
ber of a social class that is necessarily opposed to Diver’s middle-­class values.
The judgment of Diver, in generic terms, opens up a large number of spe-
cific questions about the particular role of the physician—­including the
“schematic” narrative role in the practice of medicine by which the concrete
complex of relations with patients, other physicians, and/or social institu-
tions are understood and acted upon. This last is of the utmost importance
because it is our supposition that the assumption of one or another sche-
matic narrative role is the basis for the understanding—­for the meaning—­of
any particular concrete set of events that might otherwise seem meaning-
lessly inchoate. It also allows us to see the imposition of schematic narrative
roles on experience.

Narrative and Medicine  /  273

 In the dramatic narrative of medical practice, when a situation is con-
ceived as ironic, the situation as a whole—­the situation of ill health—­is quite
often overwhelmingly confused, with the result that there is no ideal of
health. In an ironic narrative, the narrative roles themselves—­the roles of
physician, patient, family members (community), disease—­repeatedly con-
fuse themselves with one another. Thus the governing emotion of ironic nar-
ratives is confusion. (Whether confusion is an emotional or intellectual state
participates in the ambiguities of ironic narratives. In any case, there is little
ambiguity in melodrama’s triumph in the restoration of a healthy order or in
comedy’s happiness of well-­being. Neither is the suffering of tragedy am-
biguous, although its significance may be.) Perhaps a striking example is Al-
bert Camus’s The Plague, in which (as the title suggests) the disease itself is
a major actor in the novel and, at the same time, a metaphorical and literal
figure for the entire situation of the dramatic narrative of medical practice
Camus presents. Physicians become patients, a smuggler seems a hero, the
ancient confusion of medicine and religion is dramatized, and the whole nar-
rative of disease—­ the “dramatic narrative of medical practice” we are
discussing—­may be, instead, a narrative of politics or philosophy. In this
novel, health is closely related to Dr. Stone’s definition of “whatever works /
and for as long.”
Here is a schematic summary of medicine apprehended as narrative
drama.

the dramatic narrative of medical practice

Melodrama: The physician is the hero, the opponent is the disease, and
the wished-­for good is the purgation of disease. Characters are starkly
contrasted; the emotion is triumph.
Tragedy: The patient is the tragic hero, the opponent is the disease, the
physician is the helper,5 and the failed wished-­for good is purification.
Characters are less starkly contrasted, and there is general dis-­ease;
the emotion is suffering.
Comedy: The patient is the comic hero, the opponent is temporary ill-
ness, and the wished-­for good is well-­being, received jointly by the
patient and helper-­physician. Characters are softly contrasted; the
emotion is happiness.
Irony: Roles—­hero, wished-­for good, opponent, helper—­are ambigu-
ous; genre is overwhelmingly provisional. The emotion is confusion.

274  /  the chief concern of medicine

Systematic Ambiguity

By focusing on the schematic role relationships of narrative, we can under-

stand more precisely the kind of disagreement that arises about Dick Diver
in Tender Is the Night, the eponymous character in William Carlos Williams’s
“Old Doc Rivers,” or even a patient presenting fatigue, bruises, anemia, and
acute renal failure. A person skilled in narrative learns certain precise kinds
of attention, including attention to (rather than dismissal of) ambiguous roles
and/or the ambiguities of shifting roles in narrative. (It also calls for system-
atic attention to mistakes in medicine that we take up in chapter 9. Melodra-
matic heroes, like Holmes or Dupin, make no mistakes; melodramatic vil-
lains, like Dr. Goodman in Gawande’s narrative, display no goodness.) A
catalog of schematic narrative genres is more or less systematic in that it can
and often does follow a particular, methodical treatment of stories—­a narra-
tive technē—­in order to group them together in meaningful ways so that we
can reasonably articulate the similarities between Oedipus, Hamlet, the
death of John Kennedy, and, more problematically, Tender Is the Night.
Moreover, such narrative knowledge, even in schematic shorthand, can help
delimit the roles of the physician in our society and in the dramatic narrative
of medical practice. Although this schema-­based method is clearly distinct
from the strategy in scientific biomedicine that aims to erase all ambiguity,
the systematic nature of genres allows us to clearly discern more or less “reg-
ular” ambiguities (just as science pursues “regular” phenomena) that pro-
voke a reflective pause and allow the apprehension of what is unspoken in an
HPI, what information might be missing, what hypothetical elements should
be considered (e.g., the completion of the thrombotic thromocytopenic pur-
pura syndrome), and what focused action is most appropriate. Such a method
seeks not necessarily to disambiguate ambiguities but to discover, in their
more or less systematic organization, a range of provisional understandings.
Like the “method” of Monsieur Dupin in “The Murders in the Rue Morgue,”
this method (or technē) calls for the apprehension of the meaningful whole
of narrative.
The system of narrative genres can help account for many of the sur-
prises of narrative. Thus, when King Lear comes on stage at the end of the
play carrying his dead daughter, the audience is more shocked—­more over-
whelmed with pity and terror—­than it is, say, at the carnage at the end of
Hamlet. If this is so, the surprise of such an ending can be accounted for by
the fact that the narrative of King Lear includes a subplot that suggests that

Narrative and Medicine  /  275

at the end of the play, comedy-­like, his daughter Cordelia will marry the Earl
of Kent and together restore order to the kingdom. The plot organizes its
role relationships to suggest this comic resolution to the tragic action (much
like Shakespeare’s tragicomedies), and the failure to achieve this end that is
suggested—­and, indeed, called for—­by the differing schematic narrative
roles assumed by the characters provokes terror and pity. Similarly, in a story
like Chekhov’s “Misery,” the hero, Iona, is starkly seeking a receiver of his
message about the death of his son. The story is ironic in that no one listens
to him—­his customers seem a blur between an opponent and a helper—­but
the pathos of the story is provoked by the fact that he is left only with an
animal to “receive” the message.
Happy surprises also occur in narrative, as they do in medicine: thus, in
John Cheever’s “The Housebreaker of Shady Hill,” an ironic hero, Johnny
Hake, part tragic, part vicious (whose misfortune seems ambiguously brought
about, in Aristotelian terms, by both “vice or depravity” and some “error or
frailty”), is miraculously saved at the end so that irony transforms itself to
comedy. In the end, Robert Coles has noted, “at night he is now cheerful,
able to face the dark, whose significance (in himself, in others) he has real-
ized as never before. The reader smiles, is reassured—­but also may not be
quite so buoyant as Johnny is” (1989: 152). As we noted earlier, the end of
Flannery O’Connor’s “The Lame Shall Enter First” similarly promises that
Mr. Shepherd—­through the “help” of his late discerning intelligence—­will
be the receiver of his son’s filial affection, only to shock readers, through the
story’s “false” then “true” endings, with the discovery that he is his son’s op-
ponent rather than his helper or hero. The surprise reversal of the dramatic
situation of Mrs. Jones’s story we encountered in chapter 3—­much happier
than O’Connor’s shocking ending, but structurally related to it—­is accom-
plished by the transformation of the patient from object to agent.
The existence and retrospective predictability of surprises has a lesson
for diagnosticians, who themselves are often surprised—­or, worse, blinded.
The specialist in infectious diseases who examined the woman with polyar-
tiritis nodosa before the consultation presented in chapter 5 was, almost of
necessity, looking for an infection—­this was the schema he brought to the
patient-­physician encounter—­and could not quite imagine an inflammation
of the arteries. The system of narrative genres teaches us how it is that we are
signaled to “look for” particular phenomena and are shocked and surprised
when we find something else. The necessary and systematic ambiguities of
narrative teach us to be ready for surprise, to question the roles we assume,
and to reorder or re-­story series of events in relation to ironic confusion,
melodramatic triumph, tragic suffering, and/or comic happiness.

276  /  the chief concern of medicine

Doctors and Writing

Given the dramatic nature of medical practices, we should not be surprised

that there are a large number of physicians who also have been writers. Al-
ready in The Chief Concern of Medicine, we have encountered Anton Chek-
hov, William Carlos Williams, Richard Selzer, Ferrol Sams, Robert Coles,
John Stone, Rita Charon, Derek Mahon, Abraham Verghese, and Rafael
Campo; and David Hilfiker and David Rinaldi will appear in chapter 9. In a
book like On Doctoring, edited by John Stone and Richard Reynolds, many
writers associated with medicine are also encountered. These include John
Keats, Somerset Maugham, Mikhail Bulgakov, Ernest Hemingway (whose
father was a doctor, as was Aristotle’s, whom we have encountered in the
present book), Edward Lowbury, Lewis Thomas, Dannie Abse, Ursula Fan-
thorpe, Jack Coulehan, Susan Onthank Mates, and Perri Klass, among oth-
ers. The affinity between physicians and writers has to do with many of the
elements of narrative discussed in this chapter: the dramatic nature of suffer-
ing, the powerful attention for detail, and the fact that storytelling is at the
heart of both literature and doctoring. This is why it is equally unsurprising
that the narrator’s father in Grace Paley’s “A Conversation with My Father”—­
like Paley’s father himself—­was both a physician and an artist. In this conclu-
sion to this chapter, we examine a number of different narrative genres that
grow out of the practices of medicine themselves: the “parallel charts” Dr.
Charon talks about both in Narrative Medicine and in an interview; narrative
case histories as Dr. Oliver Sacks pursues them; the medical memoir as Dr.
Abraham Verghese enacts it; the medical fictions of Dr. Williams and Dr.
Selzer; and the poetry of medicine as represented by Dr. Williams, Dr. Stone,
and Dr. Campo.

The “Parallel Chart”

Physicians, like most professionals, engage in a considerable amount of writ-

ing in the course of their daily professional activities. In teaching medical
students, Dr. Rita Charon has developed a technique of “parallel charts,”
which entails the writing of aspects of medical practice that do not fit the
strict conventions of the chart. Note how many of the elements of narrative
are included: Aristotle’s seriousness, magnitude, and pity and terror, as well
as the ordinary language of storytelling. Thus Charon has noted,

Some years ago, I invented something I call the parallel chart. I was precept-
ing, supervising students during their third-­year clerkships; they were on in-

Narrative and Medicine  /  277

ternal medicine. I would meet with them three times a week, an hour and a
half at a time, and traditionally, what the preceptor does is to have the stu-
dents, and these are small groups, six, seven students, have the students pres-
ent cases, and the preceptor would give, sort of lectures about the manage-
ment of diabetes, of hypertension, or liver disease. And I saw that the
students were very good at that, they were all achingly bright, they all re-
membered what they learned in their second year, but there were aspects of
the clerkship, or of their experience, that were not being addressed, and all
they go through and all that they gain and that they lose as medical students
was sort of not being considered at all.
So, I asked them once a week to write just a few paragraphs about one of
the patients they were taking care of, and they were to write this not in tech-
nical language but just in ordinary language. I said, “There are many things
that happen to a patient in the course of a day.” I told them, “There are
things that are critical to the care of the patient that don’t belong in the
hospital chart, and you might go into this room to take care of your elderly
patient dying of prostate cancer, and when you walk in the room, you weep
because he reminds you of your grandfather who died of that disease, and
you are mourning the recent loss of your grandpa.” I said, “You can’t write
that in a hospital chart. We won’t let you. But it has to be written some-
where.”
So they would write once a week, and then one of our sessions each week
was devoted to their very simply reading to one another what they wrote, and
it was astonishing. These students were not chosen for me because they were
writers. This was just, you know, 6 out of the 160 P&S students, physicians
and surgeons is what we call our medical school at Columbia, and the prose
was astonishing. It was elevated, it was grave, it was very powerful, and as
they read to one another what they had written, and it was all about mourn-
ing and grieving and feeling helpless, feeling incompetent, feeling very an-
gry, either at disease, which is very angering, or at a system of health care that
was not ideal in addressing disease. They would read to one another what
they wrote, and they found out, “I’m not the only one who fears that I have
made a terrible mistake!” or, “I’m not the only one who feels revolted by a
patient,” because that happens, too.
And, so, in addition to helping them understand what they were going
through, the parallel chart also helped to reduce the isolation, reduce the
competition, to make them feel supported by their peers and colleagues.
(Vannatta, Schleifer, and Crow 2005: chap. 4, screen 57)

278  /  the chief concern of medicine

In Narrative Medicine, Charon calls this “narrative writing in the service of
the care of a particular patient” (2006a: 157; see 158–­74 for moving examples
of these student narratives); and she concludes that “the ability to shift one’s
perspective in order to see events from others’ points of view may be one
critical and currently missing skill in health care professionals—­and one that
can be taught” (174). The way it is taught, as she demonstrates, is to encour-
age students and physicians to pursue the very narrative organization and
understanding of experience that, as we argued in Part 1, is part of our hu-
man cognitive and affective inheritance. Such encouragement, as Charon
demonstrates, develops narrative knowledge.

Case Histories

The case history is a step beyond the chart—­both the mandatory impersonal
charted record required of practicing physicians and Dr. Charon’s “parallel
chart.” It offers, as Dr. Oliver Sacks mentions in his introduction to An An-
thropologist on Mars, the study of the “human sufferer” as well as the dis-
ease. (That parallel chart offers narratives that encompass the human suffer-
ing of both patient and empathetic physician.) “The study of disease, for the
physician,” Sacks writes,

demands the study of identity, the inner worlds that patients, under the spur
of illness, create. But the reality of patients, the ways in which they and their
brains construct their own worlds, cannot be comprehended wholly from the
observation of behavior, from the outside. In addition to the objective ap-
proach of the scientist, the naturalist, we must employ an intersubjective
approach too, leaping, as [Michel] Foucault writes, “into the interior of mor-
bid consciousness, [trying] to see the pathological world with the eyes of the
patient himself.” (1996: xviii–­xix)

In his much revised Awakenings, Dr. Sacks describes “the elaborate case-­
history, the ‘romantic’ style, with its endeavour to present a whole life, the
repercussions of a disease in all its richness.” He later goes on to note that
“diseases have a character of their own, but they also partake of our charac-
ter; we have a character of our own, but we also partake of the world’s char-
acter. . . . The disease-­the man-­the world go together, and cannot be consid-
ered separately as things-­ in-­themselves. An adequate concept or
characterization of a man . . . would embrace all that happened to him, all

Narrative and Medicine  /  279

that affected him, and all that he affected; and its terms would combine con-
tingency with necessity” (1999: xxxvii, 229). The great masters of narrative
case history are the late nineteenth-­century contemporaries Sigmund Freud
and Arthur Conan Doyle (both physicians who wrote), and the narrative
workings of their texts, as we saw in relation to Sherlock Holmes, have much
to teach and train physicians about narrative knowledge.

Memoirs

Related to the case history are the memoirs of physicians—­aspects of their

personal experience that fill their storytelling about medical practice. In
chapter 9, we will examine Dr. David Hilfiker’s narration of the mistakes he
has made in his practice and how he hopes to cope with those mistakes;
others—­such as Dr. Arthur Kleinman, Dr. Jerome Groopman, Dr. Atul
Gwande—­have written moving narratives about the experiences of doctor-
ing. The memoir, as opposed to autobiography, narrates events rather than
personal growth, even if—­as in the memoirs of Dr. Abraham Verghese, My
Own Country and The Tennis Partner—­the dramatic events presented, such
as the beginnings of the AIDS epidemic in the heartland of America or a
powerful friendship between teacher and student, imply important aspects
of the writer’s growth and development. Dr. Verghese’s description of writing
about friendship sheds important light on medical practice and education. In
the following statement, he also offers a short definition of health that com-
plements those presented in our introduction.

With both my books I clearly had no complete idea of what each book would
be, and yet writing each book led me to a revelation of sorts. For example, in
The Tennis Partner the revelation that only came to me in the writing of the
book and never came to me before that was that David was responsible for
David, that I was not responsible for David. I didn’t quite understand that
until I wrote the book. . . . So revelations like that only come to me through
the writing. So, writing has been very important to me and oftentimes, even
today as I’m working on fiction, I’ll have revelations in the writing about
something that I’ve struggled to explain to a medical student.
The converse is clearly true. I think being a doctor has been a great help to
me as a writer, even though I don’t really separate those two roles. But I think
the craft of observation that one learns as an internist, the history taking, the
attention to details, the trying to weave together certain facts into a paradigm
or a diagnosis or a syndrome, some of those things are terribly important in
writing as well. There was a phrase that I heard both in medical school and at

280  /  the chief concern of medicine

 the Iowa Writers’ Workshop, two completely different disciplines. But I
heard the same aphorism, which was, “God is in the details.” So, I think that
being a doctor is good training for being a writer, and the converse is also
equally true.
Well, I wrote The Tennis Partner primarily because I felt that most men
were notoriously silent about their deepest male friendships. . . . So, a great
deal of my motive for writing The Tennis Partner was to pay tribute to a
friendship that had been terribly important to me, and it was unique to me,
and yet I didn’t think it was unique to mankind. I think that there are a lot of
important friendships like that.
My feeling is that friendships are very much like good health—­you don’t
quite know what you have until you lose it. And forming friendships is really
terribly important in the medical world because, there is a saying in addiction
circles that addiction is a disease of secrecy and loneliness, and it strikes me
that those two words—­secrecy and loneliness—­also typify physicians. A lot of
what you do you cannot tell anybody else about, not even your spouse. There
is a tremendous amount of secrecy within the medical profession, there is a
tremendous amount of loneliness, despite all our wonderful societies and
memberships and fellowships. Many physicians are horribly alone, and there
is a great parallel between that and the world of the addict. I think some of
this emanates from the process of education. (Vannatta, Schleifer, and Crow
2005: chap. 4, screen 59)

Here Verghese is describing, as we mentioned earlier, talents for attention to

detail and observation that are part of the training of physicians and are vital
to the narrativist. We see such talent as well in Grace Paley’s father.

Physicians’ Fiction

In his introduction to William Carlos Williams’s The Doctor Stories, Robert

Coles quotes Williams’s wife, Flossie (who appears in both Williams’s fiction
and his poetry): “There’s little in a doctor’s life Bill didn’t get at when he
wrote,” she said. “She’d been there with him, of course,” Dr. Coles contin-
ues, “all along, and she knew: the periods of irritability and impatience; the
flashes of annoyance and resentment; the instance of greed, or just plain bit-
terness that ‘they’ can’t, don’t, won’t pay up; the surge of affection—­even
desire, lust; the assertion of power—­a fierce wish to control, to tell in no
uncertain terms, to win at all costs; the tiredness, the exhaustion, the despon-
dency. The rush of it all, the fast-­paced struggle, again and again, with all

Narrative and Medicine  /  281

sorts of illnesses—­and the victories over them, the defeats at their hands,
and not least, the realization (postmortem) of one’s limitations, one’s mis-
takes” (1984: xiv). The fictions of doctors—­William Carlos Williams, Anton
Chekhov, Ferrol Sams, Richard Selzer, and many others—­powerfully join
the concerns of narrative discussed in this chapter and throughout this book
to the practice of medicine. “As far as the writing itself is concerned,” Wil-
liams wrote in his Autobiography, “it takes next to no time at all. Much too
much is written every day of our lives. We are overwhelmed by it. But when
at times we see through the welter of evasive or interested patter, when by
chance we penetrate to some moving detail of a life, there is always time to
bang out a few pages. The thing isn’t to find the time for it—­we waste hours
every day doing absolutely nothing at all—­the difficulty is to catch the eva-
sive life of the thing, to phrase the words in such a way that stereotype will
yield a moment of insight. That is where the difficulty lies” (1967: 359).

Poetry

In his collection of essays The Desire to Heal: A Doctor’s Education in Em-

pathy, Identity, and Poetry, Dr. Rafael Campo describes the relationship, as
he sees it, between poetry and medicine. “So-­called formal poetry,” he writes,

holds most appeal for me because in it are present the fundamental beating
contents of the body at peace: the regularity of resting brain wave activity in
contrast to the disorganized spiking of a seizure, the gentle ebb and flow of
breathing, or sobbing, in contrast to the harsh spasmodic cough, the singe-­
voiced, ringing chant of a slogan at an ACT UP rally in contrast to the inde-
cipherable rumblings of AIDS-­funding debate on the Senate floor. The poem
is a physical process, is bodily exercise: rhymes become the mental resting
places in the ascending rhythmic stairway of memory. . . .
 . . . The Egyptians gave their dead a book full of charms and spells to be
used in the afterlife—­might not poetry, then, facilitate the passing to another
realm? Poetry is a pulsing, organized imagining of what once was, or is to be.
What life once was, what life is to be. It is ampules of the purest, clearest
drug of all, the essence and distillation of the process of living itself. (1997:
166–­67)

In this description, Dr. Campo is implying the ways in which his interests in
poetry and in medicine coincide.
The schemas of narrative knowledge can be seen in this range of narra-

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tive practices associated with and growing out of medicine, as we have sug-
gested throughout the chapters of this book. Indeed, they can help even the
busy student or physician to learn to notice things that they might otherwise
miss in the stories patients bring to them and to notice, too, the desire or
concern of their patients, which they might not have been looking for at all.
These narrative responses to illness and suffering—­to what is grave and con-
stant in human suffering—­make the less organized narrative responses of
suffering patients themselves “tell” more fully a part of the diagnosis, treat-
ment, and understanding of health care. They help physicians, more effi-
ciently than the raw experiences of pain and fear, to develop phronesis.

Narrative and Medicine  /  283

9
narrative and everyday
medical ethics
Schemas of Action

“Out with it, Tarrou! What on earth prompted you to take a hand in this?”
“I don’t know. My code of morals, perhaps.”
“Your code of morals? What code?”
“Comprehension.” . . .
“You’re right, Rambert, quite right, and for nothing in the world would I try to
dissuade you from what you’re going to do; it seems to me absolutely right and proper.
However, there’s one thing I must tell you: there’s no question of heroism in all this. It’s a
matter of common decency. That’s an idea which may make some people smile, but the
only means of fighting a plague is—­common decency.”
“What do you mean by ‘common decency’?” Rambert’s tone was grave.
“I don’t know what it means for other people. But in my case I know that it consists in
doing my job.”
—­albert camus, The Plague (1991: 130, 163)

Ethical practices—­behaviors and relationships that necessarily encompass

“good” (versus “bad”) actions—­are woven into every aspect of medical prac-
tices precisely because health care always is vitally concerned with issues of
the nature of well-­being (the good life, Aristotle’s eudaimonia), the nature of
interpersonal care (responsibilities of behavior between people, especially in
the face of suffering), the maintenance of health and well-­being in the larger
community (the public and professional roles of physicians and health care
workers), and issues of life and death (measures of crucial values). Moreover,
the ethics of attitude and action, like the meanings of narrative, is a whole
greater than the sum of its parts: both ethics and narrative are vitally entan-
gled with concern. The ethics of caring is analogous—­and organized simi-
larly—­to the “point” or “moral” of a story: it is a global phenomenon, discern-
ible everywhere within a series of events and actions. For these reasons, the
ethics of a situation can be discerned, understood, and directed in terms of

/  284  /
the frameworks presented in the preceding chapters, and like narrative con-
cern, schema-­based reasoning can help teach the work of ethics. In this way,
ethics entails particular kinds of attention to and attending on events and
relationships (discussed in chapter 7); the comprehension of narrative knowl-
edge (discussed in Part 1 and chapter 6); the creation of mutual and, to some
degree, reciprocal relationships (discussed in chapter 5); and, above all, what
Dr. Rita Charon mentioned as “the duty to act” (quoted in chapter 8).
Ethics, then, can be apprehended as the meaningful whole of action. It
can be, as Albert Camus notes, the “comprehension” of a situation resulting
in the “common decency” of fulfilling the obligation of doing the job one
undertakes. Doing the job of caretaking entails, as we have been arguing
throughout these chapters, the “practical reason” of phronesis; more particu-
larly, as Dr. Rafael Campo says, it entails service and “service learning.” Fi-
nally, students can engage in such learning through the study of literary nar-
rative and narrative schemas. In this way, the ethics of medical practices can
be “comprehended”—­discerned, understood, and acted on—­as a whole.

Ethics in Medicine

This chapter addresses two very broad questions: what is ethics in medicine,
and can ethical behaviors in medicine become a habitual part of everyday
practices? The practices of medicine, because they deal with the well-­being
of a person and of communities of people that often involve life-­and-­death
questions, highlight ethical or moral issues. Ethics in general, as we shall see,
addresses questions about the values governing private and social behavior,
their chief ends and concerns. In the practices of medicine, ethics is closely
related to personal, interpersonal, and public values that arise in and affect
the encounter between a healer and a patient, and it directs the kinds of
decisions and actions a physician makes. Ethical issues that face a physician
include reconciling the aim of living a “good life” and being a “good doctor”;
discovering and enacting proper behavior in the patient-­physician relation-
ship; fulfilling responsibilities to the larger community as a physician; and
finding or negotiating the best actions—­especially in the face of conflicting
“good” possibilities—­in the care of patients.
Ethics is a general term used to describe the various approaches to dis-
cerning and exploring the moral life, or, in other words, the right and wrong
conduct of human behavior. One approach to arriving at moral principles or
practices that regulate ethical behavior is normative ethics. This theoretical

Narrative and Everyday Medical Ethics  /  285

approach expresses how we “ought” to live our lives. The claims that you
ought to treat others as you wish others to treat you (the Golden Rule), that
you ought not to kill (according to the Ten Commandments), or that you
ought to pursue the “right intentions,” including the intentions to do no harm
and to develop compassion (following the Buddhist Eightfold Path), are prime
examples of normative rules or principles. For this reason, ethics in general
grapples with universal moral questions that govern the ways in which we as
individuals—­ and also as societies of individuals—­attempt to achieve our
“highest good,” Aristotle’s eudaimonia. What is a good life? What are proper
and good behaviors that should be shown to others? What responsibilities
does one have to one’s larger community, to one’s immediate family and
friends, and to those that one is committed to serve as a member of a profes-
sion? How does one choose between conflicting good actions? Ethics attempts
to describe the responsibilities that people—­and groups of people—­have to
articulate and pursue the “good” for themselves and in relationships with oth-
ers, with larger social communities, and even with the world we live in and
steward for the future. Most important, such responsibilities are fulfilled in
actions that enact or realize the “good” in particular choices and behaviors.
Medical ethics deals with the moral and ethical questions that arise out of
the practice of medicine. By and large, it focuses on the practices of physi-
cians and health care workers. These questions can be part of the physician’s
daily individual choices (e.g., “How ought I to relate to this patient today?”)
as well as larger societal questions (e.g., “Is it ever justified for me to withhold
information, or to withhold the truth, from a patient?”). For the past twenty-­
five years, the study and practice of medical ethics has primarily been domi-
nated by applying certain analytic principles to ethical situations, an applica-
tion known as principle-­based ethics. This conception of ethics is analogous
to the nomological sciences insofar as it is based on universal—­and possibly
formulaic—­rules or laws. In classical Greece, the ethical principles that di-
rect the practices of medicine were articulated in various versions of the Hip-
pocratic oath, and in modern times, various versions of that oath have contin-
ued to describe the ethical principles governing medicine. Hippocrates was a
fourth-­century BCE physician in classical Greece. He and other physicians
composed the Hippocratic oath—­a statement that expresses the ideal ethical
conduct for physicians. There are two parts to the oath: (1) an oath of alle-
giance to regard his teacher at the same level as his parents, and (2) an oath
to uphold certain maxims, chief of which is “Do no harm.” (Both a modern
and a classical version of the Hippocratic oath are presented in appendix 3.)
More recently, however, discussions of medical ethics have been orga-

286  /  the chief concern of medicine

nized around four general analytic principles: autonomy, beneficence, non-
malfeasance, and justice. No one can seriously question whether physicians
should respect their patients’ autonomy; whether they should do no harm to
their patients; or whether, as professionals, they should do justice to patients
as individuals and as a class of individuals. Rather these principles serve as a
guide to help physicians and others make appropriate medically related deci-
sions. The functioning of principle-­based ethics involves deductive reason-
ing, starting with a general principle and reasoning to a particular case. In
this, it assumes, as does nomological science, the commensurability of cases.
The following principles govern principle-­based ethics in medicine.

Autonomy, or self-­rule, is key to our regard for individual freedom, pri-

vacy, and the acceptance of responsibility for one’s actions. In medical
practice, respect for autonomy allows patients to make their own de-
cisions in consonance with their values.
Beneficence is best defined as seeking the “best” outcome in relation to
a patient. Beneficent behavior also includes expressing kindness and
respect for the patient. Clearly doctors have a duty or responsibility
to strive for the best outcome for their patients, using their knowl-
edge and skill to cure disease, restore function, preserve life, and re-
lieve suffering. Historically, some doctors have argued that the prin-
ciple of beneficence justified withholding the truth about grim
prognoses; in their patients’ best interests, they kept bad news about
disease to themselves. Today, many people view this behavior as di-
rect interference with the individual’s right of “autonomous” self-­
determination and have effectively challenged such “benevolent pa-
ternalism.”
Nonmalfeasance is the obligation not to harm or cause injury to others.
This is best expressed in the Hippocratic maxim Primum non nocere,
“First, do no harm.” Beneficence and nonmalfeasance are similar in
definition and are often considered or discussed as one principle. To-
gether, these two principles comprise an element of nearly every
clinical or surgical encounter where benefits and risks must be
weighed in treating patients.
Justice requires that people be treated fairly. This means that similar
cases should be treated alike, the needs of all should be taken into
consideration in allocating limited resources, and everyone should
receive equal access to medical care. Justice is not served when some
receive preferential treatment, when people are denied information

Narrative and Everyday Medical Ethics  /  287

 or services to which they are entitled, or when the interests of the few
prevail over the interests of the polity. The principle of justice is com-
plex and involves difficult decisions, such as who should receive a
heart transplant. In developing criteria for this decision, what kinds of
information—­age, education, likelihood of success in terms of life ex-
pectancy and/or quality of life—­is relevant? Who is the better candi-
date for a transplant, an addicted mother of a three-­year-­old or a
twenty-­one-­year-­old college student, a professional (physician, scien-
tist, politician) or a working-­class person?

Unlike principle-­based ethics, where abstract principles are superim-

posed on or abstracted from particular situations—­a procedure in which the
principles (and, as we saw, “commensurability”) seem to come first and take
precedence over detailed situations, often best grasped by means of narra-
tive knowledge—­there has been a tradition in moral philosophy called casu-
istry. Moral casuistry takes the terms of the situation, rather than principles
from outside a situation, to make its judgments. Rather than resembling the
“deductive” method of principle-­based ethics, it is more “inductive”—­or, as
Charles Sanders Peirce says, “hypothetical”—­in its method. Traditionally,
philosophical debate has often used casuistry as a negative term to describe
overly subtle and misleading or false reasoning. Unlike principle-­based eth-
ics, which are called on in moments of crisis or decision making, casuistical
reasoning is bound up in every meeting of physician and patient. A more
particular version of casuistry in the practice of medicine is what has come to
be called “relational ethics.” Relational ethics begins with the patient—­the
patient’s story and the patient’s chief concern—­and allows for narrative cat-
egories and skills to define the ethics of medical practice. In fact, casuistical
reasoning is an important aspect of ethical judgments in everyday practices
of medicine.
Opposed to both principle-­based ethics and casuistry is virtue ethics or
virtue theory, one of many various strategies used to supplement normative
ethics. Virtue ethics grows out of Aristotle’s concept of phronesis and his in-
sistence on a “practical syllogism,” and it does so by emphasizing—­as the
practical reasoning of phronesis does—­individual character or personal eth-
ics, rather than following specifically defined rules of conduct. Because a
virtue theory of ethics is focused on the agents or actors of ethical action, it
is analogous to the agents performing narrative roles examined in the pre-
ceding chapter, and it emphasizes the narrative element of ethical behavior
more generally. As such, it lends itself to questioning the relationship of par-

288  /  the chief concern of medicine

ticular encounters and actions to the whole of a medical encounter, to its
goals of healing, relieving suffering, and caretaking. In this, like casuistry, it
is an everyday practice of ethics, but it focuses more on habituating ethical
behavior, rather than formulating ethical judgments. As mentioned in the
introduction, virtue ethics helps discern how ethics is woven into all aspects
of medical practices—­in the ethics of seeking a “good life,” the ethics of the
patient-­physician relationship, the ethics of the physicians responsibilities to
nonpatients (family and community), and the ethics of negotiating the ambi-
guities of right action. Such discernment is aided by an understanding of the
relationship between the parts of medical practice and the whole conceived
in relation to overall goals of medicine. In other words, virtue ethics focuses
on virtues in action. Virtue ethics distinguishes itself from principle-­based
ethics insofar as it focuses on the agents of behavior rather than the behav-
iors themselves. For the same reason, but to a lesser degree, it distinguishes
itself from casuistical ethics and relational ethics insofar as it focuses on ac-
tion, particularly habitual action. As we noted earlier, Charles Sanders Peirce
defines belief as habit made conscious.
Normative ethics, principle-­based ethics, and even casuistic ethics often
engage large and powerful issues of life and death, the weighing of social and
personal goods, and irreversible critical choices in medical practices. In com-
parison, the virtue ethics we are describing grow out of ordinary, everyday
practices and action, the very stuff of narrative. For this reason, physicians
ordinarily engage in everyday ethical practices that do not partake in what
Anne Hunsaker Hawkins calls “neon ethics” (Vannatta, Schleifer, and Crow
2005: chap. 5, screen 31). The opposite to this, William Carlos Williams says,
is “something else—­the way a doctor’s general attitude toward people, his per-
sonal decency and his view of what life means, can influence the way he prac-
tices medicine” (cited in Coles 1989: 116). Dr. Howard Brody describes this in
another way when noting the argument of some feminist scholars that much of
ethical behavior in real life is like “housekeeping.” “Housekeeping,” he writes,

signifies that portion of ethical behavior that is like mopping the floor: no one
will praise you for mopping the floor; everyone will blame you for failing to
mop the floor; and no matter how good a job you did yesterday of mopping
the floor, it still has to be done all over again, indefinitely. The physician does
many things on a day-­to-­day basis purely out of habit and without any explicit
analysis. . . . The physician, for instance, does not choose each time she en-
counters a patient whether to smile and offer a friendly, warm greeting, but
her doing so means both that things will happen afterward in certain ways

Narrative and Everyday Medical Ethics  /  289

 and not in other ways and that a certain set of ethical dilemmas will arise very
seldom in her practice. (2003: 208, following Warren 1989)

In “Tintern Abbey,” more than two hundred years ago, William Wordsworth
describes this “habitual,” undeliberate activity in remarkably ethical terms:

that best portion of a good man’s life,

The little, nameless, unremembered acts
Of kindness and of love.

Aristotle provides us with perhaps the most influential systematic ac-

count of the everyday ethics of virtue theory in the Nicomachean Ethics,
where, as we have seen, he develops the notion of phronesis. According to
Aristotle, virtue of character is the mean between the excess and deficiency
of various virtues; such virtues are good habits that we acquire and that regu-
late our behavior. In fact, as we have suggested, the habitual feature of phro-
nesis might have convinced many that phronesis does not lend itself to the
systematic understanding and performances of technē—­even though other
“habits,” like playing the piano, automatically hitting backhands in tennis,
and improvising jazz, can be systematically trained. In any case, Aristotle’s
focus on virtue theory, based on the virtues that a person possesses, is, like
phronesis itself, particularly appropriate to medical ethics, since medical eth-
ics is predominantly concerned with the practices of working health care
providers. As an agent-­based ethics, it is also strongly linked to discussions
(examined in the preceding chapters) of storytelling and listening and the
dramatic interaction of people—­the “actors” of dramatic narratives as well as
patients and physicians. Like those discussions—­and like Albert Camus’s
definition, in The Plague, of the “code of morals” as “comprehension”—­
virtue ethics focuses on the dramatic action of virtuous agents to compre-
hend the meaning and concern of narrative wholes.

Schema-­Based Ethics

Aristotle offers a long—­but not exhaustive—­list of the virtues of a moral

agent. Those that are most fully useful in examining the ethics—­and the
ethical narratives—­of everyday medical practices include competency, con-
scientiousness, discernment, compassion, trustworthiness, and common de-
cency (as well as phronesis conceived as a virtue possessed by a phronimos).1

290  /  the chief concern of medicine

These virtues are closely connected to medical practices examined in the
chapters of Part 2: conscientiousness is a virtue of physicians attending to
patients (chap. 7); discernment is a virtue of physicians grasping the narrative
knowledge embedded in the patient’s story that entails a medical judgment
(chap. 6); compassion and trustworthiness are virtues of the patient-­physician
relationship (chap. 5); and the “intellectual virtue” of phronesis is a general
category, conceived in Part 2 as “clinical judgment” rather than “practical
reason.” (In checklist 4, “Virtue Actions,” in appendix 2, we unpack these
virtues in terms of particular actions that, undertaken, realize them.) Three
other virtues can be seen as “default” or assumed virtues: integrity, compe-
tence, and the virtue of common decency. Atul Gawande describes these de-
fault virtues in relation to the “discipline” of professional occupations:

all learned occupations have a definition of professionalism, a code of con-

duct . . . [consisting of] three common elements.
First, is an expectation of selflessness . . . [which] will place the needs and
concerns of those who depend on us above our own. Second is an expectation
of skill. . . . Third is an expectation of trust-­worthiness: that we will be respon-
sible in our personal behavior toward our charges. (2010: loc. 2532)

As noted in chapter 6, patients commonly complain that their doctor does

not listen, but they rarely complain that their doctor does not know enough
or is not competent; and the more global virtue of integrity reveals itself in
terms of the agent of ethic action and, as such, is more closely related to eth-
ics conceived as the pursuit of the “good life”—­eudaimonia—­rather than
selfishness. Moreover, integrity—­involving the virtue of being true to one’s
own (professional) nature—­is, in a sense, a way of understanding all the
other virtues. Finally, common decency, as we suggested in chapters 2 and 3,
is a default virtue for a social species that depends on and trusts fellow mem-
bers of the cohort and community. Such virtues of a social species inhere in
the very fact that narrative—­what Brian Boyd defines as “telling events”
(2009: 382)—­includes, as a necessary feature, the combination of teller and
receiver. This feature implies that narrative is a social (and dramatic) action
that assumes truthfulness, goodwill, and shared values.
The virtues of virtue ethics lend themselves to being understood in terms
of narrative and literature. In fact, art narrative—­classical tragedy, modern
short stories and novels, and even the powerful emotional storytelling of lyric
poetry—­is the province of virtue ethics. But perhaps equally striking, because
ethics—­and especially virtue ethics—­is so thoroughly woven within everyday

Narrative and Everyday Medical Ethics  /  291

practices of medicine, medical narratives are particularly good places to see
some of the elements of narrative that move and enlighten people. Each time
a physician enters an exam room or hospital room, he or she makes certain
choices about how to act, behave, or communicate toward that particular
patient within the context of the drama of medical practices described in the
preceding chapter. In this way, the individual “character” of a physician can
positively or negatively affect the care of patients. Physicians who demon-
strate the virtues of conscientiousness, discernment, compassion, and trust-
worthiness are more likely to exhibit positive actions, such as calling a patient
by name, making eye contact, touching the patient in a nonthreatening way,
and other such empathetic actions, which, in turn, may help many patients
establish a sense of trust and build a therapeutic alliance with their physician.
Physicians who exhibit the virtues of clinical reasoning, common decency,
and integrity are more likely to promote the well-­being of—­or at least care
for—­their patients. As a result of the demonstration of these virtues, both
patient and physician will be aware of their shared goals and the larger mean-
ing of their encounter. In such a dramatic comprehension of medical prac-
tice, the line between professional ethics (precepts or principles) and per-
sonal ethics (virtues) blur. Moreover, such blurring offers the possibility of a
“narrative ethics,” one that combines casuistic reasoning from case to princi-
ple and a dramatic ethics of virtuous agents. Ethical issues are almost always
complex; that is, ethical contest grows out of complex life situations and dra-
matic—­in the literary sense of the word—­confrontations. Thus the contested
ethical decisions that patients and physicians are faced with lend themselves
to complicated, complex reasoning and debate, so that a single approach to
questions of value and action, such as principle-­based ethics, often does not
suffice. In the practices of medicine a narrative-­based ethics can fruitfully
supplement principle-­based analyses and decision making.
What we are calling “the dramatic ethics of virtuous agents” is enacted
every day in medicine. The following vignette lends itself to an understand-
ing in terms of virtue ethics.

A thirty-­two-­year-­old woman had been ravaged by type 1 diabetes since

age thirteen. She had married at age eighteen and given birth to three
daughters. She had spent the week of the events described here in the
hospital, yet again in diabetic ketoacidosis—­caused largely by several
infected boils on her skin. She was put in the intensive care unit for the first
thirty-­six hours, then out on the medicine wards, to gain enough strength to
return home. “Home,” however, had a new meaning recently: she had

292  /  the chief concern of medicine

moved out of the family home, accusing her husband of abusing her
physically. She smoked two packages of cigarettes a day and was often
outside the hospital smoking, so that the intern and resident, as well as the
attending physician, commonly had a difficult time locating her.
Caring for this woman proved very difficult. The intern and resident
found her angry in general, irrational in her decision making, and
commonly attempting to play one caretaker against another. She believed
that her stomach was “dead”—­she “remembered” that her previous doctor
told her so—­and thus that she obviously couldn’t take oral antibiotics.
Because of this, the resident had to keep her in the hospital.
On one particular day, the resident burst into the patient’s room without
knocking. With very little introduction, he began telling the patient that she
was ready to go home. He listed a series of actions the patient must do to
take good care of diabetes, such as checking her blood sugar twice a day,
exercising daily, dieting, and taking the medications exactly as prescribed.
The patient, having had this disease for nearly twenty years, had heard all
this before, yet she rarely performed any of these tasks. The patient began
to answer with reasons why she could not check her blood sugar (the strips
were too expensive) or exercise (she must look after three young
daughters). She said that she found it difficult to eat the diabetic diet
because of lack of funds and that, besides, she usually vomited most of her
food. In response to the patient’s excuses, the resident interrupted her
twice, raised the volume of his voice, and proceeded to argue with the
patient concerning every point of the discussion. This exchange escalated in
a very short time into a fight. The patient told the resident to get out of the
room, and in five minutes, the nursing staff paged the attending physician
because the patient was threatening to leave the hospital with an
intravenous line in place.

Rancorous scenes like the preceding one between patient and doctor
are, unfortunately, not uncommon. The patient in this vignette has a
chronic illness that is expensive and difficult to manage. She suffers from a
psychiatric abnormality—­probably borderline personality disorder—­and
from recent marital stress. This patient is going to be very difficult to care
for under the best of circumstances. The skills one needs to deal with her
whole illness and predicament appropriately are different from the skills
needed to treat her infection and diabetic ketoacidosis. For the physician
to be competent to care for this patient in total—­to exhibit the “common
decency,” as Camus says, of “doing his job”—­he must have sufficient bio-

Narrative and Everyday Medical Ethics  /  293

medical knowledge and also the virtues of conscientiousness, discernment,
and compassion. This resident, while competent to order the appropriate
antibiotic and bring the patient smoothly out of the ketoacidotic state, fails
to demonstrate Aristotelian virtues. A conscientious physician would have
recognized in the patient’s “unspoken” story that the patient is not a well-­
balanced, mature adult, capable of behaving in a rational manner toward
her illness. Such a physician would have been more mindful of the patient’s
limitations. Moreover, in dealings with this patient, a discerning physician
would have grasped and considered the patient’s psychosocial story as a
meaningful whole. Finally, a compassionate physician would have recog-
nized and acknowledged the patient’s plight as an abused wife and single
parent coping with a terrible chronic illness and an inadequate income, in
the action of verbal empathy.
Competence in the domain of biomedical knowledge and clinical
action—­diagnosis and treatment—­is easily tested quantitatively. But compe-
tence in the realm of narrative knowledge and virtuous action—­apprehending
the whole of the story and acting according to the virtues of good behav-
ior—­is less easy to quantify: such competence, as we noted in chapter 1,
possesses a functional reality that is grasped after the fact.2 However, com-
petency in both domains defines the “good doctor” practicing everyday ethi-
cal medicine. Moreover, virtue ethics—­as opposed to principle-­based ethical
judgments or even casuistical reasoning—­lends itself to the methodical or
systematic weaving of ethics into the everyday practices of medicine; it lends
itself to schemas of understanding. Virtue ethics—­conceived in terms of the
narrative knowledge and narrative skill of repeatedly relating part to whole—­
signals the necessity for a “pause” in action (see chap. 8) to ask about consci-
entiousness, discernment, compassion, and overall decent behavior in the
face of suffering. The resident can ask himself—­even in the midst of hectic
medicine—­whether he is demonstrating conscientiousness, or achieving dis-
cernment; whether he is compassionate in the face of even the most unpleas-
ant suffering; and whether his actions are most likely, in this particular situa-
tion with this particular patient, to result in accomplishing goals of healing or
relieving suffering or simply taking care of another person.

Virtue Schema

In the Nicomachean Ethics, Aristotle defines virtue partly as “a state of char-

acter concerned with choice . . . determined by a rational principle, and by

294  /  the chief concern of medicine

 that principle by which the man of practical wisdom [i.e., a phronimos] would
determine it” (2.6.1107a; trans. Ross). In an instance like the previously dis-
cussed one of a patient recovering from diabetic ketoacidosis, the physician
can choose to behave toward the patient in such a way that the virtues of
decency, discernment, conscientiousness, trustworthiness, compassion, and
competence manifest themselves. Such choices can be aided simply by re-

Doctor Dogood Comforts The Crying Child

Decency, Discernment, Conscientiousness, Trustworthiness, Compassion, Competence

membering these virtues as they manifest themselves in the heuristic phrase

In appendix 2, we offer virtue-­action checklists that present specific activities
whose performance, we suggest, will indicate whether or not the virtues of
discernment, conscientiousness, discernment, trustworthiness, and compas-
sion are enacted. Such checklists are based on Aristotle’s assumption that
virtues are, by definition, virtues in action. Decency and competence are
“default” virtues for different reasons: competence (or, as Gawande says,
“the expectation of skill”) is simply a professional given; while decency is
achieved by means of the enactment of the other virtues.3

Everyday Ethics and the Vicarious Experience of Narrative

Literary narrative is particularly powerful in demonstrating the place of eth-

ics in the everyday practices of medicine. Ethics, in an important sense, is the
fabric of every encounter with a patient; it is a set of principles used not only
to live a good life but to practice ethical medicine and to “do right.” Everyday
practices of medicine involve, first and foremost, the relationship of patient
and physician—­the different ways in which physicians interact with, treat,
and care for their patients. These practices are essentially ethical in the sense
that they entail interactions and behaviors that strive to be good and proper.
In the Nichomachean Ethics, Aristotle defines ethics—­what he calls “virtue
of character”—­as “good habits” that we acquire and that regulate our behav-
ior. Whether or not he means that ethical behavior is habitual in the sense of
automatic, Aristotle is suggesting that ethical behavior inhabits the practices
of everyday life, as opposed to what Hawkins calls the “neon ethics” of high-­
profile ethical dilemmas in medicine. The acquirement of such habitual be-
havior quite often takes the form of—­and is discernible in—­the kinds of

Narrative and Everyday Medical Ethics  /  295

narrative experiences we have been examining. Everyday ethical practices
grow out of experience, direct or vicarious. They are acquired through at-
tending to experience and through the grasping of its meaning. Such behav-
ior—­we can call it ethical behavior—­is embodied in interpersonal relation-
ships and in action growing out of experience, knowledge, and the human
relationships they produce.
A novel like Roddy Doyle’s The Woman Who Walked into Doors presents
the vicarious experience of everyday ethics in medicine. In the novel, a doc-
tor encounters Paula, a victim of continuous domestic violence. Paula does
not share her story of abuse with her physician, and she reports that he never
asks for her story.

—­What made you do that?

Fuckin’ doctors.
—­What made you do that?
Stupid fuckin’ bastards. What made me do that? Looking at my eye. Look-
ing for my eye, behind the pulp. He didn’t want an answer; he muttered,
thought he was being nice. Silly you; look what you did to yourself. None of
them wanted answers.
—­A little bit of make-­up will cover that up for you.
None of them looked at me.
—­As right as rain.
None of them saw. Tut-­tut-­tut and another prescription. More pills to
wash down. There was sometimes no food in the house but there was always
valium.
—­Do you take a drink, Missis Spencer?
Plenty of rest. Put your feet up for a while. Get your hair done; spoil your-
self.
—­Put this woman to bed the minute you get home, Mister Spencer, and
bring her a cup of tea.
—­Yes, doctor.
The two of them, looking after me. Laughing at me. The woman who
walked into doors. They didn’t wink at each other because they didn’t have
to.
They were all the same; they didn’t want to know. They’d never ask. Here’s
a prescription; now fuck off. The young ones were the worst, the young ones
in Casualty. So busy, so important.
—­It’s people like you that waste my time.
I should have boxed her ears. A kid in a white coat, playing. Shouting at the

296  /  the chief concern of medicine

 nurses. A fuckin’ little child with no manners. And I took it from her.
—­Sorry, doctor.
—­Next. (Doyle 1996: 189–­90)

This passage describes a physician who fails to attend to the patient’s experi-
ence and grasp its meaning. Moreover, Doyle’s narration of his behavior and
actions creates a vicarious experience of this failure—­precisely the experi-
ence of the physician’s failure in the ordinary, everyday practices of medicine.
Doyle presents doctors who see stereotype and fail to look for insight. In
his novel, the physicians fail to notice Paula’s physical findings (which are
indicative of abuse) and her repeated visits to the hospital for similar inci-
dents, thus failing to apprehend the narrative knowledge the situation pres-
ents to them. In particular, the preceding passage describes a physician who
fails to apprehend the whole. Such apprehension entails gathering together
disparate details into a pattern of relationships, a relational whole: in Doyle’s
narrative of Paula’s encounter with her physician, the physician fails to ob-
serve or recognize the signs of domestic violence—­the meaningful whole of
her various wounds and symptoms (see chap. 6 in the present book). He also
fails to provide a safe environment where Paula can tell her story without
Charlo, her abuser, in the exam room—­thus failing to create a situation of
careful listening (see chap. 7). Moreover, he fails to create any kind of mean-
ingful rapport or relationship with his patient (see chap. 5). Failing to appre-
hend the whole of her story, to attend to his patient, and to relate to his pa-
tient, the physician sends his patient home with drugs and recommends rest.
He returns her to an environment in which her life is literally in jeopardy.
Paula is scared, angry, and frustrated at her physician—­her emotions are
enacted in her silent sarcastic responses—­for failing to ask, for failing to act
on her behalf, and for failing to protect her.
The failures we are describing are realized in the experience of Paula
and, vicariously, in the reader of her story. The Woman Who Walked into
Doors presents Paula’s story as a whole—­literally in her own first-­person
voice—­against which we can measure the doctor’s actions in relation to her
even more than we can measure the resident’s actions in relation to another
seemingly “uncommunicative” and uncooperative patient, the woman with
diabetes and ketoacidosis; that is, this literary narrative provokes vicarious
experience in its readers. It does so by making explicit the theory of mind we
described in chapter 2: Doyle narrates the unsaid dialogue between Paula
and the health care workers she encounters, so that what young children
begin to do naturally about the age of four—­namely, automatically (but also

Narrative and Everyday Medical Ethics  /  297

systematically) to grasp possibilities of another’s thoughts and intentions—­is
presented to us in narrative form. Paula is guessing what the health care
workers are thinking—­it is the educated guess of theory of mind—­even while
readers do not have to guess what Paula is thinking. (Readers do have to
guess the feelings of the woman with ketoacidosis, which is why our discus-
sion of that narrative had to emphasize the implications—­including the “ed-
ucated guess” of a diagnosis of borderline personality disorder.) In this way,
the aesthetics of art narrative, as Scott Stroud contends, create “subjective
perspectives or experiences the narrative opens up to the reader,” in what is
called “Subjective Knowledge Theory” (2008: 19). “This type of knowledge,”
he argues, “will be gained by virtue of the literary narrative’s aesthetic quali-
ties, which result in a certain type of activity in the reader,” including the
reader’s “identification with the values, beliefs, and/or behaviors of the simu-
lated agent” (20).
Such aesthetic qualities, Stroud says, create a “simulation” of experience
from which a reader can “construe” possible endings and concerns for fic-
tional stories. (In this, he agrees with Francis Steen’s conclusions we encoun-
tered in chapters 2 and 3.) The reader uses “the imagination to test the via-
bility of certain values and goals in terms of what results they would have for
one’s life and its flourishing”; and “powerful fiction,” Stroud concludes, “is
useful in getting one to possibly revise, strengthen, or change one’s values.
Literary narrative, therefore, holds important cognitive value in enabling
readers to grow and develop morally” (2008: 26; in this passage, Stroud is
citing Gregory Currie’s use of the term flourishing [1997: 54], which, as we
have seen, is a viable translation of Aristotle’s eudaimonia). Although he does
not say so, both the generality of “imagination,” as Stroud describes it, and
the specificity of “certain values” are determined by provisional schemas that
the reader brings to her experience, thereby informing and constituting that
experience. In other words, narrative “creates” (so to speak)—­or at least
conditions—­such experience by means of schemas that inform and consti-
tute the seeming immediacy of experience. As Stroud says, precisely the ex-
perience that narrative gives rise to—­one of the salient features of narrative—­
makes it an important element in moral education.
Such vicarious experience is clear, Stroud argues, in literary or “art” nar-
rative, because “through symbolic means (such as written stories), individu-
als can see how a value or pattern of action ‘plays out’” (2008: 35). To de-
scribe the power of literary narrative, Stroud contrasts what we are calling a
“popular narrative” with the art narrative of Joseph Conrad’s Heart of Dark-

298  /  the chief concern of medicine

ness, by giving a “fictional account” of an interaction of two people and then
quoting from Conrad’s novel “in order to show the difference between a
merely imagined interaction . . . and a simulated experience of a subject
([Conrad’s] Marlow) being in a specific conversation with a specific charac-
ter” (30). Stroud’s contrast is parallel to our discussion of the woman with
ketoacidosis and our subsequent quotation of Doyle’s narrative. “The first
account,” Stroud notes, “while conveying many of the same details, does not
have the same experiential meaning of the second . . . [that manifests itself
in] the textual devices of ellipses and fragmentary sentences that allow the
reader to simulate the actual state of Marlow partially attending to [his inter-
locutor’s] utterances” (31). In a similar fashion, by means of the “textual de-
vices” of Paula’s fragmentary responses, her expletives, her imitating the
imagined conversation of her caretakers (“Tut-­tut-­tut and another prescrip-
tion. More pills to wash down”), and her meek apology contrasted with her
anger, frustration, and sarcasm, Doyle creates what Stroud calls “subjective
knowledge” in his readers. The pronounced details of art narrative call atten-
tion to themselves through what we described as the “aesthetic effect” of
Chekhov’s “loaded rifle” in chapter 3, where every detail of an artful narra-
tive counts as a “telling detail.”
Moreover, in his analysis, Stroud emphasizes the ethical effects of such
aesthetic narratives. In this discussion, the term models that he cites de-
scribes the “schemas” we describe throughout this book. He argues

that “a great deal of information about human values, thinking, patterns, and
behavior is gained from models [schemas] portrayed symbolically through
verbal or pictorial means.” Indeed, given the limited experiences one has
with the world and other people, such “vicarious” or “observational” learning
must be what accounts for the wide range of thinking and behavioral strate-
gies that humans possess. One sees another person in a situation and can see
how her values and strategies for action play out in terms of her expectations,
goals, and so forth. An observer (reader) then can appropriate those values
and strategies if they seem to be advantageous to what she wants to be or
wants to do. (2008: 35, citing Bandura 1994: 66)

In this way, the vicarious experience of art narrative powerfully contributes,

in the very “subjective knowledge” that it provokes, to the moral education of
its readers. This is particularly clear in medicine. What the physician or med-
ical student “wants to be or wants to do” is to be an engaged health care

Narrative and Everyday Medical Ethics  /  299

worker whose first responsibility is to care for her patient. As we noted in
chapter 2, Edmund Pellegrino has argued that the professions of medicine
and health care offer a more ready agreement “on a telos”—­that is, “an end
and a good”—­in their work than can be found in more general consider-
ations of moral values, in that they offer an agreement of the moral good of
“a healing relationship between a health care professional and a patient, [in
which] most would agree that the primary end must be the good of the pa-
tient” (1995: 266).
For this reason, physicians and, indeed, the medical profession itself
understand that when patients go to a doctor, they have certain fundamen-
tal rights. The American Medical Association outlines fundamental ele-
ments of the doctor-patient relationship. These include

The right to receive information from physicians and to discuss the ben-
efits, risks, and costs of appropriate treatment alternatives.
The right to make decisions regarding the health care that is recom-
mended by the physician.
The right to courtesy, respect, dignity, responsiveness, and timely atten-
tion to health needs.
The right to confidentiality.
The right to continuity of health care.
The basic right to have adequate health care. (“Patient Rights,” http://
www.emedicinehealth.com/patient_rights/article_em.htm)

When Paula visits her doctors, many of these rights and expectations are vio-
lated; she is not treated with respect; she does not receive adequate or—­
given her many visits to this hospital—­continuous care. Because of these
violations—­that is, because of shared moral values, which the AMA makes
explicit and which are implicitly rendered in Doyle’s dramatic representation
of the encounter between a physician and a seemingly silent and docile
patient—­readers consistently come to identify with Paula and, as Stroud
says, experience both her “situation” and the felt violations by her physician.
In this example, the narrative knowledge conveyed by the patient’s story, ap-
prehended in the telling details of self-­conscious narrative art, makes the
moral element of everyday doctoring a felt aspect of the narrative itself—­the
experience of outrage in the face of the physician’s dismissal of his patient
and the act of self-­conscious reflection that vicarious outrage provokes.
Moreover, the awareness born of experience and reflection makes the ab-
stract rights described by the AMA seem somehow more real in their narra-

300  /  the chief concern of medicine

tive violation, a part of “experience” itself.

Medical Mistakes and Everyday Ethics

In Roddy Doyle’s The Woman Who Walked into Doors, Paula’s physician fails
at attending and paying attention to his patient, barely veiling his contempt
for a seeming alcoholic woman from a different social class. Such attention is
an important aspect of the everyday ethics of medicine, and the narrative
representation of the failure to consistently achieve it provokes consideration
of the ordinary ethics of everyday behavior, simply because the “textual de-
vices” of Doyle’s literary narrative—­Paula’s silent dialogue, her imagined re-
sponses, the contrast between the actual scene and her imagined scene—­
disrupt, momentarily, the communicative function of language, to create the
necessity of reflection. We can see this in another art narrative, Sophocles’s
tragedy Philoctetes, a play—­closer to Aristotle than Doyle’s narrative—­that
can help us better understand the role of positive emotions in making every-
day ethical decisions in medicine and also the positive effects of the small
narratives of mistakes in the moral education of a phronimos.
Philoctetes, like the classical tragedy Aristotle discusses in the Poetics
more generally, dramatizes the role of individual values in the ethical decision-­
making process by focusing on the important role of emotions in action. In
this tragedy, Philoctetes has been banished to the island of Lemnos to live out
his life, diseased and in pain. This is one of the few classical tragedies that
actually presents suffering on stage. The chorus of sailors under Neoptole-
mus’s command provides a moving description of Philoctetes’ plight.

He was lame, and no one came near him.

He suffered, and there were no neighbors for his sorrow
with whom his cries would find answer,
with whom he could lament the bloody plague
that ate him up.
No one who would gather
fallen leaves from the ground
to quiet the raging, bleeding sore,
running, in his maggot-­rotten foot.
Here and there he crawled writhing always—­
suffering like a child
without the nurse he loves—­

Narrative and Everyday Medical Ethics  /  301

 to what source of ease he could find
when the heart-­devouring suffering gave over.
(Sophocles 1957: 222)

The play’s hero, Neoptolemus, recognizes Philoctetes’s pain and suffering

and reacts with compassion. This dramatic situation encompasses the atten-
tion, the apprehension of meaning, and the creation of a relationship that
describe everyday ethical practices. But more important—­ especially for
health care workers reading this play—­this situation leads Neoptolemus to
act in relation to Philoctetes’s suffering. It is this emotion of compassion that
persuades Neoptolemus to tell Philoctetes the truth. The narration of his
truth telling presents most of the elements in the AMA catalog of patient
rights. Neoptolemus and Odysseus had schemed to trick Philoctetes into re-
turning to Troy to assure the Greek victory over the Trojans. Neoptolemus’s
encounter with Philoctetes’s suffering convinces him that living a “good life”
does not include trickery, which he recognizes as not part of his nature.
Philoctetes asks him, “Is it disgust at my sickness? Is it this that makes you
shrink from taking me?” Neoptolemus replies, “All is disgust when one leaves
his own nature and does things that misfit it” (230).
Neoptolemus’s sense of himself, his “disgust” that he has betrayed his
own best nature, reveals one aspect of “everyday ethics,” namely, the need
most people feel to achieve some version of what has been called the “good
life”—­Aristotle’s eudaimonia, Jefferson’s “pursuit of happiness”—­for them-
selves. It is everyday because “the good life”—­whether it be Mr. Head’s ev-
eryday relationship with his grandson, Dr. Nicholas’s everyday relationships
with his patients, or Dr. Selzer’s end-­of-­life narrative for himself as mediated
through a dying boy (see chap. 5)—­is a thoroughly quotidian category. Neop-
tolemus comes to realize that he has a sense of himself—­and the “good” he
hopes for and expects from himself—­that transcends particular relationships
and actions in an apprehension of wholeness. In other words, Sophocles por-
trays Neoptolemus grasping the meaning of his actions—­actions that he
comes to see are mistakes—­in relation to what he takes to be the meaning of
his life, his “nature.” Sophocles offers the dramatic realization and represen-
tation of integrity, a personal virtue that manifests itself in relation to other
people. In this drama, Neoptolemus is the hero, fulfilling his own nature of
the sought-­for good. Philoctetes is his helper, and Odysseus is his opponent.
The result of this drama is first apprehended as an emotion (“disgust”), but it
leads to a clear comprehension, in everyday terms, of what is the proper ac-

302  /  the chief concern of medicine

tion of the hero, the “recognition” of the Aristotelian hero. Such an appre-
hension of eudaimonia calls on the same skills of narrative understanding—­
careful listening (in this case, to Neoptolemus’s own feelings and agenda),
perceiving narrative knowledge, forging interpersonal relationships, and de-
termining subsequent action on the basis of such understanding—­that we
have discussed in earlier chapters. Its achievement is that of a phronimos.
In Sophocles’s drama, Neoptolemus learns from his mistake: this, in fact,
might well be what Aristotle means by anagnorisis in his analysis of tragedy;
and it might well be the ethical element in the narrative altogether (the wit-
ness who learns). Certainly, the recognition and acknowledgment of the pos-
sibility of mistake is at the basis of Gawande’s The Checklist Manifesto, which
begins its (historical) argument of the necessity of checklists with the crash
of Boeing’s “flying fortress” in a test flight in 1935. “Checklists,” Gawande
argues, “seem to provide protection against . . . failures. They remind us of
the minimum necessary steps and make them explicit. They not only offer
the possibility of verification but also instill a kind of discipline of higher
performance.” He goes on to note that “the routine recording of the four
vital signs” became the norm in American hospitals in the 1960s, “when
nurses . . . . designed their patient charts and forms to include the signs, es-
sentially creating a checklist for themselves” (2010: loc. 516). What the care-
givers are checking for are not positive mistakes—­though failure to check on
a patient’s overall condition is itself a mistake—­but early signs of possible
health failures, what we might call “schemas of possible or provisional
mistakes”—­or better, schemas for learning from mistakes. Certainly, check-
list 4, “Virtue Actions,” in appendix 2 (see also n. 3 in this chapter) provides
a list of actions for which failed performance—­like the failure of the test pilot
in 1935 to unlock the elevator and rudder controls—­might well result in the
disastrous misdiagnosis (or partial diagnosis) and misbehavior of the resident
treating the woman with diabetic ketoacidosis.
In any case, medical mistakes occur in every aspect of the practices of
everyday medicine, from the emergency room to a routine visit in the doctor’s
office, even if they are rarely as egregious as Neoptolemus’s treatment of the
person in his care. They are made because physicians and other health care
professionals who provide for the well-­being of patients are themselves hu-
man beings and subject to human limitations (they are fallible tragic heroes
and not the seemingly superhuman heroes of melodrama, like Dupin or
Holmes). Such mistakes can help us discern the ways in which narrative un-
derstanding contributes to grasping the ethical dimension in medical prac-

Narrative and Everyday Medical Ethics  /  303

tices. We already saw this in the mistakes of Paula’s doctors in The Woman
Who Walked into Doors, but in his medical memoir Healing the Wounds: A
Physician Looks at his Work, Dr. David Hilfiker describes mistakes in medi-
cine in a more systematic fashion. “Mistakes,” he writes, “are an inevitable
part of everyone’s life. They happen; they hurt—­ourselves and others. They
demonstrate our fallibility. Shown our mistakes and forgiven them, we can
grow, perhaps in some small way become better people. Mistakes, under-
stood this way, are a process, a way we connect with one another and with our
deepest selves” (1985: 58). Hilfiker goes on to notice that, partly because of
“technological wonders and near-­miraculous drugs, modern medicine has
created for the physician an expectation of perfection.” Such perfection, he
says, “is a grand illusion, of course. . . . Doctors hide their mistakes from pa-
tients, from other doctors, even from themselves” (59). Hilfiker confesses
that he is troubled by the fact that he is a healer who at times does more harm
than good. He also calls on the medical profession to deal openly with medi-
cal mistakes—­to talk about these concerns with colleagues and patients alike.
The illusion of perfection also suggests some of the limitations of
principle-­based ethics. Based on universal, abstract precepts of proper be-
havior, the principles of ethics allow for the judgment of action without fully
examining “the circumstances, ends and means, reversals of fortune, unin-
tended consequences” of a narrative whole (Ricoeur 1984: x). Often the
judgments of principle-­based ethics will take into account the ends and
means of behavior (under the category of justice). Other aspects of this nar-
rative description of events, such as the circumstances and even the unin-
tended consequences, may be taken into account to some degree, even
though they are not clearly linked to the four principles. But the “reversal of
fortune”—­Aristotle’s peripeteia—­is something principles do not attend to in
any meaningful fashion.
In his chapter titled “Mistakes,” Dr. Hilfiker narrates the story of a mis-
take he makes with his pregnant patient Barb Daily. Mrs. Daily’s urine sam-
ples repeatedly test negative for pregnancy. Dr. Hilfiker and the Dailys—­
Barb and her husband, Russ—­are friends. Although the discrepancy between
her seeming pregnancy—­Barb has been pregnant before and repeatedly tells
Dr. Hilfiker she feels pregnant—­and the negative results could be resolved by
an ultrasound, Dr. Hilfiker does not recommend it. “Barb,” he notes,

would have to go to Duluth for the examination. The procedure is also ex-
pensive. I know the Dailys well enough to know they have a modest income.
Besides, by waiting a few weeks, I should be able to find out for sure without

304  /  the chief concern of medicine

 the ultrasound; either the urine test will be positive or Barb will have a mis-
carriage. I call her and tell her about the negative test result, about the pos-
sibility of a miscarriage, and about the necessity of seeing me again if she
misses her next menstrual period. (1985: 56)

After additional urine tests, Dr. Hilfiker performs a dilation and curettage (D
and C) and discovers he has aborted a live fetus.
This narrative presents a powerful reversal of fortune—­for Barb and
Russ Daily and for Dr. Hilfiker. Instead of the joy of a second child in their
family, the Dailys are deeply disappointed. Instead of helping his patient
and friend, Hilfiker, in trying to care for his patient economically as well as
medically, has created an unintended consequence, namely, the termina-
tion of Barb’s pregnancy. Such an unintended consequence and reversal of
fortune is part and parcel of everyday medical practices. It does not involve
the “neon ethics” of large social disagreements over such issues as the
meaning (or beginning) of life, the distribution of medical resources, eu-
thanasia, or the opposition between cure and care. Such large ethical di-
lemmas lend themselves to principle-­based judgments (although, as we
note later in this chapter, they also can be discussed in terms of narrative-­
based ethics). But Hilfiker’s mistake is his inability to properly discern the
“character” of his relationship to the Dailys, to understand that he is a
medical advisor and not an economic watchdog. In this action, he violated
the principle of autonomy.
The reason the Dailys do not sue him, Hilfiker suggests, is precisely be-
cause he was a friend as well as a physician, and as a friend, he faced his guilt
“through confession, restitution, and absolution.” Medicine, however, does
not make a place for these three actions:

the medical profession seems to have no place for its mistakes. Indeed,
one would almost think that mistakes were sins. And if the medical pro-
fession has no room for doctors’ mistakes, neither does society. The num-
ber of malpractice suits filed each year is symptomatic of this. In what
other profession are practitioners regularly sued for hundreds of thou-
sands of dollars because of misjudgments? I am sure the Dailys could
have successfully sued me for a large amount of money had they chosen
to do so. (1985: 65)

In this paragraph, Hilfiker presents the end—the “moral” of this story. And
in this narrative as a whole he also presents his mistake in terms that can be

Narrative and Everyday Medical Ethics  /  305

recognized as—that present the schema of—­a small “classical” tragedy, the
suffering and meaning of which can be grasped as a whole, including “the
circumstances, ends and means, reversals of fortune, unintended conse-
quences” of this sad event.
In “Mistakes,” Hilfiker not only describes a number of medical errors he
has made as a practicing physician but also identifies several reasons why he
believes physicians sometimes make mistakes. In some cases,

physicians simply do not know enough medical information to make an

informed decision—­and they do not know that they do not have
enough medical information;
they do not have the necessary technical skills that are required;
they are simply careless;
they suffer from a failure of judgment (as in Hilfiker’s failure to judge
between his desire to do no harm to Barb Daily’s physical condition
and his desire to protect her family’s economic condition); or
feeling pressured or rushed, tired or distracted, they suffer from a failure
of will, even though they know the right thing to do.

Medical mistakes can result in misdiagnoses, wrong treatments, medication

miscalculations, or errors during medical procedures. The consequences of
such actions can lead to pain and suffering for the patient and their family,
permanent disability, or even death. The virtues we described earlier are
closely related to such mistakes, and attending to them—­systematically
checking them, as we suggest in appendix 2—­can help anticipate and prevent
them. In this case, Dr. Hilfiker could have compassionately acknowledged
Barb Daily’s “life situation” that is implicit and explicit in her History of Pres-
ent Illness and subsequent interactions, and in so doing, he could have ex-
plicitly discussed his sense that the urine tests presented accurate informa-
tion and his concern over the costs of an ultrasound. He could have also
explicitly discussed why he trusted tests over Barb’s sense of her own body.
In his chapter, he does not discuss the mistake of not listening or responding
to his patient’s narrative description of her feelings of being pregnant.

Lack of Knowledge; Lack of Skill

Hilfiker’s category of lack of knowledge refers particularly to professional

competence and the failure of that competence in action when a physician or
health care worker simply does not have enough biomedical knowledge. But

306  /  the chief concern of medicine

understanding the ethical practices of medicine in relation to narrative and
phronesis suggests that there are other areas of not knowing enough: not
knowing enough about the cultural background of a patient (as in Anne Fad-
iman’s The Spirit Catches You and You Fall Down, discussed in chap. 6), not
knowing enough about recovering narrative knowledge, and not knowing
enough about the reciprocal elements of the patient-­physician relationship.
These kinds of knowledge, perhaps more than biomedical knowledge, are
ethical because they focus on interpersonal relationships. Similarly, Hilfiker’s
category of lack of skill also refers to professional competence—­in this case,
the health care worker’s ability to do particular procedures and to take ap-
propriate measures. Atul Gawande’s narrative “Education of a Knife” de-
scribes the acquisition of surgical skills, and what is most notable about such
skills is the fact, as he says, that “conscious learning becomes unconscious
knowledge” (2002: 21). In other words, such competence—­and we are argu-
ing that narrative knowledge is also one such skill—­is a function of the very
habit that Peirce understands as the essence of belief.
Patients expect and deserve their physicians to be competent. Develop-
ing and maintaining competence is an obligation of the profession and, as
such, an issue of everyday medical ethics. The whole of professional compe-
tence is composed of two domains. The first domain is that of biomedical
knowledge and action—­diagnosis and treatment of disease. Competence in
this domain includes a deep and wide knowledge in the biomedical sciences,
human psychology, and human behavior. The patient expects that his physi-
cian will know the medical meanings of his story, physical findings, lab re-
sults, and other technological findings; and he expects that his physician will
know what should be done about them. Moreover, as we have seen, the pro-
fession itself regularly and routinely publishes evidence-­based treatments
and evidence-­based guidelines for particular conditions, to help physicians
maintain biomedical competence. The second domain is that of the phro­
netic skills of narrative knowledge and virtuous behavior we described in
Part 1. As we saw in chapter 4, diagnosis also entails a sense of the logic of
hypothesis that requires working engagement with narrative knowledge. But
it includes explicitly caring about the patient’s plight—­being concerned
enough to listen conscientiously and discern the meaning of her story—­and
acting on those concerns. It includes being compassionate and trustworthy—­
knowing and demonstrating empathy toward the patient’s suffering and re-
specting the privacy of the patient. And it includes competence in doing the
job for the patient and developing a plan of medical action in concert with
the patient’s needs, wishes, and chief concern. Medical competence includes

Narrative and Everyday Medical Ethics  /  307

both domains, and a chief purpose in The Chief Concern of Medicine is to
offer the profession schema-­based understanding and schema-­based check-
lists to help physicians act on the knowledge of the medical humanities and
narrative knowledge, which are, we noted in Part 1, teachable skills (technē).
One set of skills, the biomedical, requires a Cartesian approach to the pa-
tient. The other—­which, with its interpersonal attention and care, embodies,
in fact, virtuous behavior—­requires the narrative skills we described in Part
1. Thus a working definition of clinical competence in everyday practices of
medicine should include mastery of narrative knowledge and skills as well as
the mastery of bioscientific knowledge and skills. Such mastery (which exhib-
its the virtue of competence and perhaps even integrity) allows for the com-
mon decency of performing one’s chosen profession well—­in the disciplined
of professional occupations Gawande describes—­with both self-­respect and
respect for those with whom one works.

Carelessness

Hilfiker’s category of carelessness—­which might more technically be called

malfeasance—­is apparently more clearly an ethical category than the failure
of competence he describes in terms of lack of knowledge and lack of skill. It
is a failure of attention, a failure to adequately attend to the patient; and in
terms of the virtue ethics we are describing, it is a failure to achieve the vir-
tue of conscientiousness. Chapter 7 examines attention in relation to the ways
physicians listen to patients and attend to both spoken and unspoken narra-
tive information they present. Conceiving such attention in relation to ethics
makes clear the obligations a physician brings to the everyday practices of
medicine: attention takes its place within what we have called the “dramatic
narrative of medical practice” (see chap. 8) as a way to achieve nonmalfea-
sance. Closely related to carelessness in its ordinary usage, this mistake is a
lack of caring for a patient in terms of respect and compassion, the profes-
sional failure to attend to the patient’s chief concern. In terms of virtue eth-
ics, it is a failure to achieve the virtues of compassion and trustworthiness.
One powerful narrative example of the ethical failure of trustworthiness on
the part of a physician we have already encountered is Jean Stafford’s story
“The Interior Castle,” in which we are told that Dr. Nicholas lies outright to
Pansy when he tells her that she is in no danger even though he knows better.
That Hilfiker does not catalog this “mistake” of outright lying—­just as he fails
to record what might be called the “normative” mistakes of drinking on the
job and sexually abusing patients—­underlines the ways in which the mis-

308  /  the chief concern of medicine

takes he is cataloging are everyday rather than melodramatic failures. (The
failure to listen, which he does not catalog, is also an everyday failure.) Still,
lack of empathetic compassion for (if not trustworthiness toward) patients is
an important and ordinary mistake of doctoring: it entails problems with lis-
tening and comprehending the patient’s story and creating effective relation-
ships between patient and physician as they have been discussed in Part 2.
“The Interior Castle” is a powerful story, in part because it represents a lack
of compassion that is layered with the seemingly more egregious ethical fail-
ure of lack of trustworthiness.

Failure of Judgment

Hilfiker’s category of failure of judgment often entails the failure to grasp the
meaningful whole of a situation or narrative, a failure to acknowledge and
honor the meaning and import—­the narrative knowledge—­embodied in a
patient’s story. In terms of virtue ethics, it is a failure to achieve the virtue of
discernment. Conceiving such discernment in relation to ethics makes clear
the obligations a physician brings to the everyday practices of medicine: good
judgment takes its place within the dramatic narrative of medicine as a way
to achieve beneficence. Hilfiker’s treatment of Barb Daily is a clear example
of a failure of judgment in that it presents an attempt to balance different
“goods”—­his patient’s physical well-­being and her economic well-­being—­
that ends in the failure of his chief responsibility as a doctor. Such failures are
often fraught with ambiguity. (Carelessness is not ambiguous.) This is even
clearer in what might be seen as a “successful” failure of judgment. Thus, in
Ferrol Sams’s story “Epiphany,” Dr. Goddard carefully balances his patient’s
desire against standard procedures of care. Embedded in his success, how-
ever, is a narrative representation of how a physician, even with good inten-
tions, could be setting himself up for making an error in judgment. Dr. God-
dard had agreed to treat his patient’s hypertension the old-­fashioned way
without tests, in a manner similar to Dr. Hilfiker’s failure to give Mrs. Daily
the opportunity to take an ultrasound. Dr. Goddard knew the patient had
hypertension, but he also knew that the standard of care was to rule out
causes of “secondary hypertension,” and to do so, he needed to run some
tests. Gregry refused any additional laboratory tests and a complete physical
exam, but Dr. Goddard never explicitly (and compassionately, according to
our checklist 4, “Virtue Actions”) acknowledges his patient’s “life situation”
by explaining the risks of Gregry’s choice to forgo tests. Fortunately for
­Gregry and for Dr. Goddard, the diagnosis was correct, and the medications

Narrative and Everyday Medical Ethics  /  309

given to Gregry reduced his blood pressure. However, it was possible that
Dr. Goddard’s diagnosis might have been incorrect—­or that he might have
missed something important by not conducting a complete evaluation—­in
which case Gregry, like Barb Daily, could have gotten worse rather than bet-
ter. In both cases, the physician decided for his patient instead of deciding
with the patient. As in Hilfiker’s story, Sams offers a narrative representation
of everyday medical practices that emphasizes the inherent ambiguity in dis-
cerning and pursuing the “good.”
Another kind of failure in judgment is less a biomedical problem than
one of properly discerning one’s role. This can be seen in the tension be-
tween private and professional roles, especially in a physician’s relationships
with personal friends and family members. This is a particularly clear in-
stance of the ways that the schematic narrative roles examined in chapter 8
can help delineate and sometimes even resolve ethical dilemmas—­in this
case, a dilemma organized around “judgment.” A powerful literary text that
treats this issue is F. Scot Fitzgerald’s Tender Is the Night. Dick Diver, that
novel’s protagonist, is a doctor who has married his psychiatric patient Ni-
cole. As noted earlier, the novel presents a narrative that can be compre-
hended as either tragic, the reversal of fortune of a good but not perfect man,
or ironic, the failure of a self-­indulgent person who repeatedly mistakes so-
cial admiration for love. The ambiguity of this literary judgment is directly
related to the ambiguous ethical issue for the novel—­and the more general
ethical issue for the practicing physician treating friends and family mem-
bers. (In his writing, Dr. Sigmund Freud notes that psychoanalysis requires
payment to be effective medicine. He means, possibly, that without the pro-
fessionalism of a financial transaction, a physician can find herself in an ethi-
cally ambiguous position.) At one point, Fitzgerald writes,

Dick tried to think what to do. The dualism in his views of [Nicole]—­that of
husband, that of psychiatrist—­was increasingly paralyzing his faculties. In
these six years she had several times carried him over the line with her, dis-
arming him by exciting emotional pity by a flow of wit, fantastic and disasso-
ciated, so that only after the episode did he realize with the consciousness of
his own relaxation from tension, that she had succeeded in getting a point
against his better judgment. (1962: 188)

By his own account, Dr. Diver has a failure in judgment that can be ac-
counted for in terms of the roles that narrative creates for its characters.

310  /  the chief concern of medicine

Fitzgerald’s is a nuanced and complicated treatment of an ethical situation.
Much more common—­more “everyday”—­is the situation of Dr. Nicholas in
Stafford’s “The Interior Castle,” who, probably thoughtlessly, imagines him-
self in the “default” role of hero when, in fact, he should conceive of himself
as the patient’s helper. In any case, an awareness of schemas of narrative
roles allows physicians to attend to—­and to make self-­conscious judgments
about—­the ethics of interpersonal relationships.

Failure of Will

Hilfiker’s category of failure of will entails the failure to act in ways that are
implicit in the choice to work in health care—­namely, to promote the health
and well-­being of a patient and to do no harm, the seeming self-­evident telos
of health care Pellegrino describes and the “expectation of selflessness” and
of responsible “trustworthiness” Gawande describes (2010: loc. 2532). As Dr.
Rita Charon notes in an interview we cited earlier, after forming a relation-
ship with a patient, attending to the patient’s story, and grasping its meaning,
a physician has “a duty to act.” This duty to act makes clear the obligations a
physician brings to the everyday practices of medicine: action—­like the “ac-
tion” and “verbs” described in relation to the structure of narrative in the
preceding chapter—­governs (rather than simply taking a place within) the
dramatic narrative of medicine as an ethical enterprise.
Richard Selzer’s story “Brute” is a powerful narrative describing the fail-
ure of will—­or really, as we said earlier, the acting out of mindless willfulness—­
that fails to make the well-­being of the patient the governing goal of medical
practice. “Brute” presents a stark right-­and-­wrong situation by means of its
powerful aesthetic language: metaphors call attention to the rhythms of lan-
guage even while the ordinary rhythms of ethical behavior is violently dis-
rupted, and the contrast of civilized language and barbarous behavior con-
tributes to the vicarious experience of viciousness in this story. But in another
story, “Imelda,” Selzer uses a heightened sense of narrative form to create
vicarious identification with the young narrator faced with ethical ambiguity.
In that story, a third-­year medical student serves as narrator and assistant to
a renowned chief of plastic surgery, Dr. Hugh Franciscus, accompanying him
and a medical team to Honduras. There, Dr. Franciscus operates on a young
girl’s cleft palate posthumously, after she died on his operating table. Early in
the short story, the medical student states that Dr. Franciscus was considered
by some to be “arrogant, that he exalted activity for its own sake,” and when

Narrative and Everyday Medical Ethics  /  311

the student returns from the trip, he adds,

It had seemed to me then to have been the act of someone demented, or at

least insanely arrogant. An attempt to reorder events. Her death had come to
him out of order. It should have come after the lip had been repaired, not
before. He could have told the mother that, no, the lip had not been fixed.
But he did not. He said nothing. It had been an act of omission, one of those
strange lapses to which all of us are subject and which we live to regret. It
must have been then, at that moment, that the knowledge of what he would
do appeared to him. The words of the mother had not consoled him; they
had hunted him down. He had not done it for her. The dire necessity was his.
(Selzer 1996: 22, 32)

Besides representing the arrogance of his action of operating on the dead

girl, the story also creates the necessity of considering how the practices of
everyday medicine abound with ethical ambiguity. It does so by situating the
reader closely to the narrator’s point of view and creating a sense of their
identity. Thus the medical student concludes years later, “I, too, have not
been entirely free of her. Now and then, in the years that have passed, I see
that donkey-­cart cortège, or his face bent over hers in the morgue. I would
like to have told him what I now know, that his unrealistic act was one of
goodness, one of those small, persevering acts done, perhaps, to ward off
madness” (36). This narrative creates the powerful ambiguity of grasping the
ethical meaning of an action by giving the narrator’s sense of what happened
at two distinct moments in his life, a feature that provokes Stroud’s sense of
vicarious subjective knowledge: is Dr. Franciscus an arrogant surgeon at-
tempting to reorder an event with a demented need for control that includes
his dishonesty with his patient’s mother, or does he powerfully desire to see
the child “made whole”?
In other words, the “will” of the surgeon in this narrative does not fail as
such—­he acts with powerful dispatch. Rather, the ambiguity lies in whether
his action fails or succeeds in fulfilling the ethical imperatives of doctoring.
The categories of autonomy, malfeasance, beneficence, and justice find
themselves inextricably mixed together in this narrative of an everyday ac-
tion of a surgeon—­an extreme action, to be sure, but still an act of violence
(which, antiseptically, is always present in surgery) that also can be under-
stood as an act of caring. His action presents the circumstances, ends and
means, reversals of fortune, and unintended consequences of a narrative
whole that calls for ethical judgment without easily resolving itself into a

312  /  the chief concern of medicine

particular judgment. In the end, his action transformed Dr. Franciscus and
his sense of the world. At the end of the story, the narrator notes,

Hugh Franciscus continued to teach for fifteen years, although he operated

a good deal less, then gave it up entirely. It was as though he had grown tired
of blood, of always having to be involved with blood, of having to draw it, spill
it, wipe it away, stanch it. He was a quieter, softer man, I heard, the ferocity
diminished. There were no more expeditions to Honduras or anywhere else.
I, too, have not been entirely free of [Imelda]. Now and then, in the years
that have passed, I see that donkey-­cart cortège, or his face bent over hers in
the morgue. I would like to have told him what I now know, that his unreal-
istic act was one of goodness, one of those small, persevering acts done, per-
haps, to ward off madness. Like lighting a lamp, boiling water for tea, wash-
ing a shirt. But, of course, it’s too late now. (35–­36)

In this ending, the narrator-­assistant—­not only the helper to the hero-­

physician Dr. Franciscus, but also simply the narrator-­sender of Imelda’s
story, a story of a girl seemingly violated in life and death by the surgeon’s
arrogance—­makes a moral judgment at odds with his earlier judgment of Dr.
Franciscus’s insane arrogance. Moreover, he measures that judgment, as nar-
rative often does—­and as he situates his readers to do—­against canons of
everyday life actions—­lighting a lamp, boiling water, washing a shirt.

Narrative and Ethical Successes

Medical mistakes occur, yet, needless to say, the vast number of incidents in
the practices of medicine are successful: a working professional and human
relationship is established and sustained; ailments are cured or alleviated;
the patient’s needs and concerns are fulfilled. Literary narrative—­as well as
life experience—­provides examples of ethical success in practices of medi-
cine. Moreover, as Stroud suggests, literature can help discern and develop
the skills necessary to recognize the successful working of ethical practices.
Two ethical virtues mentioned earlier are represented and developed within
the context of literary narrative: the Aristotelian “intellectual virtue” of phro-
nesis, which we examined closely at the beginning of this book, and the ev-
eryday virtue of common decency. These virtues realize themselves within
casuistic development leading from the concrete instance to the ethical prin-
ciple and within the dramatic narrative development of contest and debate.

Narrative and Everyday Medical Ethics  /  313

 As we suggested in chapter 2, Aristotle conceives of phronesis as an “in-
tellectual virtue.” By this, he means it is a virtue of knowledge and skill, born
of experience and discernment, combined with virtues of compassion and
trustworthiness, that results in an “intellectual” comprehension of the work
of health care, including the understandings of the goal of health itself. In
this, phronesis, conceived as a virtue, is combined with the extraintellectual
attitude of decency. In chapter 3, we describe the “shared enterprise” of nar-
ration between teller and listener, and in chapter 5, we describe the “shared
enterprise” between patient and physician, with the model physician re-­
storying and restoring the patient. Chapter 5 also describes imbalances of
power between physician and patient. The intellectual virtue of phronesis—­
its development of clinical judgment—­takes the ideals and abuses of the
patient-­physician relationship into account in the work of health care. Above
all, phronesis organizes the work of doctoring within a “covenant of trust”—­
Aristotle’s trustworthiness—­particularly in relation to balancing power and
empathy. The white coat of medicine is a symbol of power and professional-
ism. It differentiates medical students and physicians from hospital visitors
and volunteers and signifies to patients that the person wearing the coat will
have the knowledge and skills necessary to provide appropriate medical care
and will also have the discernment and good judgment to achieve empathetic
understanding and effective action.
If phronesis, as we argued, lends itself to technē—­to its systematic devel-
opment and deployment in its more or less measurable combination of
knowledge, skill, and wisdom—­decency is a much vaguer concept. Never-
theless, it is a virtue that is readily comprehended by all of us, by ordinary
people. Thus, in American history, a nationally televised challenge to Senator
Joseph McCarthy’s decency in 1954—­after the senator attacked a young in-
tern, he was asked, “Have you no decency sir?”—­led directly to his loss of
public support. In an early political biography of McCarthy, Richard Rovere
noted that “the hearings created an image of the destructive personality . . .
[the army lawyer, Joseph Linden] Welch tried to examine. McCarthy was not
merely above the law in refusing to name his informants; he was above, or
outside, any system of order, of fair play, of decency, or even simulated re-
spect” (1960: 218). Decency, like phronesis, combines respect for the au-
tonomy of others, striving after beneficent behavior toward others, the avoid-
ance of harm (“malevolence”), and a strong sense of justice or “fair play.” In
The Plague, as we noted in the epigraph to this chapter, Camus describes this
virtue as one possessed by the physician Bernard Rieux, who tells his friend

314  /  the chief concern of medicine

and fellow worker in fighting the plague in north Africa that “common de-
cency” simply “consists in doing my job” (1962: 163). For Camus, the virtue
of decency is not heroically melodramatic. Rather, it is an everyday virtue
combining knowledge, skill, fulfilling promises, and trying one’s best. “Doing
my job”—­especially for health care workers—­simply consists in fulfilling the
implicit promise and obligations one takes on in pursuing what we called, in
the introduction, the “privileged” career of doctoring.

Virtues and Literary Form: The Example of Death and Dying

The everyday ethics of medicine we have been examining in relation to Aris-

totle’s appropriate virtues—­competency in knowledge and skill, conscien-
tiousness, discernment, compassion, trustworthiness, phronesis, de-
cency—­by and large lend themselves to narrative forms that, usually, are not
the stark form of melodrama. Even the most “melodramatic” of these sto-
ries—­Dr. Nicholas’s outright lying to his patient, the doctor in “Brute” enact-
ing violence against his patient—­are tempered by ambiguity more usually
found in tragedy, comedy, and irony. The narratives we have discussed in the
previous section fall into these narrative forms: The Woman Who Walked
into Doors takes the form of a comedy (or, more accurately, a kind of Shake-
spearean tragicomedy, where all the elements of a tragedy are resolved, al-
most magically, by the “comic” recognition she achieves that she does not
deserve to be beaten). Philoctetes is a classical tragedy, though again with the
“deus ex machina” of a comic resolution. Dr. David Hilfiker’s narrative of
Barb and Russ Daily is an out-­and-­out tragedy, replete with peripeteia, rec-
ognition, and katharsis. Dr. Sams’s “Epiphany” also seems to be a comedy—­
even the title suggests a powerfully illuminating resolution—­though the doc-
tor’s willingness to cut corners, even though it “comically” has no bad
consequences, all too easily could have resulted in a failure in judgment. Dr.
Selzer’s “Imelda” is a disturbingly ironic story, never quite clarifying the pos-
sibilities of arrogance or kindness, for the narrator and protagonist as well as
for the readers. Even what might be taken as comic successes in Albert Ca-
mus’s The Plague and “Epiphany” are tempered—­in the first case by the
enormous suffering it portrays (including the death of one of the novel’s
medical heroes), in the second by ambiguities of judgment in Dr. Goddard’s
medical decision and in his seeming participation in Gregry’s racism. All of
these narratives avoid stark and absolute contrasts—­the “neon ethics” of

Narrative and Everyday Medical Ethics  /  315

good and evil, right and wrong, and life and death—­that inhabits controver-
sial ethical dilemmas in our world in the narrative form of melodrama.
Still, the defining instance of any ethics—­but especially the “virtue eth-
ics” we have been examining, linked as it is to narrative forms—­arises in the
face of death and dying. Unlike many ethical values that can be more or less
debatable, the stark contrast between life and death is uncontestable: even
when the physiological definition of death is debated, there is no debate
about the opposition between vitality and inertness. Moreover, this stark—­
and “melodramatic”—­contrast between life and death is, in fact, a part of
everyday practices of medicine. Unlike controversies over organ transplants
(see Dr. Richard Selzer’s story “Whither Thou Goest” [1998]), abortion, and
other situations, death is almost always part of everyday medicine and almost
always entails “everyday” virtues. Thus, hovering behind all of these narra-
tives of the preceding section—­sometimes explicitly (as in the murderous
rage of Gregry or Paula’s husband, Charlo, or in the widespread dying in The
Plague), sometimes by suggestion (as in the dangers facing patients such as
Pansy in “The Interior Castle”), sometimes only vaguely implicit (as in
“Brute” or Philoctetes)—­is the stark and potentially “melodramatic” confron-
tation of life and death. Great suffering and death are always-­present possi-
bilities in medical practices. For medicine, they are everyday occurrences,
even though, in the United States and many other “developed” societies,
they are rare enough to seem extraordinary and to be subject to denial.4 Be-
cause of this, medical practices of all sorts present an ethical drama of every-
day practices that, like the tragedy examined in chapter 8, often (perhaps
always) touch on these occurrences in ways that illuminate extraordinary—­
but everyday—­practices of medicine.
The fact that medical practice often involves death and dying under-
scores the ethical aspect of medicine in everyday practices. Also, more than
at any other time in the patient-­physician relationship, the importance of
narrative understanding is paramount when the patient is dying. This critical
juncture in health care asks physicians to listen carefully, to recognize their
patient’s plight, and to respond with the virtues discussed in the previous
section: conscientiousness, discernment, compassion, trustworthiness, de-
cency, competency, and integrity. New technologies have fundamentally al-
tered the way physicians practice medicine and how we die. These scientific
advances are used to help sick patients get better but also to postpone
death—­frequently without regard to patients’ determination of what consti-
tutes quality of life for them or what constitutes their well-­being. Some of the
most complicated ethical issues in the practice of medicine—­physician-­

316  /  the chief concern of medicine

assisted suicide, prolonging life, prolonging death, advance directives, pa-
tient autonomy—­occur during events surrounding the end of life. Narrative
helps physicians and other health care providers not only to understand the
meaningful whole of patient’s experience but also to ask ethical questions
that will drive the decision-­making process for medical care. Such questions
include “What are the goals of medical treatment?” and “How can I help this
patient die with dignity?” Aristotle talks about the virtue of “the good life,”
and in a similar fashion, medical practices can help articulate the narrative
question “What does a ‘good death’ mean for this person?”
There is no one concept that defines a “good death.” That construct does
not lend itself to the “unpacking” of definitions in the manner we used to
describe health in the introduction. Rather, it is defined on an individual
basis by dying patients and their families—­although certain types of medical
care can make dying easier. A main concern for many patients facing the end
of life is that they will die alone and in pain, but Dr. Ira Byock makes clear
that this does not have to be the case, and if physicians are engaged with their
patients, the end of life can be a better experience. “Through my years as a
hospice doctor,” Dr. Byock writes,

I have learned that dying does not have to be agonizing. Physical suffering
can always be alleviated. People need not die alone; many times the calm
caring presence of another can soothe a dying person’s anguish. I think it is
realistic to hope for a future in which nobody has to die alone and nobody has
to die with their pain untreated. But comfort and companionship are not all
there is. I have learned from my patients and their families a surprising truth
about dying: this stage of life holds remarkable possibilities. Despite the ar-
duous nature of the experience, when people are relatively comfortable and
know that they are not going to be abandoned, they frequently find ways to
strengthen bonds with people they love and to create moments of profound
meaning in their final passage.
As a physician, being present as someone is dying tears the boundaries
between the personal and professional realms of my being. The experience
of a patient dying challenges me to accept a more intimate, and yet more
deeply respectful, relationship with that person. I do not know how it could
be otherwise. While I may bring clinical skills and years of experience to the
task, ultimately I am simply present, offering to help and wanting to learn.
(1997: xiv)

Knowing what patients want, their chief concern—­through shared decision

Narrative and Everyday Medical Ethics  /  317

making and good communication—­will help physicians assist patients in
achieving a “good death.”
It is somewhat ironic that the Greek word euthanasia translates into
“good death.” Simply defined, it is the killing of another by an intentional act
or omission that is for his or her supposed benefit. When a physician com-
mits the act or omission, this is called physician-­assisted suicide. This “neon”
ethical dilemma asks difficult questions: how should physicians respond
when competent, terminally ill patients request help in dying, and whose
right is it to choose? Such questions come only (or often) when there is noth-
ing else to do. Physicians also have end-­of-­life stories, though they are often
helpers in, rather than the central heroes of, these stories. As such, however,
they are faced with the everyday ethics woven into the very fabric of medi-
cine. We here use three art narratives written by physicians—­a lyric poem, a
short story, and a prose poem—­to illustrate differing responses to the terri-
ble ethical dilemma occasioned by the implicit or explicit request for assis-
tance with hastening death.

(1) Dr. David Rinaldi’s “Let’s Talk About It”

with all the talk
about Dr Death
news-­bites sandwiched
between circus and tragedy
hesitantly I say
in my confusion
“I understand him”
but still . . .
as a physician
morally and ethically . . .
and yet . . .

terminal pain . . .
and yet . . .
and surreptitiously
remember
how very secretly
I thought
thought how
Dad’s castrated body
lay crooked in

318  /  the chief concern of medicine

prostatic pain on
his sweaty Tennessee cot
his wife’s terminal phone voice
drawling out the daily news . . .
how very secretly
I calculated
how many of
those little pain-­killers
it might take . . .
and silently remember
how I put it all
out of my Hippocratic mind
yet felt ashamed
for weakness . . .

and so I waited. . . .
(Rinaldi 1994: 1)

(2) Dr. Richard Selzer’s “Mercy”

The physician in Dr. Richard Selzer’s story “Mercy” responded differently to
a patient request for physician-­assisted suicide. In this controversial short
story, the physician has a forty-­two-­year-­old patient dying of pancreatic can-
cer. The patient’s disease is marked by increasing pain and suffering that
“cannot be relieved by any means short of death” (Selzer 1982: 71). The pa-
tient and his family beg the physician to give more morphine, but the physi-
cian knows that more morphine means killing the patient. The physician—­
unable to let his patient suffer—­begins to inject a lethal dose of the pain-­killing
drug, while the wife and mother wait in the hall. The patient’s breathing be-
gins to slow, but for some reason, the patient won’t die. The physician mo-
mentarily considers crushing the unconscious man’s windpipe, but cannot
bring himself to commit the intentional act. Finding the patient’s family in
the hall, he says, “He didn’t die,” “He won’t . . . or can’t.” They are silent. “He
isn’t ready yet.” “He is ready,” the old woman says. “You ain’t” (74).

(3) Dr. Rafael Campo’s “Doctor Kevorkian”

At the hospice, there was a bowl of jelly beans on the coffee table in the TV
room. A patient of mine was sitting there with me, dying of breast cancer

Narrative and Everyday Medical Ethics  /  319

 while she watched a rerun of Bonanza, a show that stopped airing new epi-
sodes before I was born. One of the show’s handsome young stars died of
pancreatic cancer when I was still in medical school. I remember that she
asked me during a commercial if I would give her a prescription for some
pills. She was scared of dying alone, in pain. I told her that I was no Doctor
Kevorkian, but that I believed it was my job to help her die with dignity. She
said that death should be like birth, with family and friends all around you,
medicine to keep you comfortable until it was all over, and a doctor at your
side in case of any complications. I couldn’t look at her; the more I stared at
the jelly beans, the more they began to look like a bowl of multi-­colored pills,
benzodiazepines and narcotics and antidepressants, all the sweet flavors of
relief. She began to cough by the time the show came back on, a deep rattle
that made the soft sound of my own breathing unnerving to me. I had to at-
tend a certain number of births during my medical training, but not deaths;
the hospital where I worked published annual statistics on the number of
babies born on its maternity ward, but the number of deaths each year was
guarded like an embarrassing secret. I looked at my cachectic patient re-
flected in the television’s gruesome single eye: its convexity shrunk and de-
formed her to the size of a plump fetus, and she was grinning at a robust
Michael Landon, her image superimposed upon his large white teeth which
looked like they were the whitest teeth the world had ever known, and I un-
derstood that in death she was traveling back to her own pure beginning.
That in death she would be reborn. (Campo 1999: 28)

The preceding narratives’ differing responses to requests for assistance

with death represent the ambiguity that often accompanies the ethical di-
lemmas physicians experience in the everyday practices of medicine. Such
dilemmas are always closely tied to the particular experiences and configura-
tions of events that surround the end of life. In these narratives, different
environments of the end of life—­at home, in a hospital, and in a hospice—­
emphasize the narrative elements associated with death and dying. This is
most clear in the third of these narratives, Dr. Campo’s prose poem “Dr.
Kevorkian,” where the patient narrates her “good death” in the environment
of a hospice while her doctor joins in her story.
These three narratives offer different responses to the pain and suffering
that accompanies dying. The speaker in Dr. Rinaldi’s poem is a physician
whose father’s body is “crooked in prostatic pain.” The doctor is highly am-
bivalent: he thinks about “Dr. Death”—­a nickname for Dr. Kevorkian, an

320  /  the chief concern of medicine

outspoken advocate for physician-­assisted suicide—­and also about “how
many of those little pain killers it might take” to relieve his father’s pain. But
at the same time, he remembers his Hippocratic vows that preclude the kind
of assistance he wants to provide for his father. The title of this powerful
poem, “Let’s Talk about It,” underlines the manner in which the issue of
death and dying is not openly discussed in the medical community or, for
that matter, in contemporary American society. In Dr. Selzer’s story, the nar-
rator is also a physician who thinks about his dying patient and his pleading
family from some time in the future. This physician—­unlike either Dr. Rin-
aldi’s doctor or Dr. Campo’s doctor—­is willing to give his patient a drug over-
dose in order to end his suffering. But Selzer’s story—­like Rinaldi’s poem—­
underlines the powerful ethical dilemma of measuring life against suffering.
This always-­possible situation makes medical practices particularly difficult
and heartbreaking and makes necessary the explicit discussion of ethical
choices that medicine demands. Finally, the speaker in Dr. Campo’s prose
poem is also a physician, but in this case, his patient is not a family member,
nor is there a family member present. The doctor is both sorrowful and a
little ashamed in the face of his patient’s dying and her fear—­after all, he’s
young enough to have been born after Bonanza stopped airing—­but he is
not ambivalent about his position on physician-­assisted suicide the way Dr.
Rinaldi’s physician is. Still, like Rinaldi’s patient, his patient is “shrunk and
deformed.” This prose poem, unlike Rinaldi’s poem, offers an image of a
“good death,” and the doctor assumes that such a death—­ dying “with
dignity”—­ is possible. Perhaps part of the disturbing nature of “Doctor
Kevorkian”—­including the strangeness of its title—­is the young doctor’s in-
ability to find a way of caring for his patient beyond the jelly beans of imag-
ined life-­ending drugs or her scenario of a good death. These texts, however,
do not unpack, schematically, the concept of a “good death” the way we un-
pack the concept of “health” in the introduction. Instead, ambiguously, they
offer a continuum of overlapping responses to what Dr. Raphael Campo de-
scribes in his poem “The Couple” as “the absolute—­ . . . the light, / the awful
light of what we know must come” (2002: 70). (For a discussion of the proce-
dure of “unpacking” in the humanities, see appendix 1.)
Death is often viewed in the medical community as the enemy—­the su-
preme narrative opponent of melodrama—­to be beaten at all costs; death is
thought of as the failure of medicine. Aggressive therapy becomes the mode
of treatment in an effort to cure the illness and prolong life. Still, implicit in
the debate over a “good death” is a clear—­or at least a clearer—­understanding

Narrative and Everyday Medical Ethics  /  321

of the goals that patients desire from their medical care. Treatment priorities
vary considerably—­some patients request aggressive medical care, while
others prefer emphasizing comfort when a prolonged, sometimes painful,
and often unlikely “cure” is the alternative. The narrative of The Death of
Ivan Ilych, discussed in the following chapter, offers a sustained narrative
that concerns these alternatives. Determining a patient’s goals of medical
care is important if the physician is to help his patient achieve a “good death”
and die with dignity.
As part of their efforts to educate physicians on end-­of-­life care, the
American Medical Association developed a seven-­step protocol for develop-
ing and articulating goals of medical care. The steps are

1. creating the right setting;

2. determining what the patient knows;
3. exploring what the patient expects/hopes for;
4. suggesting realistic goals;
5. responding empathically;
6. negotiating a plan and following through on it; and
7. revising the plan as needed. (American Medical Association 1999:
10)

These steps correspond, to one degree or another, to the virtues discussed in

the preceding sections of the present chapter. For instance, explicitly explor-
ing a patient’s hopes and expectations (step 3) and responding empathically
(step 5) exhibit the virtue of compassion; negotiating a plan (step 6) is, as we
saw in chapter 2, the clinical reasoning of Aristotle’s phronesis; and suggest-
ing realistic goals for a suffering person (step 4) exhibits decency. In any case,
all seven steps for negotiating goals of care—­often with their corresponding
virtues—­are powerfully dramatized in Margaret Edson’s play Wit.
A play like Wit presents an ethical drama of death and dying. In terms of
the narrative schemas we have described, it can be seen as the struggle be-
tween patient and physician concerning who, precisely, is the narrative’s
hero. In the play, the heroine, Vivian Bearing, a professor of seventeenth-­
century poetry, is diagnosed with stage-­four ovarian cancer. The play por-
trays her interaction with doctors and other health care workers and the
kinds of self-­exploration and self-­knowledge that facing death provokes. The
drama begins with her physician Dr. Kelekian communicating to her the di-
agnosis of her illness.

322  /  the chief concern of medicine

 vivian: I’ll never forget the time I found out I had cancer.

(DR. HARVEY KELEKIAN enters at a big desk piled high with papers.)

kelekian: You have cancer.

vivian: (To audience) See? Unforgettable. It was something of a shock.
I had to sit down. (She plops down.)
kelekian: Please sit down. Miss Bearing, you have advanced meta-
static ovarian cancer.
vivian: Go on.
kelekian: You are a professor, Miss Bearing.
vivian: Like yourself, Dr. Kelekian.
kelekian: Well, yes. Now then. You present with a growth that, unfor-
tunately, went undetected in stages one, two, and three. Now it is an
insidious adenocarcinoma, which has spread from the primary ad-
nexal mass—­
vivian: “Insidious”?
kelekian: “Insidious” means undetectable at an—­
vivian: “Insidious” means treacherous.
kelekian: Shall I continue?
vivian: By all means.
(Edson 1999: 7)

The play enacts the “continuation” of this conversation, with the actors
speaking at the same time, at cross-­purposes, without listening to each other.
This opening scene presents a patient-­physician interaction that allows itself
to be examined in relation to the seven-­step protocol of developing and ar-
ticulating goals of medical care and also in relation to the virtue ethics dis-
cussed in the preceding sections of this chapter.
Setting the stage and creating the right environment for communicating
bad news and negotiating goals of medical care are activities that require
advance planning and consideration by the physician. (Some may think that
“competence” in creating the right setting [step 1 of the AMA protocol] is no
less a part of treating a patient than competence in biomedical knowledge or
skill.) In Wit, the oncologist, Dr. Kelekian, fails to create the “right setting”
for giving his patient bad news. He enters his office and finds his patient,
Vivian, waiting. His desk is piled high with papers, so that a patient might
easily imagine she is interrupting the doctor’s “real” work. Dr. Kelekian sepa-
rates himself from his patient by sitting behind the desk as he describes a

Narrative and Everyday Medical Ethics  /  323

life-­threatening illness to her. Such a physical barrier reinforces that pater-
nalistic and all-­powerful stance that is, as we have seen, common in patient-­
physician relationships.
While communicating to Vivian that she has metastatic ovarian cancer,
Dr. Kelekian immediately assumes that she will want aggressive therapy and
that she will enroll in his clinical research trial. Kelekian notes to Vivian,
“This treatment is the strongest thing we have to offer you. And, as research,
it will make a significant contribution to our knowledge” (Edson 1999: 11). In
this scene, there is a conflict of interest between Dr. Kelekian as a researcher
and as her physician—­such conflict on the part of a physician might well re-
flect on the virtues of integrity and, perhaps, decency. Moreover, he also fails
to determine his patient’s hopes and expectations (discernment) or to negoti-
ate a plan of treatment with her (phronesis). In short, he fails to assess and
care for the whole patient. In this encounter, he disregards Professor Bear-
ing’s autonomy—­her right, as a patient, to make informed choices about her
health care. (In narratives described earlier in this chapter, Dr. Hilfiker and
Dr. Goddard also fail to create a situation for their patients to make informed
choices, but with less self-­centered arrogance than Dr. Kelekian displays.) At
no point in Vivian’s treatment is she ever asked to participate in the decision-­
making process. Clearly, Dr. Kelekian’s plans for his patient are not open to
negotiation.
On what is perhaps a more basic level, Dr. Kelekian does not attend to
Professor Bearing’s suffering or pain—­both the physical pain of her condi-
tion and, more generally, her emotional or spiritual pain as she faces death
and reviews and judges her life. Vivian notes to the audience the indignities
of being a patient: “One thing can be said for an eight-­month course of can-
cer treatment,” she says: “it is highly educational. I am learning to suffer”
(Edson 1999: 31). Patient narratives are an important source for enhancing
physicians’ understandings of what suffering means to an individual patient
and also how such narratives may help physicians develop strategies to lessen
their patients’ suffering and pain, but as we suggested earlier, art narratives,
like Wit, often provoke the vicarious experience—­ Stroud’s subjective
knowledge—­more fully.
Setting overall goals for care is part of the everyday ethical practice of
medicine and is crucial if there is to be an appropriate balance between
disease-­oriented treatments and those intended to maintain function and re-
lieve suffering. Such a balance—­that takes place every day in the practice of
medicine as one patient with a more purely “curable” acute condition (e.g., a
broken leg) is followed by another with a chronic condition that requires

324  /  the chief concern of medicine

adaptations and relief rather than “cure”—­requires a shift in thinking from
problem-­based medical care to goal-­oriented medical care. Problem-­based
care is Cartesian in that this method of care makes a distinction between the
patient (the subject) and the problem (the object). When care is purely
problem-­based, the meaningful whole of the patient is lost or irrelevant to
the objective of healing. In contrast, goal-­oriented care is like narrative: it
calls for the understanding or apprehension of complex phenomena (of
events, situations, and even personhood and identity) in terms of the relation
between the parts and the whole. Moreover, as we argued in Part 1, as an
instance of phronesis, it presents itself in terms of narrative, which is itself
“goal oriented.” Goal-­oriented care centers on the “whole” of the patient and
guides medical decision-­making toward treatment and interventions that
speak to and cut across various problems. Cartesian problem-­based care fo-
cuses on the cause and proceeds on the assumption that analyzing a problem
to its smallest, “basic” components facilitates the discovery of cause and cure.
Goal-­oriented care focuses on the end or goal of a situation; like narrative,
the end or goal helps define the meaning of the situation (or a life) grasped
as a whole and what is proper action of behavior in light of that goal. In Wit,
Dr. Kelekian is very much focused on the problem (or the object)—­so much
so that he fails to assess Vivian’s desires and hopes—­and he fails to extend
any compassion or empathy in their interaction.
The meaningful whole of this scene is the bad news the physician con-
veys to his patient. Giving bad news to patients is perhaps one of the most
difficult communication skills (technē) for physicians to learn. Patients fre-
quently report that they are able to remember exactly what the physician
said when breaking the news, although they may remember very little of the
conversation following the diagnosis. Thus the first scene in Wit begins with
Vivian saying, “I’ll never forget the time I found out I had cancer.” When
they hear their diagnosis, patients experience a “reversal of fortune”—­
Aristotle’s peripeteia. Principle-­based ethics do not attend to this particular
experience in any meaningful fashion. Vivian has now experienced a peripe-
teia, and her life will never be the same. Dr. Kelekian had the opportunity to
communicate this devastating news while attending to his patient, learning
her story, creating a relationship, and negotiating a plan, but he failed to do
so. The way Dr. Kelekian breaks the bad news is very similar to what patients
and their families often report about such conversations with physicians.
This is due to a complex set of factors: physicians have had little educational
preparation on how to deliver difficult news; bad news is often apprehended
as a problem distinct from patients’ goals; when it is a prognostication of

Narrative and Everyday Medical Ethics  /  325

death, bad news is often understood as a failure of medicine; and finally, bad
news often provokes awkwardness based on a peripheral awareness of the
physician’s own mortality.5
Death and dying—­ like many of the principle-­ based issues of what
Hawkins calls “neon ethics”—­certainly point to an area of ethical decision
making calling for abstract values asking that “universal” truths be brought to
bear on the ethics of medical practice. Yet, as Dr. Byock notes, the extremity
of death—­especially in face of the “universal” values of life, health, and well-­
being—­blurs the opposition between transcendental moral values and every-
day ethical practices. Thus, even in the face of death, the virtues described in
this chapter—­which can be enumerated in relation to the dramatic narrative
categories of the patient-­physician relationship, the patient’s story, doctors
listening, and the drama of medical practices we have described—­are em-
phasized and validated. Moreover, such a virtue ethics can be examined in
relation to knowledge and skills—­the technē of humanistic knowledge and
narrative skills—­just as the biomedical aspects of doctoring can be examined
in relation to knowledge and skills. Such humanistic knowledge and narrative
skills, like biomedical knowledge and skills, are part of the obligations physi-
cians and health care workers assume in taking up the jobs they have chosen
for themselves to confront human suffering with healing, relief, and care. In
this chapter, we have been able to examine ethical practices within everyday,
ordinary—­ as opposed to extraordinary and “melodramatic”—­ aspects of
health care. Such ordinary events in health care—­everyday successes, differ-
ent kinds of mistakes, even the more or less explicit everyday encounters
with issues of life and death in medicine—­call for the ordinary language of
narrative rather than the extraordinary language of philosophical ethical
analysis. In such narratives, the ethical behaviors of judgment and interper-
sonal relationships are most often unnoticed, habitual kinds of housekeeping
activities that are recoverable from dramatic stories in which agents manifest
“character” by acting out and embodying particular virtues. This kind of nar-
rative ethics realizes itself in everyday virtues—­discernment, decency, com-
petence, trustworthiness, conscientiousness, and compassion—­that occur in
everyday actions, everyday narratives; they are found in a smiling welcome,
in honest listening, in comforting a crying child.

326  /  the chief concern of medicine

Conclusion
10
reading the death of ivan ilych

Suddenly he felt the old, familiar, dull, gnawing pain, stubborn and serious. There was
the same familiar loathsome taste in his mouth. His heart sank and he felt dazed. “My
God! My God!” he muttered. “Again, again! And it will never cease.” And suddenly the
matter presented itself in a quite different aspect. “Vermiform appendix! Kidney!” he
said to himself. “It’s not a question of appendix or kidney, but of life and . . . death. Yes,
life was there and now it is going, going and I cannot stop it. Yes. Why deceive myself?
Isn’t it obvious to everyone but me that I’m dying, and that it’s only a question of weeks,
days . . . it may happen this moment. There was light and now there is darkness. I was
here and now I’m going there! Where?” A chill came over him, his breathing ceased, and
he felt only the throbbing of his heart. . . .
“What’s the use? It makes no difference,” he said to himself, staring with wide-­open
eyes into the darkness. “Death. Yes, death . . .”
Anger choked him and he was agonizingly, unbearably miserable. “It is impossible that
all men have been doomed to suffer this awful horror!”
—­leo tolstoy, The Death of Ivan Ilych (1886: chap. v)

Reading Ivan Ilych

Leo Tolstoy’s novella The Death of Ivan Ilych is a significant literary text that
brings together many of the themes of The Chief Concern of Medicine. It is
a story that resonates with the experience of health care workers—­with the
experience of physicians, nurses, and others confronted with suffering and
dying—­and at the same time provokes powerful feelings about our shared
knowledge and, indeed, our shared lives as human beings. In significant
ways, Tolstoy’s The Death of Ivan Ilych is a modern version, in novelistic
prose narrative, of the ancient themes of the pity and terror of suffering that
classical tragedy portrays and that Aristotle and, later, Joyce discuss. In its
two narrative frames—­that of Ivan’s friends contemplating his death and that
of Ivan himself living through his death and dying—­it enacts the conflict and
provisional assignment of narrative roles to the recognizable agents in the
story that the narrative schema of actants we have presented suggests: is Ivan
the hero of this story or an ancillary helper or opponent in the drama of his

/  329  /
friends, his physicians, his family? Or, perhaps more significant, does his op-
ponent, the “awful, solemn act,” the “awful, terrible act” of dying (chap. VII)
become, through Tolstoy’s narrative art, his helper, leading, in the end, to the
achievement of tragic status for this seemingly ordinary, conventional man?
It is easy to imagine applying checklist 2 from appendix 2 to the situation
of Ivan Ilych, as follows:

Who is he?
Ivan Ilych (a name like our “John Smith”).
What is his emotion?
Fear.
What is the story that he “tells”?
It is before us to listen to, after the opening chapter.
What is his chief complaint?
9/10 abdominal pain (left side) and sour taste in his mouth.
What is his chief concern?
It is the question of what does this illness mean to him in terms of its
severity, its outcome, its necessitating the “re-­storying” of his life val-
ues.

Moreover, his story is replete with the “hot words” of checklist 3—­not only
those spoken, but those “unsaid” or metaphorically implied, such as a seem-
ing parallel with Christ in his suffering, which we mention later in this chap-
ter. Even the virtue-­actions checklist we supply in appendix 2 (checklist 4)
might illuminatingly be applied to Ivan himself in his final interactions with
his son and his wife, and many of the schemas of narrative comprehension
and narrative interchange we present in appendix 3 can help us make
sense—­as Ivan tries to make sense—­of the very “surprising fact” of his ill-
ness. In fact, the schematic reading of the novella we offer in this chapter—­
based on the schemas of narrative knowledge and the medical humanities we
have presented throughout these chapters—­might well offer the example of
a useful, if superficial, encounter with narrative that may serve, in its very
superficiality, as a schematic guide for case-­based reasoning in encountering
the everyday, “popular” narratives of patients. For all these reasons, The
Death of Ivan Ilych offers an important text for the training of medical and
other students and for discerning the connections between narrative and
medicine.
To these ends, this chapter examines The Death of Ivan Ilych, in
relation—­and as a kind of conclusion—­to the chapters of The Chief Concern

330  /  the chief concern of medicine

of Medicine. It aims at demonstrating and emphasizing how the representa-
tion of the patient-­physician relationship within a larger life narrative can
help delineate important aspects of that relationship, as examined in chapter
5; how strategies for the doctor’s listening, examined in chapter 7 (especially
in the context of the strategies for reading that prose fiction demands), can
be more readily discerned in the context of Tolstoy’s novella; how the under-
standing of and interpretative participation in literary narrative, examined in
chapter 8, make readers and listeners more attentive; how the story of Ivan
Ilych can highlight the relationship between narrative and ethical practices
in medicine, examined in chapter 9; how The Death of Ivan Ilych presents
the patient’s story, examined in chapter 6 and throughout this book, in a par-
ticular narrative that explores and represents aspects of life and suffering
shared by all people; and how the functional realism of narrative knowledge
and narrative schemas, examined in Part 1 and operationalized in relation to
medicine in Part 3, presents itself in an extended analysis of an art narrative.

Summarizing and Re-­storying The Death of Ivan Ilych

To begin, let us summarize the plot of Tolstoy’s novella. Such a summary or

“re-­storying,” as Kathryn Montgomery notes in the context of the practice of
medicine, is an always-­possible feature of narrative, and this possibility is
further evidence that narrative is a structured process of cognition. Our abil-
ity to summarize narratives is an important aspect of narrative that we de-
scribed in earlier chapters: namely, it is indifferent to its modes of presenta-
tion. People—­even young children—­recognize two narratives as the “same”
even if they are related in different media, with different characters, and in
different details describing the sequence of events. Such a summary contrib-
utes to the cognitive power of narrative and to the feature, which Walter
Benjamin notices, of its ability to be retold. So we summarize the story here
and also, as Benjamin notes, make it our own by “re-­storying” it in the con-
text of The Chief Concern of Medicine.
The Death of Ivan Ilych begins at the chronological end of the story,
when the death of Ivan Ilych Golovin is announced. A group of judges is
gathered together at the courthouse when they hear the announcement, and
they console themselves with the thought that death has come to Ivan and
not themselves. They begin to think of the career opportunities Ivan’s death
will create. Ivan’s friend Peter Ivanovich attends the funeral at Ivan’s house
and talks with his wife, Praskovya Fedorovna Golovina, about her pension. At

Reading The Death of Ivan Ilych   /   331

Ivan’s house, Peter meets Gerasim, Ivan’s young manservant. “Well, friend
Gerasim,” said Peter Ivanovich, so as to say something. “It’s a sad affair, isn’t
it?” Gerasim answers, “It’s God’s will. We shall all come to it some day.”
The novella then moves back more than thirty years to describe Ivan’s
life. He is the second of three sons, an average and ordinary person. Ivan
grows up to become an examining magistrate; he moves to a new province
and marries. When Praskovya Fedorovna becomes pregnant, however, the
well-­planned conventional life Ivan has created for himself is disrupted with
domestic discord, and he puts more and more energy into his official life. As
a magistrate, he tries to function as impersonally as possible. His career pro-
gresses, although he is disappointed not to obtain the post of presiding judge
in a university town. Because he needs a higher salary to maintain his life-
style, he goes to St. Petersburg to look for a better position. At that time, a
change in the administration of the Ministry of Justice situates a close friend
in a position of authority, and Ivan is able to obtain a prestigious and well-­
paid position in St. Petersburg. Before his family arrives, he obtains a new
house. One day, as he is hanging drapes from a stepladder, he slips and bangs
his side against the window frame. However, the injury does not seem to be
serious. His family arrives, and he settles into a conventional life of work,
family, and playing bridge.
Ivan’s left side begins to bother him, and he experiences an unpleasant
taste in his mouth. Both make him irritable and quarrelsome. Several doctors
are consulted, but they disagree on the nature of the illness. Moreover, they
treat Ivan with the same kind of impersonal, professional detachment that he
brings to prisoners at the bar. As his illness progresses, Ivan becomes depressed
and fearful: work, entertainment, even cards, his favorite pastime, cease to give
him any pleasure. Ivan gets worse and worse, and he begins to fear and dread
death. His illness, he comes to fear, is a question of life and death. While his
family, friends, and doctors insist that his sickness is a momentary incident in
his life, he knows—­even as he tries to forget—­that he is dying. In the midst of
his suffering, Gerasim, his peasant servant, helps him with his ordinary bodily
functions and soon is spending entire nights with the dying man. To ease his
pain, Gerasim supports Ivan’s legs on his shoulders. More than anyone else,
Gerasim provides Ivan with compassion, pity, and honesty, even while his wife
and doctors pretend he is not dying. One night, Ivan dreams of a black sack
into which he is pushed, and he awakens in great fear.
As he lays confined on his sofa, his pain growing, Ivan realizes that the
further back he looks, the more real and joyful his life was. He wonders
whether or not he has lived correctly in his conventional life, and the suspi-

332  /  the chief concern of medicine

cion that he has somehow wasted his life pains him as much as his physical
distress. At the moment of his death, Tolstoy again uses the image of a black
sack enveloping Ivan.

At that very moment Ivan Ilych fell through and caught sight of the light, and
it was revealed to him that though his life had not been what it should have
been, this could still be rectified. He asked himself, “What is the right thing?”
and grew still, listening. Then he felt that someone was kissing his hand. He
opened his eyes, looked at his son, and felt sorry for him. His wife came up
to him and he glanced at her. She was gazing at him open-­mouthed, with
undried tears on her nose and cheek and a despairing look on her face. He
felt sorry for her too. (chap. XII)

At the moment of his dying, pitying his son and wife, he experiences bright
light, and amid his pain, he experiences a sense of great joy. Then Ivan Ilych
dies.
Embedded in the realistic details of The Death of Ivan Ilych is Tolstoy’s
more or less didactic message, his satiric presentation of the failings, as he
sees them, of bourgeois upper-­class Russian life in the late nineteenth cen-
tury.1 To this end, he presents an uncompromising critique of the material-
ism, individualism, and anticommunitarianism of the bourgeois Russian soci-
ety of his day. Tolstoy’s representation of the blindness to death and dying of
his characters and of the society they live in is part of his satiric presentation
of the selfish upper-­class blindness to responsible behavior in the world. The
meaningless superfluity of Ivan’s father’s career—­he “had made the sort of
career which brings men to positions from which by reason of their long
service they cannot be dismissed, though they are obviously unfit to hold any
responsible position” (chap. II)—­presents a satiric judgment of the ordinary
conventional values of people who do not measure their actions in relation to
the pity and terror that suffering and death provoke.
Of course, Ivan Ilych is the primary object of Tolstoy’s satirical realism,
and his descriptions of Ivan’s “normal” life, such as the representation of his
marriage in one instance, offer a pointed satire. In Ivan and Praskovya Fe-
dorovna’s marriage, Tolstoy notes, only

rare periods of amorousness . . . still came to them at times . . . [that were

like] islets at which they anchored for a while and then again set out upon
that ocean of veiled hostility which showed itself in their aloofness from one
another. This aloofness might have grieved Ivan Ilych had he considered that

Reading The Death of Ivan Ilych   /   333

 it ought not to exist, but he now regarded the position as normal, and even
made it the goal at which he aimed in family life. (chap. II)

Here—­and throughout the novella—­Tolstoy presents a remarkable “realis-

tic” account of domestic discord: the details of the dynamics of hostility and
argument are powerful in their generalizations and economy, and his meta-
phoric description of the “ocean of veiled hostility” (as Viktor Shklovsky says
of the Russian notion of “defamiliarization” we describe later in this chapter)
changes the “form” but not the “nature” of what he is describing in the subtle
effectiveness of Tolstoy’s art narrative. Tolstoy’s language is clearly (and for-
mally) metaphorical, yet the metaphors do not call attention to their linguis-
tic quality but, rather, clarify the “reality” (the nature) of what he represents.
Equally important in this satire are the implications for the physician and
health care workers: just as Ivan makes the hostility of his domestic life the
context in which he fulfills his official duties, affecting (implicitly) his con-
sciousness of power, his dignity, and “above all his masterly [and impersonal]
handling of cases,” so physicians sometimes can allow their own personal
history to affect their duties. (Never in his official work does Ivan pursue the
simple attempt at self-­conscious awareness that our “Self-­Appraisal Schema”
[checklist 1 in appendix 2] suggests for physicians and other professionals.)
In his realistic satire, Tolstoy allows readers to become aware of physicians’
attitudes, assumptions, and motivations, of which his characters seem ordi-
narily unaware.
Tolstoy’s larger aim in The Death of Ivan Ilych—­his chief concern—­is to
present Ivan’s inner life, the reevaluation of what he believes and values in
the face of his suffering and death. The great power of this novella, as many
have noted, is its ability to offer the vicarious experience of Ivan’s dying. In
important ways, the realism and the satire of The Death of Ivan Ilych mea-
sure themselves against this overarching purpose of stimulating vicarious
experience so that its readers can experience precisely what is not part of
their everyday, what is “screened,” as Tolstoy says, by everyday activities: the
warranted “reality” of death. The vicarious experience that narrative gives
rise to, as Scott Stroud argues, situates readers in a position that allows them
to reevaluate their values and behavior: this is the ethical work, he contends,
of literary narrative. The richness and detail of Tolstoy’s descriptions of the
world and of experiences make his description of Ivan’s dying and of Ivan’s
response to dying seem particularly real; and the reality of death and dying
presented by the novella makes its satire particularly biting.
We should add that Tolstoy’s satire of physicians is not the central focus

334  /  the chief concern of medicine

of his novella: in fact, in this novella, Tolstoy is not really concerned with
thinking deeply about the nature of doctoring and the physician-­patient rela-
tionship (although he does think deeply about suffering, healing, death, and
dying). Rather, the focus of the depiction of indifference on the part of Ivan
Ilych’s doctors is situated elsewhere within the larger context of Tolstoy’s at-
tempt to expose and critique bourgeois materialism and individualism. In
this context, his physicians are, then, a caricatured and almost perfect expres-
sion of the very values he abhors; they are ironic and satiric representations
that are not models of dedicated, if clueless, physicians awaiting recupera-
tion through the technē of narrative medicine. Still, The Death of Ivan Ilych
does suggest the centrality of narrative knowledge and understanding to an
interpretation of Ivan Ilych himself and in relation to his family and contem-
poraries more generally, and we can take it up to suggest a narrative schema,
so to speak—­or at least an instance of case-­based reasoning—­for the argu-
ments of our book. In the following discussion, then, we are taking up Ivan’s
story in the manner that Benjamin describes listeners taking up the stories
they hear to continue “a story which is just unfolding” (1969: 86). Such a
procedure means, among other things, to listen carefully as well as retell a
story, and to that end, we offer extended citations from the novella, following
Tolstoy’s voice even as we retell his narrative.

The Patient-­Physician Relationship

Re-­storying The Death of Ivan Ilych lends itself particularly well to the study
of the patient-­physician relationship, because the protagonist of the novella,
Ivan Ilych Golovin, is himself a professional—­an examining magistrate—­
who, like physicians and consulting detectives, deals directly with physical
evidence, the evidence of stories, and people caught up in life crises. This
section revisits, in relation to Tolstoy’s novella, many of the schematic repre-
sentations of the patient-­physician relationship examined in chapter 5. The
physicians Ivan encounters when his illness becomes uncomfortable enough
and worrisome enough for him to call them are very different from the ideal
doctor that Anatole Broyard describes when he writes about his final illness
in Intoxicated by My Illness. Broyard’s ideal doctor, as he says, aims at mak-
ing his medical condition “livable for me” (1992: 41). Ivan’s doctors do not
aim at making his condition “livable.” Indeed, they are not in the least inter-
ested in questions of life and death at all.
After one scene in Tolstoy’s novella in which Ivan Ilych has been particu-

Reading The Death of Ivan Ilych   /   335

larly unfair to his wife and then explains that his irritability is due to his not
being well, his wife insists that he see a celebrated doctor. The passage de-
scribing the doctor visit satirizes—­and perhaps caricatures—­the attitude of
the physician, even as it eloquently describes the patient’s chief concern.

He went. Everything took place as he had expected and as it always does.

There was the usual waiting and the important air assumed by the doctor,
with which he was so familiar (resembling that which he himself assumed in
court), and the sounding and listening, and the questions which called for
answers that were foregone conclusions and were evidently unnecessary, and
the look of importance which implied that “if only you put yourself in our
hands we will arrange everything—­we know indubitably how it has to be
done, always in the same way for everybody alike.” It was all just as it was in
the law courts. The doctor put on just the same air towards him as he himself
put on towards an accused person.
 . . . [Yet] to Ivan Ilych only one question was important: was his case seri-
ous or not? But the doctor ignored that inappropriate question. From his
point of view it was not the one under consideration, the real question was to
decide between a floating kidney, chronic catarrh, or appendicitis. It was a
question the doctor solved brilliantly, as it seemed to Ivan Ilych, in favour of
the appendix, with the reservation that should an examination of the urine
give fresh indications the matter would be reconsidered. All this was just
what Ivan Ilych had himself brilliantly accomplished a thousand times in
dealing with men on trial. (chap. IV)

Like the discourse of an angry patient, Tolstoy’s description presents disdain

(“Everything took place as he had expected and as it always does”), negative
judgment (“the look of importance”), and sarcasm (“brilliantly accom-
plished”) as it enacts satire. Moreover, it does so by representing the two
narrative frames we mentioned earlier, juxtaposing the conventional bour-
geois Ivan and the suffering human being.
Throughout his career, Ivan strictly separated professional and private
life—­in significant part, this is the conventionality of the professional bour-
geois class of Tolstoy’s time—­even while he acted on the very lives of those
who came before him as a magistrate. “In his work itself,” Tolstoy notes,
“especially in his examinations, he very soon acquired a method of eliminat-
ing all considerations irrelevant to the legal aspect of the case, and reducing
even the most complicated case to a form in which it would be presented on
paper only in its externals, completely excluding his personal opinion of the

336  /  the chief concern of medicine

matter, while above all observing every prescribed formality” (chap. II).
Ivan’s attitude to those who come before him is not quite the “paternalism”
described in chapter 5—­it does not possess the impassioned violence of the
physicians in “The Use of Force” or “Brute”—­and neither does it possess the
intellectual arrogance of Mr. Sheppard in O’Connor’s “The Lame Shall En-
ter First” or, as Tolstoy presents it, the consistent professional arrogance and
condescension of Dr. Nicholas in Stafford’s “The Interior Castle.”2 Yet, like
all of these characters, Ivan situates himself, in his role as judge, as the hero
of the narrative. His “heroism” takes the form of a self-­satisfied abstention
from action that never forgets an impersonal professionalism, which “com-
pletely excludes his personal opinion of the matter, while above all observing
every prescribed formality” (chap. II).
What the doctors forget in Ivan Ilych—­just as the lawyers forget it in the
first chapter of the novel, when they learn the news of Ivan’s death and won-
der, almost immediately, about who will obtain his now-­vacant position and
how that change will affect other appointments—­is that the question of life
and death that faces Ivan faces all people as well. Ivan himself had such indif-
ference to life and death. “In the depth of his heart,” Tolstoy writes, Ivan

knew he was dying, but not only was he not accustomed to the thought, he
simply did not and could not grasp it.
The syllogism he had learnt from Kiesewetter’s Logic: “Caius is a man,
men are mortal, therefore Caius is mortal,” had always seemed to him cor-
rect as applied to Caius, but certainly not as applied to himself. That Caius—­
man in the abstract—­was mortal, was perfectly correct, but he was not Caius,
not an abstract man, but a creature quite, quite separate from all others. He
had been little Vanya. . . . What did Caius know of the smell of that striped
leather ball Vanya had been so fond of? Had Caius kissed his mother’s hand
like that, and did the silk of her dress rustle so for Caius? Had he rioted like
that at school when the pastry was bad? Had Caius been in love like that?
Could Caius preside at a session as he did? (chap. VI)

Tolstoy’s description here of the difference between the logical knowledge of

a syllogism and the narrative knowledge of Ivan’s lived, memoried life under-
lines the ways narrative functions. It does so by suggesting the schematic ele-
ments of the speech act of communication as Roman Jakobson describes
them (see Chap. 7): the contact of smell and touch; the implicit short story
message of the school riot; Ivan as speaking subject, presiding over sessions,
and as listening subject, attending to inner voices, in the context of life as a

Reading The Death of Ivan Ilych   /   337

whole, “with all the joys, griefs, and delights of childhood, boyhood, and
youth” (Chap. VI).
At the same time, it also offers the schematic features of narrative (see
Chap. 3): particularly notable here are the very experience of this narrative, its
sequence of events, its recognizable agents (namely, Ivan rather than Caius), a
witness who learns (Ivan himself), and, underlined by the fear of death, a
chief concern (as well as the teller and listener whom Jakobson describes).
Ivan’s narrative reasoning suggests a schema for the self-­centered profession-
alism Tolstoy is satirizing in the novella. In a philosophical analysis of The
Death of Ivan Ilych, F. M. Kamm argues that the assumption that Caius is a
“man in the abstract” reveals Ivan’s own inability to take “seriously the nonab-
stract reality of other persons” (2003: 203). Kamm’s insight suggests a possible
schematic analysis of Ivan’s problem and attitude; that is, Kamm notes that
“the ‘turning of the tables’ motif” is strong in the story (2003: 204). This judg-
ment is based on Tolstoy’s aesthetic rendering of what we are describing as
the two narrative frames of The Death of Ivan Ilych. Thus the “turning of the
tables,” Kamm notes, recurs throughout the narrative.

Doctors treat him as a set of organs rather than a person whose life is at stake,
in the way he has treated defendants as interesting cases rather than persons
whose lives were at stake. His wife takes up a standard line to help her cope
with his illness as he took up a standard line with her. (Her line fails to deal
seriously with him as a dying person; she claims that he is to blame for not
following doctors’ orders; if he followed them, he need not die.) In sum, Ivan
believed that it was alright to act on a maxim toward others that he would not
be willing to universalize, including to have applied to himself. (2003: 204)

In this analysis, Kamm is unpacking a schema of Tolstoy’s strategy for argu-

ment and understanding: “the ‘turning of the tables’ motif” he describes is a
strategy to make sense of experience, just as the schemas of cognitive psy-
chology help make sense of events themselves and also condition the experi-
ence of events. In fact, Kamm’s analysis is based on the schematic element of
the two temporalities of narrative (implicit in the dynamics of its story and in
the fact that it is both articulated and received). With such a strategy, Tolstoy
is pursuing a “primitive”—­or at least simple—­sense of the Christian maxim
to “do unto others,” even if, in its satire, it is negatively applied.
With such a satiric strategy, Tolstoy demonstrates how the professional-
ism of both Ivan as a magistrate and his doctors as physicians—­professional
instances of the “denial of death” that many have observed in modern life
(Becker 1973)—­misses the forest for the trees in the lifework of professional

338  /  the chief concern of medicine

practitioners: both Ivan and his doctors miss the meaningful whole of their
roles as professionals in law and medicine dealing, at the extreme, with life
and death issues. That meaningful whole is, as Tolstoy says, provoked by the
“thought” and “the reality itself” of death. In his poem “Sunday Morning,”
Wallace Stevens says that “death is the mother of beauty” (1971: 66–­70), and
in his novel Howards End, E. M. Forster says, “Death destroys a man: the
idea of Death saves him” (1921: 239). Both Stevens and Forster describe the
way in which literature engages the thought and reality of death. Aristotle
does so as well in his analysis of tragedy, as do Tolstoy in The Death of Ivan
Ilych and Raphael Campo when he describes “the absolute—­ . . . the light, /
the awful light of what we know must come,” in his poem “The Couple”
(2002: 70). Stevens, Forster, and Campo are suggesting that the idea and
reality of death are touchstones of value: they confront the human sufferer
with the overwhelming necessity to decide what is important in her or his
life. This is, in fact, a pragmatic warranted assertion about the meaning of
death. The professionalism of Ivan’s doctors—­like Ivan’s own professional-
ism as a magistrate and person—­obscures this warranted reality that is part
and parcel of the practice of medicine. Near the end of The Death of Ivan
Ilych—­near the end of Ivan’s life—­Ivan overcomes this failure to acknowl-
edge death, even as he creates a positive sense of identity between himself
and others.

He lay on his back and began to pass his life in review in quite a new way. In
the morning when he saw first his footman, then his wife, then his daughter,
and then the doctor, their every word and movement confirmed to him the
awful truth that had been revealed to him during the night. In them he saw
himself—­all that for which he had lived—­and saw clearly that it was not real
at all, but a terrible and huge deception which had hidden both life and
death. (Chap. XI)

In seeing himself in others—­as discussed later in this chapter—­Ivan attains

a kind of empathy for his fellows that he never had as a judge.
As well as its negative representation of the extreme professionalism of
Ivan’s doctors, The Death of Ivan Ilych presents a positive representation of
the patient-­caregiver relationship, in the caretaking of Ivan’s servant, Gera-
sim, the hero’s helper in this narrative. From the very beginning of the
novella—­its first chapter, which presents the funeral of Ivan and from which
the rest of the text is a flashback—­Gerasim is presented as the person who
responds to cliché with truth. Peter Ivanovich says to him (“so as to say some-
thing”), “It’s a sad affair, isn’t it?” Gerasim responds, “It’s God’s will. We shall

Reading The Death of Ivan Ilych   /   339

all come to it some day” (chap. I). While Ivan is dying, Gerasim treats him
with a similar sense of forthright honesty. He is virtually the only person who
treats the “awful, solemn” act of dying with the respect it calls for—­terror at
its awfulness, solemn pity for its human sufferer.

What tormented Ivan Ilych most was the deception, the lie, which for some
reason they all accepted, that he was not dying but was simply ill, and only
need keep quiet and undergo a treatment and then something very good
would result. He however knew that do what they would nothing would
come of it, only still more agonizing suffering and death. This deception tor-
tured him—­their not wishing to admit what they all knew and what he knew,
but wanting to lie to him concerning his terrible condition, and wishing and
forcing him to participate in that lie. Those lies—­lies enacted over him on
the eve of his death and destined to degrade this awful, solemn act to the
level of their visitings, their curtains, their sturgeon for dinner—­were a ter-
rible agony for Ivan Ilych. . . . He saw that no one felt for him, because no one
even wished to grasp his position. Only Gerasim recognized it and pitied
him. And so Ivan Ilych felt at ease only with him. He felt comforted when
Gerasim supported his legs (sometimes all night long) and refused to go to
bed. . . . Gerasim alone did not lie; everything showed that he alone under-
stood the facts of the case and did not consider it necessary to disguise them,
but simply felt sorry for his emaciated and enfeebled master. Once when
Ivan Ilych was sending him away he even said straight out: “We shall all of us
die, so why should I grudge a little trouble?”—­expressing the fact that he did
not think his work burdensome, because he was doing it for a dying man and
hoped someone would do the same for him when his time came. (chap. VII)

In Gerasim’s pity and empathy for Ivan, he presents a version of doctoring as

caring rather than curing. One aim—­a proper aim—­of medicine is the cure
of the patient. This is the positive functionality of a denial of death in medi-
cine. Yet another proper aim of medicine is the care of the patient, even
when that patient has little hope of recovery or even of continuing to live.

The Doctor’s Listening

The Death of Ivan Ilych narrates some pointed examples of the ways in which
doctors and caretakers listen to the patient; acknowledge or fail to acknowl-
edge his concerns, agenda, and suffering; and respond to their patient and to

340  /  the chief concern of medicine

the situation of their profession. Tolstoy’s novella offers insight into many of
the issues examined in chapter 7. As we saw in that chapter, an important
part of the patient-­doctor encounter is the fact that each patient brings to it
a particular agenda, his chief concern. If the physician can learn to listen to
that concern early in the encounter, rather than turning his attention to his
own agenda, the time will be spent more efficiently. Just as the police in the
stories of Arthur Conan Doyle and Edgar Allan Poe bring their own agendas
to the events they encounter, so Ivan’s physicians make their professional
concern or “agenda”—­the successful diagnosis of Ivan’s condition—­the gov-
erning framework of the patient-­physician interview. In the case of Ivan Il-
ych, the concern he brings to his physicians is, first of all, his anxiety, his
vague apprehension that his ailment is not minor but something of over-
whelming importance. Thus, in the midst of his everyday life, “the pain in his
side, regardless of the stage the proceedings had reached, would begin its
own gnawing work. Ivan Ilych would turn his attention to it and try to drive
the thought of it away, but without success. It would come and stand before
him and look at him, and he would be petrified and the light would die out
of his eyes, and he would again begin asking himself whether It alone was
true” (chap. VI). Even earlier in the course of his illness, Ivan is anxious
about what is causing his pain. Tolstoy offers a remarkable narrative of the
doctor’s listening by narrating the physician’s response to his examination. As
already noted, when he goes to visit a “celebrated doctor,” “everything took
place as he had expected and as it always does”: “The doctor said that so-­
and-­so indicated that there was so-­and-­so inside the patient, but if the inves-
tigation of so-­and-­so did not confirm this, then he must assume that and that.
If he assumed that and that, then . . . and so on. To Ivan Ilych only one ques-
tion was important: was his case serious or not? But the doctor ignored that
inappropriate question” (chap. IV). For this doctor, whatever Ivan says is
“inappropriate”; the only appropriate discourse is that of the doctor himself.
In this “doctor babble”—­“The doctor said that so-­and-­so indicated that
there was so-­and-­so inside the patient” and so on—­the doctor allows his own
professional language to shut off the anxiety of his patient. Instead of listen-
ing to and confronting Ivan’s overriding concern—­“To Ivan Ilych only one
question was important: was his case serious or not?”—­the physician focuses
solely on the biomedical concerns of his science, in order not to listen. This
is Tolstoy’s remarkable narrative insight: namely, that the scientist-­doctor
brings to his encounter with the patient his own emotional concerns, includ-
ing concerns for professional advancement, as well as fearfulness in the face
of death or, at least, discomfort in the face of the patient’s anxiety. Moreover,

Reading The Death of Ivan Ilych   /   341

he does so in ways that allow him to avoid the concern and anxiety of his
patient. No one likes to give bad news, and one strategy to avoid confronting
one’s own and one’s patient’s anxiety is to fall into “doctor babble.” Ivan’s
physicians participate in the same denial—­of the existential crisis of his life
provoked by his illness—­exhibited by everyone in Ivan’s life: “The awful, ter-
rible act of his dying was, he could see, reduced by those about him to the
level of a casual, unpleasant, and almost indecorous incident (as if someone
entered a drawing room defusing an unpleasant odour) and this was done by
that very decorum which he had served all his life long” (chap. VII). Such
denial on the part of physicians allows for the “detachment” of science, but
at the cost—­as Anatole Broyard has noted—­of a certain bargain exchanging
humanity for authority.

Literary Narrative

The Death of Ivan Ilych is not primarily a story about medicine; rather, it is a
story about dying. Like the narratives of suffering and dying embodied in
classical and later tragedy, Tolstoy’s novella can remind us of the close link
between medicine and literature embodied in the pity and terror Aristotle
describes in tragedy. The Death of Ivan Ilych offers examples of tragic “rec-
ognition,” and in the course of its narrative, it arouses both pity for and terror
in the face of its human sufferer. What powerfully connects The Death of
Ivan Ilych to medicine is the manner in which overwhelming meaning—­the
significance of events that cannot be evaded, reinterpreted, or found to be
peripheral to human life (in short, its chief concern)—­is confronted in the
forms of illness and suffering. Early in the novella, in his desperate search for
healing and care, Ivan discovers that all the strategies of evasion and forget-
fulness, which his doctors and family and even his younger self so easily fall
into, are no longer available to him. Illness emphasizes meaning. As Tolstoy
notes of Ivan, the pain and suffering of illness can make self-­deception im-
possible: “something terrible, new, and more important than anything before
in his life, was taking place within him of which he alone was aware” (chap.
IV).
In the very first chapter of The Death of Ivan Ilych, when Ivan’s friends
gather at his house for his funeral, Tolstoy represents the drama of suffering
in the way in which Peter Ivanovitch, Ivan’s friend, responds to this encoun-
ter with death and dying. The following passage depicts Peter’s conversation
with Ivan’s wife, Praskovya Fedorovna.

342  /  the chief concern of medicine

 “He suffered terribly the last few days.”
“Did he?” said Peter Ivanovich.
“Oh, terribly! He screamed unceasingly, not for minutes but for hours. For
the last three days he screamed incessantly. It was unendurable. I cannot
understand how I bore it; you could hear him three rooms off. Oh, what I
have suffered!”
“Is it possible that he was conscious all that time?” asked Peter Ivanovich.
“Yes,” she whispered. “To the last moment. He took leave of us a quarter
of an hour before he died, and asked us to take Volodya away.”
The thought of the suffering of this man he had known so intimately, first
as a merry little boy, then as a schoolmate, and later as a grown-­up colleague,
suddenly struck Peter Ivanovich with horror, despite an unpleasant con-
sciousness of his own and this woman’s dissimulation. He again saw that
brow, and that nose pressing down on the lip, and felt afraid for himself.
“Three days of frightful suffering and the death! Why, that might suddenly,
at any time, happen to me,” he thought, and for a moment felt terrified.
But—­he did not himself know how—­the customary reflection at once oc-
curred to him that this had happened to Ivan Ilych and not to him, and that
it should not and could not happen to him, and that to think that it could
would be yielding to depression which he ought not to do, as Schwartz’s ex-
pression plainly showed. After which reflection Peter Ivanovich felt reas-
sured, and began to ask with interest about the details of Ivan Ilych’s death,
as though death was an accident natural to Ivan Ilych but certainly not to
himself. (chap. I)

In this scene, Tolstoy presents and seemingly erases the terror of death,
which could happen to Ivan—­or Caius, for that matter—­but never to Peter.
The rest of the narrative works to describe the terror of death and suffering
that seems so private to Ivan yet is, as Tolstoy knew, a defining feature of hu-
man life. “Life, a series of increasing sufferings,” Ivan notes, “flies further
and further towards its end—­the most terrible suffering” (chap. X). It is no
accident that the pious Tolstoy gives his protagonist a name as ordinary in
Russian as “John Smith”—­that he makes Ivan an “everyman”—­and presents
his suffering as lasting the same, almost archetypal time period as that of the
suffering Jesus. Moreover, like Aristotle and much literary narrative, the rest
of The Death of Ivan Ilych also works to describe pity for the human
sufferer—­even for such self-­deluded people as Peter Ivanovitch, Praskovya
Fedorovna, and the younger Ivan himself.
In The Death of Ivan Ilych, Tolstoy makes, as clear as any writer in our

Reading The Death of Ivan Ilych   /   343

tradition, the connection between the emotions of pity and terror that Aris-
totle describes in tragedy—­emotions, we have seen, that Joyce describes as
“grave and constant.” In his narrative, Tolstoy presents Ivan the child in the
adult, and in so doing, he describes aspects of human growth and develop-
ment on a level that creates a sense of qualities of life that almost all people
might share. Such constancy is part and parcel of the paternalism described
in chapter 5 as an element of the patient-­physician relationship. Paternalism,
as described in that chapter, is at once condescending and dismissive. But
synonyms for paternalism, such as the adjective fatherly or the verb to mother
captures a sense of nurturance and care that Ivan, like the rest of us, hopes
to encounter in his experience.

Apart from this lying, or because of it, what most tormented Ivan Ilych was
that no one pitied him as he wished to be pitied. At certain moments after
prolonged suffering he wished most of all (though he would have been
ashamed to confess it) for someone to pity him as a sick child is pitied. He
longed to be petted and comforted. He knew he was an important function-
ary, that he had a beard turning grey, and that therefore what he longed for
was impossible, but still he longed for it. And in Gerasim’s attitude towards
him there was something akin to what he wished for, and so that attitude
comforted him. Ivan Ilych wanted to weep, wanted to be petted and cried
over, and then his colleague Shebek would come, and instead of weeping and
being petted, Ivan Ilych would assume a serious, severe, and profound air,
and by force of habit would express his opinion on a decision of the Court of
Cassation and would stubbornly insist on that view. This falsity around him
and within him did more than anything else to poison his last days. (chap.
VII)

The translation used here, by Louise and Aylmer Maude, is contemporane-

ous with the novella (the Maudes were friends of Tolstoy’s). The word pity
has become almost negative since that time, precisely because it seems to
carry with it condescension and dismissiveness. (More recent translations of
The Death of Ivan Ilych use the translation “feel sorry for” or “compassion.”)
But pity in the way that Tolstoy uses the term comes close to Aristotelian pity
and, powerfully, to the meaning of the word empathy as it is defined in chap-
ter 5 in terms of empathetic recognition, understanding, and action. Gerasim
does not “suffer with” Ivan, yet his very attitude, as Ivan notes, recognizes,
acknowledges, and acts on his sense of profound, empathetic pity.
At the moment of his death, Ivan feels such pity for his son and his wife.

344  /  the chief concern of medicine

“This occurred at the end of the third day, two hours before his death,” when
his hand falls on his son’s head.

He opened his eyes, looked at his son, and felt sorry for him. His wife came
up to him and he glanced at her. She was gazing at him open-­mouthed, with
undried tears on her nose and cheek and a despairing look on her face. He
felt sorry for her too. . . .
 . . . With a look at his wife he indicated his son and said: “Take him away . . .
sorry for him . . . sorry for you too. . . .” He tried to add, “Forgive me,” but
said “Forego” and waved his hand, knowing that He whose understanding
mattered would understand.
And suddenly it grew clear to him that what had been oppressing him and
would not leave him was all dropping away at once from two sides, from ten
sides, and from all sides. He was sorry for them, he must act so as not to hurt
them: release them and free himself from these sufferings. “How good and
how simple!” he thought. (chap. XII)

Perhaps the pity and terror of literature—­and perhaps the pity and terror
aroused in medicine as well—­are gathered together in the “forgiveness” that
Ivan feels but cannot quite pronounce. The Maude translation nicely con-
fuses the English words forgive and forego, but the Russian is even more
powerful in combining the way in which the clarifying terror of death pro-
vokes a sense of profound, empathetic pity, by portraying Ivan as attempting
to express his recognition and repentance with the word forgive (in Russian,
prosti) but saying, instead, “pass through” (in Russian, propusti) (see John
1993: 81–­82). Both literature and medicine teach us that we all “pass through”
certain grave and constant life events.

Ethics and Practicing Medicine

The Death of Ivan Ilych underlines the manner in which ethics—­the con-
cern for creating a good life for oneself, for pursuing good behaviors in rela-
tions with others, for helping to create and sustain community, and for find-
ing criteria for judgment and action, all gathered together in Aristotle’s term
eudaimonia—­is woven into the practices of healing and care in medicine. As
Ivan Ilych finds himself dying, in the extended flashback after the funeral of
the first chapter, he repeatedly asks himself questions about the choices he
made in his life, the conventions by which he lived. By presenting Ivan’s an-

Reading The Death of Ivan Ilych   /   345

guish for discovering whether or not he lived as he “ought to have”—­
especially in the contexts of the behaviors of his doctors, his family, and his
servant, Gerasim—­the narrative of his death helps us to understand the eth-
ics that is part and parcel of medicine.
In the context of Aristotelian virtue ethics we described in the preceding
chapter, the conventions by which Ivan lived follow the contours, but not the
essence, of virtues. His conventional life, described early in the novella, is,
first of all, presented as the form of Aristotle’s virtuous “mean”—­Ivan, the
middle son of three, “was neither as cold and formal as his elder brother nor
as wild as the younger, but was a happy mean between them—­an intelligent
polished, lively and agreeable man” (chap. II)—­yet it is a mean that betrays
the spirit of Aristotle’s virtues. In the passages that follow—­and many others
like them throughout The Death of Ivan Ilych—­Tolstoy pursues his satire
not through angry sarcasm (which is ubiquitously present in the novella), but
by means of the darker irony of presenting the conventional forms, but not
the nature, of significant values.

Of his marriage, we are told, “to say that Ivan Ilych married because he
fell in love with Praskovya Fedorovna and found that she sympathized
with his views of life would be as incorrect as to say that he married
because his social circle approved of the match. He was swayed by
both these considerations: the marriage gave him personal satisfac-
tion, and at the same time it was considered the right thing by the
most highly placed of his associates” (chap. II).
Of his married life, Tolstoy notes that Ivan Ilych “only required of it those
conveniences—­dinner at home, housewife, and bed—­which it could
give him, and above all that propriety of external forms required by
public opinion. For the rest he looked for lighthearted pleasure and
propriety, and was very thankful when he found them, but if he met
with antagonism and querulousness he at once retired into his sepa-
rate fenced-­off world of official duties, where he found satisfaction”
(chap. II).
Of his “official duties” and career, we are told that Ivan “started for Pe-
tersburg with the sole object of obtaining a post with a salary of five
thousand rubles a year. He was no longer bent on any particular de-
partment, or tendency, or kind of activity. All he now wanted was an
appointment to another post with a salary of five thousand rubles”
(chap. III).
Of his new house, the renovations of which caused the accident that

346  /  the chief concern of medicine

 seems to mark the beginning of his illness, Tolstoy says, “in reality it
was just what is usually seen in the houses of people of moderate
means who want to appear rich, and therefore succeed only in resem-
bling others like themselves: there are damasks, dark wood, plants,
rugs, and dull and polished bronzes—­all the things people of a cer-
tain class have in order to resemble other people of that class. His
house was so like the others that it would never have been noticed,
but to him it all seemed to be quite exceptional” (chap. III).

When he finds himself dying, however, Ivan begins to question those

conventions around which he organized his life. Faced with death and
dying—­with the enormous life disruption of illness, disease, decrepitude—­
the “everyman” Ivan is forced to examine the moral and ethical dimensions
of his life. Above all, he comes to recognize the virtues we discussed in the
preceding chapter, as they are summed up in Gerasim’s sense of pity for the
shared fate of human beings. Thus he asks what is a good life, what consti-
tutes valuable relations with others, what responsibilities does a person have
to the community into which he is born, what are the criteria by which one
chooses particular actions. Thus we might even say that Aristotle’s pity—­a
species of the empathy in the patient-­physician relationship that is also at the
heart of the medical/literary notion of katharsis—­is a possible source or
headwater for the virtues we described in chapter 9.
Another source of such virtues, we have suggested, can be seen in narra-
tive and the narrative knowledge it sets forth. The kind of reasoning in which
Ivan participates is “casuistry” or “analogical reasoning.” Such reasoning
from analogy—­reasoning based not on abstract principles that govern the
understanding of particular events but on analogies between one event and
another, one situation and another that can be discerned on the level of case-­
based reasoning and the schemas of experience—­allows ethical judgments to
arise out of the situations of narrative rather than to be imported to or im-
posed on situations. In Ivan’s thought, the measures of the good life, good
relationships, and responsibility are contemplated “narratively,” in relation to
his past life.

Latterly during the loneliness in which he found himself as he lay facing the
back of the sofa, a loneliness in the midst of a populous town and surrounded
by numerous acquaintances and relations but that yet could not have been
more complete anywhere—­either at the bottom of the sea or under the
earth—­during that terrible loneliness Ivan Ilych had lived only in memories

Reading The Death of Ivan Ilych   /   347

 of the past. Pictures of his past rose before him one after another. They al-
ways began with what was nearest in time and then went back to what was
most remote—­to his childhood—­and rested there. If he thought of the
stewed prunes that had been offered him that day, his mind went back to the
raw shriveled French plums of his childhood, their peculiar flavour and the
flow of saliva when he sucked their stones, and along with the memory of that
taste came a whole series of memories of those days: his nurse, his brother,
and their toys. (chap. X)

This description rich with detail—­for instance, Tolstoy has the ability to
transform stereotype into experience by allowing us to see the drying of
plums into prunes—­offers a touchstone for value in Ivan’s life and in narra-
tive ethics more generally. It also creates vicarious experience as we de-
scribed it earlier, following Scott Stroud.
Still, neither here nor elsewhere does Ivan think of his responsibilities in
terms of the virtues—­conscientiousness, discernment, compassion, phrone-
sis, or even common decency—­that help define value in the context of the
drama of interpersonal relationships. In fact, save for Gerasim, the virtues we
described in the preceding chapter are almost never the explicit focus of this
narrative. This omission—­as much Tolstoy’s as Ivan’s—­removes contempla-
tion of ethics almost solely to the realm of the personal, though an admirable
quality of Gerasim is his ability to transform the personal into criteria by
which to govern interpersonal relationships and to determine action. More-
over, there is little about the particular ethics of physicians in The Death of
Ivan Ilych other than the implied absence of virtues most discernible in the
contrast between the empathetic care Gerasim offers his master—­exhibiting
compassion, conscientiousness, discernment, and wonderful decency—­and
the professional indifference of his physicians and the personal indifference
of his family. Still, by making the ethics of his lived life the focus of Ivan’s at-
tention as he dies and by ending his life with his achieved sense of pity for
those around him—­an achievement that suggests that Ivan has attained many
of Gerasim’s virtues—­Tolstoy is able to suggest his ability to honor those
around him so that, as Dr. Rita Charon says for the physician, he seems to be
able, like Gerasim, “not to trivialize” the story of suffering, “not to dismiss it,
not to forget it” (Vannatta, Schleifer, and Crow 2005: chap. 4, screen 2).
The duty to honor a life story and the duty to act based on that honor and
respect are tied up, in both medicine and literature, with the terror and pity
of death and dying. As noted earlier, “what tormented Ivan Ilych most was

348  /  the chief concern of medicine

the deception, the lie, which for some reason they all accepted, that he was
not dying but was simply ill. . . . The awful, terrible act of his dying was, he
could see, reduced by those about him to the level of a casual, unpleasant,
and almost indecorous incident . . . by that very decorum which he had
served all his life long” (chap. XI). Faced with this awfulness, the physician,
like Gerasim, has an obligation to remember and pursue the virtues of Aris-
totle: compassion, discernment, truthfulness, and focused action.

The Patient’s Story

Above all, The Death of Ivan Ilych is a patient’s story. It is the story of Ivan’s
illness, a History of Present Illness, including etiology, symptoms, and prog-
nostication. It is the story of Ivan’s suffering and the meaning his suffering
imparts to his illness in terms of both narrative knowledge and narrative
ethics—­its chief concern. Such meaning entails, in these dimensions, an “ill-
ness” of a community and an ethos of conventional behavior, so that wife,
child, and even professional colleagues (lawyers and doctors) and servants
are caught up in it. As such, it also entails the enactment of Ivan’s denial and
the narrow scope of his recognition, the particular story filter his conven-
tional life creates for his story. In its story of dying—­which is both unique to
Ivan and the general tragedy to which every person (and Ivan as “everyman”)
is liable—­it is a place where narrative and medicine meet and illuminate one
another.
Like Grace Paley’s father, who “had been a doctor for a couple of decades
and then an artist for a couple of decades” and so was “interested in details,
craft, technique” (1974: 164), Tolstoy’s novella offers a powerfully detailed
description of the life and world of Ivan Ilych. His writing in The Death of
Ivan Ilych—­like his writing throughout his career—­presents a world, in de-
scriptive details, that is at once recognizably our own and remarkable in the
details it focuses on. Attention to curious detail and surprising fact, as we
have seen, is shared by diagnosticians and detectives. Tolstoy’s description of
Ivan’s dead body, early in the novella, is one such example of a detailed real-
istic description that at once is familiar to readers and startling in the details
to which it attends (many of the art narratives discussed in The Chief Con-
cern of Medicine, such as those by William Carlos Williams, Flannery
O’Connor, Jean Stafford, Rafael Campo, Richard Selzer, are realistic in this
complicated way).

Reading The Death of Ivan Ilych   /   349

 The dead man lay, as dead men always lie, in a specially heavy way, his rigid
limbs sunk in the soft cushions of the coffin, with the head forever bowed on
the pillow. His yellow waxen brow with bald patches over his sunken temples
was thrust up in the way peculiar to the dead, the protruding nose seeming
to press on the upper lip. He was much changed and grown even thinner
since Peter Ivanovich had last seen him, but, as is always the case with the
dead, his face was handsomer and above all more dignified than when he was
alive. The expression on the face said that what was necessary had been ac-
complished, and accomplished rightly. Besides this there was in that expres-
sion a reproach and a warning to the living. This warning seemed to Peter
Ivanovich out of place, or at least not applicable to him. (chap. I)

In this “realistic” description—­with minute attention to the details of Ivan’s

features and coffin—­Tolstoy adds generalizations about death (how “dead
men always lie”; how the face is handsome and dignified, “as is always the
case with the dead”) that force the reader, if not Peter Ivanovich, to rethink
and reevaluate their ordinary, stereotypical responses to experience.
Many years ago, Russian scholars—­older contemporaries and teachers of
Roman Jakobson in Moscow—­described Tolstoy’s ability to “defamiliarize”
experience or make it “strange” by means of techniques or devices that at-
tend to unusual details, use language in odd or nonconventional ways (e.g.,
the rhymes of poetry or extended metaphoric descriptions), or present curi-
ous points of view. In one example, they describe Tolstoy’s attention to the
boards of a stage rather than to the dancers. The “Russian formalists” (as
they were called—­in chapter 3, we cited Rita Charon’s reference to them)
made the techniques of “defamiliarization” a defining feature of literature in
general, and this feature is more pronounced in art than in popular narrative.
In his important essay “Art as Technique” (1917), the Russian formalist Vik-
tor Shklovsky notes that “Tolstoy makes the familiar seem strange by not
naming the familiar object. He describes an object as if he were seeing it for
the first time, an event as if it were happening for the first time. In describing
something he avoids the accepted names of its parts and instead names cor-
responding parts of other objects. . . . The familiar act of flogging [in one
example from Tolstoy] is made unfamiliar both by the description and by the
proposal to change its form without changing its nature” (Shklovsky 1989:
59).
In their work, Shklovsky and the Russian formalists offer a general—­and,
purportedly, “scientific”—­definition of literature in terms of particular uses
or strategies of language aiming to bring new life to stereotypical experience.

350  /  the chief concern of medicine

Perception, Shklovsky writes, “becomes habitual, . . . automatic”; the habit of
ordinary speech “devours works, clothes, furniture, one’s wife, and the fear
of war.” For this reason, he goes on, “art exists that one may recover the sen-
sation of life; it exists to make one feel things, to make the stone stoney.” To
be made new and poetically useful, language must be “defamiliarized” and
“made strange,” as Shklovsky says, through linguistic displacement, which
means deploying language in an unusual context or effecting its presentation
in a novel way (Shklovsky cited in Davis and Schleifer 1991: 131). Defamil-
iarization is, therefore, the manner in which poetry functions to rejuvenate
and to revivify language. Tolstoy’s deployment of realistic detail in novel ways
allows his fiction to be recognizably real—­it does not change the “nature” of
what is represented—­even while its “formal” description calls attention to
meaningful details (the heaviness, handsomeness, and dignity of a dead
body) that are usually overlooked. Embedded in the realistic details of The
Death of Ivan Ilych is Tolstoy’s more or less didactic message, the novel’s
satiric focus, which we mentioned at the beginning of this chapter.
Yet despite—­or along with—­the cognitive, didactic purpose of the no-
vella also stands a potent realism that provokes powerful emotion. Thus Tol-
stoy makes Ivan’s suffering and anguish real in narrating his dark encounter
with the things of his everyday life.

And to replace that thought he called up a succession of others, hoping to

find in them some support. He tried to get back into the former current of
thoughts that had once screened the thought of death from him. But strange
to say, all that had formerly shut off, hidden, and destroyed his consciousness
of death, no longer had that effect. Ivan Ilych now spent most of his time in
attempting to re-­establish that old current. He would say to himself: “I will
take up my duties again—­after all I used to live by them.” And banishing all
doubts he would go to the law courts, enter into conversation with his col-
leagues, and sit carelessly as was his wont. . . . But suddenly in the midst of
those proceedings the pain in his side, regardless of the stage the proceed-
ings had reached, would begin its own gnawing work. Ivan Ilych would turn
his attention to it and try to drive the thought of it away, but without success.
It would come and stand before him and look at him, and he would be petri-
fied and the light would die out of his eyes, and he would again begin asking
himself whether It alone was true. . . . And what was worst of all was that It
drew his attention to itself not in order to make him take some action but
only that he should look at It, look it straight in the face: look at it and without
doing anything, suffer inexpressibly. (chap. VI)

Reading The Death of Ivan Ilych   /   351

The mechanism of Tolstoy’s realism—­like the mechanism of his defamiliar-
ization—­is uncomplicated. By using simply an italicized pronoun—­which he
does even more extensively later in his narrative—­Tolstoy is able to convey
to his readers the dreadful anguish and suffering that Ivan feels. By means of
this literary (or discursive) device, he represents Ivan’s inner emotional life in
the midst of his everyday realistic experience. Tolstoy calls attention to such
details in his storytelling, but they can be discerned and appreciated in ev-
eryday narratives as well, where stereotype can yield insight and where rou-
tine can be transformed into meaningful encounter. Remember, as we noted
in chapter 5, Dr. Vannatta’s delight in his patient’s phrase “he wasn’t very
good at making a living, but he was sure good at making babies.” A conscious
sense of the art of storytelling—­in this case, the patient’s play of the word
“making” even in the midst of an anxious interview—­enriches an ordinary
interview in a busy day.
As well as Ivan’s conscious dread of dying, Tolstoy presents his night-
mares, describing them with the metaphor of a “black sack,” a figural use of
language that reappears at the very end of his life.

Till about three in the morning he was in a state of stupefied misery. It

seemed to him that he and his pain were being thrust into a narrow, deep
black sack. . . . He was frightened yet wanted to fall through the sack, he
struggled but yet co-­operated. And suddenly he broke through, fell, and re-
gained consciousness. Gerasim was sitting at the foot of the bed dozing qui-
etly and patiently, while he himself lay with his emaciated stockinged legs
resting on Gerasim’s shoulders; the same shaded candle was there and the
same unceasing pain. (chap. IX).

Tolstoy powerfully conveys the dream by presenting it first as a conscious

thought (in the sentence beginning “It seemed to him”), only to show, as Ivan
“regained consciousness,” that it was a frightening dream. Using wordplay
like Dr. Vannatta’s patient, Tolstoy plays on the word there in the final sen-
tence, which equates the reality of an object in the world with the reality—­
the “thereness,” Shklovsky might say—­of pain.
At the very end of the narrative, Tolstoy returns to the figure of a black
sack to describe Ivan’s dying.

For three whole days, during which time did not exist for him, he struggled
in that black sack into which he was being thrust by an invisible, resistless
force. He struggled as a man condemned to death struggles in the hands of

352  /  the chief concern of medicine

 the executioner, knowing that he cannot save himself. And every moment he
felt that despite all his efforts he was drawing nearer and nearer to what ter-
rified him. He felt that his agony was due to his being thrust into that black
hole and still more to his not being able to get right into it. He was hindered
from getting into it by his conviction that his life had been a good one. That
very justification of his life held him fast and prevented his moving forward,
and it caused him most torment of all.
Suddenly some force struck him in the chest and side, making it still harder
to breathe, and he fell through the hole and there at the bottom was a light.
What had happened to him was like the sensation one sometimes experi-
ences in a railway carriage when one thinks one is going backwards while one
is really going forwards and suddenly becomes aware of the real direction.
(chap. XII)

With this repetition of the “same” figure of the black sack, Tolstoy is pursuing
the art of narrative to render “telling” effects in the manner we describe in
chapter 2. In this second rendering, however, the figure of the “black sack” is
the narrative’s descriptive term rather than an illusion of Ivan’s nightmare.
By using this figural term as part of the narrative itself, the narrative creates
the further illusion that what is dreamed is, at first, presented as real. This is
something that ordinary everyday narratives rarely, if ever, do: everyday nar-
ratives have their particular ends and concerns, which do not, ordinarily, con-
sciously strive for the defamiliarizing effect of having seemingly objective
narrators take up characters’ seemingly subjective language. Tolstoy’s use of
Ivan’s dream figure (the “black sack”) creates a powerful aesthetic resonance
in his story: it enacts the pity Ivan feels for his son and wife—­a fully Aristote-
lian pity—­insofar as the “real” world of the narration now seems to coincide
with the inner world of the character. In the very repetition of this figure of
language, the impersonal narrator appears to empathize with Ivan’s terrible
dream. Moreover, Tolstoy’s description of the sensation one sometimes expe-
riences in a railway carriage is a perfect example of defamiliarization.
Tolstoy—­like writers of art narrative more generally—­is able to provoke
in his readers the vicarious experience his characters possess. The ability of
literature to create or provoke such experience—­its uses of “techniques” or
“devices,” as Shklovsky says, but also its more general ability to provoke em-
pathy for characters and situations that may well be a function of the ability
of humans to imagine other people’s mental states (theory of mind)—­is its
particular importance to the practice of medicine. Tolstoy allows us to under-
stand, comprehend, and—­in some vague or approximate way—­feel the kind

Reading The Death of Ivan Ilych   /   353

of experiences that his character endures. He does this through the tech-
niques of particular linguistic devices (e.g., his italicized pronoun) and par-
ticular narrative devices (e.g., confusing his reader as to Ivan’s dream or us-
ing character’s metaphorical language to present actual events). More
generally, he also creates shared, vicarious experiences of character and
reader simply by emphasizing the things his readers share with Ivan so that
they can comprehend those things they have not yet shared with him. Such
sharing is, in part, the work of schemas of experience and case-­based reason-
ing in which, as Thomas Nickles has noted, “some sort of similarity metric [is
employed] to find one or more cases similar to the presented case” (1998:
70). Such it is with Ivan’s childhood memories.

There also the further back he looked the more life there had been. There
had been more of what was good in life and more of life itself. The two
merged together. “Just as the pain went on getting worse and worse, so my
life grew worse and worse,” he thought. “There is one bright spot there at the
back, at the beginning of life, and afterwards all becomes blacker and blacker
and proceeds more and more rapidly—­in inverse ration to the square of the
distance from death,” thought Ivan Ilych. And the example of a stone falling
downwards with increasing velocity entered his mind. (chap. X)

A passage like the preceding one allows readers to identify with Ivan’s expe-
rience—­to vicariously share his knowledge. It does so by combining logico-­
scientific reasoning (the “inverse ration to the square of the distance” is akin
to Ivan’s logical understanding of Caius’s mortality) with Ivan’s life memories
to which the reader has been privy.
More generally, the manner in which The Death of Ivan Ilych presents
Ivan’s terror at dying—­the dread of the “awful, solemn act,” the “awful, ter-
rible act” of dying (chap. VII)—­allows its readers the vicarious experience. It
does so by means of its detailed descriptions (realism, defamiliarization, sat-
ire); its odd metaphorical language (“It,” “black sack”); its narrative organiza-
tion (flashback creating recognition); and its contrast of characters (“the
‘turning of the tables’ motif” [Kamm 2003: 204]), such as Ivan’s friends and
family versus Ivan himself, the healthy Ivan versus the ailing Ivan, or Ivan’s
doctors versus Gerasim. In such complex, artful narrative, which provokes a
sense of felt experience for readers, Tolstoy employs all the salient features
of narrative we have isolated: its sequence of events, its recognizable charac-
ters, its end and its concern, the fact that it is articulated and received (this is
the motor of defamiliarization), a witness who learns. At the same time, Ivan

354  /  the chief concern of medicine

Ilych allows its readers a last feature of narrative, the vicarious experience of
pity for Ivan’s dying by means of its larger narrative organization as well as its
detailed descriptions of Ivan’s suffering: after the first chapter, the chrono-
logical life story is told twice, first as flashback and then as Ivan’s reevaluation
of his life experiences. In its entirety, The Death of Ivan Ilych presents real-
istic information about suffering and dying, despite the fact that it is almost
impossible to come up with a “realistic” diagnosis of Ivan’s physical condi-
tion. In fact, its meticulous realistic details gives rise to a sense of what Joyce
calls the “secret cause” of illness and suffering, even while its larger narrative
structures establish the basis of an empathetic comprehension of Ivan’s hu-
man experience, a sense of what Joyce calls the “human sufferer” of disease
and ailment. Such knowledge and comprehension are available in the pa-
tient’s story; they, in fact, constitute the narrative knowledge that is part and
parcel of practicing medicine. Such knowledge and comprehension are ac-
cessible through careful listening; they form the basis of effective and fulfill-
ing patient-­physician relationships and effective doctoring. Such knowledge
and comprehension allow us to recognize and help determine the ethical
dimension and ethical activity of practicing medicine.

Conclusion

In these ways, then, reading The Death of Ivan Ilych in the contexts of a com-
mitment to medicine and of its everyday activities and practices offers us all,
patients and physicians alike, a richer sense of the vocation of health care and
also a richer sense of our shared human lives. Many of the writers, physicians,
scholars, and even patients we have encountered telling stories and analyzing
experience in The Chief Concern of Medicine have suggested, as we noted in
the beginning, that to be a health care worker is an especially privileged posi-
tion in our and in any society. Like many other professions, health care has
the potential for great social, intellectual, and—­as we mentioned in the
introduction—­spiritual rewards, in its engagements with the great crises of
health and illness, well-­being and suffering, and life and death that face all
people. In its encounters with ailing human beings, the profession of medi-
cine also entails interactions with people that touch on the vital centers of
human life in general. It is our hope that the fulfillment of our goal of dem-
onstrating the ways that the medical humanities can be integrated into prac-
tices of medicine also demonstrates what we asserted at the beginning of this
book: that there are few professions that call on the intimacies, the emotions,

Reading The Death of Ivan Ilych   /   355

the potentiality of honest and heartfelt interchange that characterize the best
part of our private lives as does a profession in medicine. Medicine and doc-
toring are built around this human relationship between patient and physi-
cian; they are grounded in storytelling, good listening, and the sense—­which
can always be improved and shared—­of how stories work; and because they
touch on the great crises of our shared lives, they are always, in their smallest
gestures as well as largest decisions, a profoundly ethical enterprise. But say-
ing these things is a way of saying that the privilege of doctoring simply un-
derscores the fact that the work of medicine in the face of suffering and also
in its restorations of health is, more generally, something we all share in as we
provide and encounter care and caretaking in our lives. To make us mindful
of this—­again as both patients and physicians—­is an important aspect of the
significance of narrative in medical practices.

356  /  the chief concern of medicine

afterword
The Nexus of Literature and Medicine;
The Interactions of Patient and Physician

We began this book’s discussion with a philosophical argument that the ob-
jects of humanistic understanding obtained through narrative knowledge are
real and that this reality is a result of narrative understanding and reflection.
This reality is demonstrated in a pragmatic way by attending to the actions
that spring from the apprehension of dramatic stories and by the outcomes
or consequences resulting from exposure to their literary structure and con-
tent. We have demonstrated that the consequences of having studied and
reflected on the features of narrative structure, character development and
motives, time lines in narrative—­in a word, the details and larger structures
of narrative—­create in medical learners and practitioners an opportunity to
engage the patient in a way that is important for the development of rapport
and the establishment of a profound patient-­physician relationship. We have
stated that the patient’s story deserves focused attention because it is the only
data, at least early in the relationship, that results from the patient’s experi-
ence of the symptoms that brought him to see the doctor in the first place.
We argue—­in opposition to some, like the positivists, who pursue a narrow
sense of what is meant by the “scientific”—­that not beginning with the pa-
tient’s narrative but rather relying too early on biomedical tests—­which are
scientifically (i.e., quantitatively) verifiable—­is to get the proper sequence of
investigation backward.
We have further argued that paying attention to the knowledge embed-
ded in the patients’ stories avoids two common errors in the current-­day
practice of medicine. One is the failing to see the patient as a unique, valued,
and honorable individual who deserves to have her story and concerns heard,

/  357  /
understood, and integrated into medical treatment. The second is thinking
of patients’ stories as shrouds veiling a “truth” that only exists in the confines
of biomedical knowledge—­knowledge that is assumed to be the sole starting
point for the creation of the diagnosis. By honoring each individual story and
by applying the knowledge gained through the study of narrative, we can use
the patient’s story as the most efficient route to the understanding of her
chief concern and the correct diagnosis of her chief complaint. It stands to
reason that engagement with the medical humanities and narrative knowl-
edge, perhaps early in a medical student’s career, creates an opportunity to
attend to these important issues in caring for a patient. This, we have argued,
is how the important nexus between narrative studies and medicine aids in
the development of Aristotle’s phronesis. We have argued that the practice of
medicine can and should proceed beginning with a patient’s chief complaint
and advance through a thorough understanding of the patient’s story, his His-
tory of Present Illness (HPI), toward his chief concern. By attending to the
chief concern as well as uncovering a correct diagnosis, we accomplish both
the proper outcome and goal of biomedical medicine and the proper out-
come and goal of humanistic understanding, namely, attending to the pa-
tient’s suffering, whether it be in relieving symptoms, restoring well-­being,
or simply developing pragmatic strategies for carrying on.
We have turned to the works of Aristotle in relation to phronesis, to vir-
tue ethics, and to explanations and elaborations of Aristotle in Martha Nuss-
baum and Alasdair McIntyre to explore how the study of narrative and nar-
rative structure provides students and practitioners of medicine with
understanding and skills that we believe are more reliable guides to the in-
vestigation of illness than the abstract notions of science alone. It is not that
the abstract ideas of science are misleading; but when pursued without the
road map provided by the experience of the patient in relation to her symp-
toms they commonly cause the doctor to miss the point and, consequently, to
miss the diagnosis. Just as important, when used alone, abstract scientific
knowledge—­in the absence of the narrative knowledge provided by the ex-
perience of the patient—­can cause the doctor to ignore the patient’s chief
concern associated with her suffering. It has been our contention in the
pages of this book—­just as it is implicit (and sometimes explicit) in the dis-
cussions of Martha Nussbaum, Rita Charon, Richard Kleinman, and many
others—­that narrative knowledge aids in the understanding of the experi-
ences that patients bring to physicians; that the story the patient tells is gov-
erned by the schemas that govern the understanding of narrative; and that

358  /  the chief concern of medicine

these schemas, understood as provisional “rules” of narrative, are teachable.
Because they are teachable, we believe their addition to medical school cur-
ricula and to continuing medical education will shorten the time it takes a
physician to develop phronesis.
In the title of this book and in much of its content, we have argued that the
chief concern of the patient should take a larger role in the process of the
practice of medicine. This chief concern, we have noted, has analogies in the
study of narrative insofar as the stories, as a mode of understanding, and in-
deed the characters in stories, as they are developed, emphasize human mo-
tive. These motives—­or “desires,” as Charon describes them—­relate to what
the author or the character wants the reader to know as it relates to the teller’s
motive, the “why” of their telling the story. In the case of medicine, the chief
concern is what the patient-­teller wants his physician to know. This, we main-
tain, is altogether different from his chief complaint, which is merely a way of
beginning the story. It is understood by physicians who have practiced medi-
cine for many years that the chief concern of medicine may lie in a completely
different category from that of the symptoms that cause the patient to present
to the doctor. A good example of this was presented in chapter 3, in which the
woman who needed surgical closure of bedsores was chiefly concerned that
she would have complications depending on astrological signs and phases of
the moon. It is our contention that a physician who seeks the chief concern
along with the biomedical details of the HPI, one who is empathically attuned
to the patient’s concerns, regardless of how they might conflict with scientific
reasoning, is more likely to get the job done—­the ethical and “practical ac-
tion” that Aristotle is discussing in his presentation of phronesis. We further
suggest that the scientifically trained physician who is also narratively trained
is more likely to attend to these concerns than the physician only trained in
the (practically useful) abstractions of positivist biomedical science.
By “getting the job done” we mean accomplishing the end of the bio-
medical task, which is making a diagnosis, and also accomplishing the end of
the narrative task, which is attending to the patient’s concern—­what the pa-
tient thinks this illness means. We think that making the chief concern ex-
plicit functions to move the discussion between patient and physician into
another category—­from symptoms of biomedicine to concerns embedded in
the patient’s experience expressed in narrative. Moreover, this is also a move-
ment from knowledge to action, in the same way that that the practical rea-
soning of phronesis and abduction ends in action. Getting the job done in
medicine entails discovering—­which is to say, negotiating with the patient—­

Afterword  /  359
what “health” and “illness” mean in a particular situation and establishing a
pragmatic plan of action that grows out of that situation. This movement
from one category to another is demonstrated in the following vignette.

A resident physician saw a new patient in the clinic. He had come

because he was unhappy with his previous physician. He had presented to
the previous doctor with ascites (fluid in the abdominal cavity), and a CAT
scan of the abdomen had revealed cirrhosis of the liver. The resident
concentrated on the patient’s physical examination, CAT results, and blood
tests. When the attending physician asked her what the patient wanted
them to do that the other physician had not done she did not have an
answer.
The attending physician recognized in this account that important parts
of narrative were missing, namely, (1) exactly why did the patient not return
to the first doctor (something missing in the “sequence of events” that, as
E. M. Forster says, transforms a series of events into the graspable whole of
plot [1927]); and (2) what specifically was his chief concern about this
cirrhosis (the “end” or point of the story). Moreover, he also recognized in
the account something about the young resident physician as well: that she
was troubled about her encounter with her patient without quite knowing
what was wrong. In focusing on the unspoken concern of the resident’s
account, he was focusing on the teller as well as the tale. What was wrong,
he sensed, although she did not quite articulate it either to her attending
physician or to herself, was a vague understanding that she—­like the
physician whom the patient had left—­was somehow not getting the job
done. She was troubled—­again, without quite understanding it—­that, for
all her knowledge and clear perception of the cause of this man’s problem,
she hadn’t found the means of caring for him. Vaguely, there was something
missing in her encounter with this patient that led her to believe that there
was something wrong with how she was doing her job.
The attending physician entered the room and after introduction asked
the patient what he understood the problem to be. The patient answered
“cirrhosis” and further explained that it was causing the fluid. The attending
physician then asked the patient, “What is your primary concern about this
cirrhosis?” The patient said, “Well I don’t want to die of it.” By making the
patient’s chief concern explicit, the attending physician has elicited what
the patient thought the diagnosis of cirrhosis meant—­probable death. The
conversation has now shifted from a discussion of symptoms and diagnoses
to one of meaning. The patient has been able to express his fear of death.

360  /  the chief concern of medicine

This allowed the attending physician to focus on that concern, and, most
important, it allowed him to begin a negotiated action plan. Without this
new information the young resident physician was getting ready to tell the
patient the same thing the first doctor told him, to focus on the ascites and
ignore the patient’s chief concern in the same manner as Ivan Ilych’s
doctors do. The attending physician explained to the patient the several
possible causes of cirrhosis—­hepatitis b, hepatitis c, genetics, nonfatty liver
disease, autoimmune problems, alcohol—­and discussed the patient’s
alcohol consumption. The patient denied being an alcoholic, despite the
fact that he drank to excess on a daily basis. The attending physician told his
patient that, in fact, cirrhosis is serious and life threatening but the patient
could attend to his concern about the fatal nature of his condition by his
actions. “Cirrhosis usually does not get better,” he told his patient, “but it
can get worse. And we can work out something you can do to give us a
chance that it doesn’t get worse.” He had a sense that the first physician the
patient had seen, like the young resident, never moved from biomedicine to
narrative knowledge and never gave himself or his patient the chance to
move from the category of factual knowledge to the category of action.

An important lesson that narrative teaches the doctor is that narrative

presents both authorial desire and a witness that learns. The doctor who is
narratively trained is much more likely to see himself as a witness to this
drama and to learn from it, ­as opposed to the narratively naive doctor, who
might see himself as the hero of the story and think that he already possesses
the necessary knowledge, so that he does not learn from what is always po-
tentially an incredibly rich encounter. In Chapters 3 and 8—­in contexts of
systematic analyses and practical strategies—­we have offered discussions of
the characteristics and function of narrative. We have discussed how teach-
ing this narrative knowledge to medical students and practicing physicians
can enhance their ability to recognize and acknowledge the patient’s suffer-
ing and apprehend the story so as not to miss important and necessary details
that will determine the final outcome or “end” of treatment.
In explicating this nexus between literature and medicine we have ex-
plored fairly completely, we believe, the interactions between a patient and
physician. Beginning with the patient-­physician relationship, where the de-
velopment of rapport is essential to a rich and therapeutic engagement, we
have explored the effects of art narrative or literary studies on its develop-
ment. We have followed Richard Selzer in demonstrating how an older re-
tired physician’s sharing of stories with a dying young boy can create rapport,

Afterword  /  361
understanding, and learning by both the physician and the boy. We have
shared an instance in the practice of Dr. Vannatta in which the vicarious ex-
perience of art narrative (in his case Beloved) led to rapport where none ex-
isted and even helped him empathize with his patient’s chief concern, her
inability to afford her medications. These are but two of many examples in-
dicative of the idea that empathic understanding springs from narrative ap-
prehension of another’s suffering—­and that suffering springs not only from
her chief complaint but from her life situation more globally conceived. We
have offered the idea that the engagement with literary studies can provide
learners and practitioners of medicine with vicarious experiences that aid in
these processes—­processes that, otherwise, are often the result of the expe-
rience of many years of practice. We have discussed the outcomes associated
with the development of rapport and of empathic responses in the practice
of medicine. Habituating empathic responses, such as those we see in Dr.
Orwig’s interaction with Ms. Silcox in chapter 5, leads we believe, not only to
a stronger therapeutic relationship but also to greater patient satisfaction
and—­as an added important bonus—­to better physician satisfaction. This
latter outcome has been expressed to the authors by many physicians who
have habituated these behaviors. It is precisely these outcomes, as well as
others we are measuring, that are the consequences of studying literature
and the schemas that govern both literary and ordinary narrative as part of
the preparation for the practice of medicine; they fulfill the criteria of func-
tional reality as it was defined in the pragmatic philosophical traditions ex-
plored in chapter 1.
The humanistic understanding of the medical humanities on which this
book places its focus and the narrative knowledge that aids in its apprehen-
sion are applied most importantly to the patient’s story of illness (HPI). As we
have stated many times in this book, the HPI is the most important diagnos-
tic information. It is also the most narrative portion of the patient database.
This story is told through many filters—­among them age, race, religion, cul-
ture, sexual orientation, and class. These filters apply equally to the story-
teller (the patient) and the listener (the physician). It is important for the
physician to become conscious of these filters and to make cognitive adjust-
ments to ensure that the distortions to which, potentially, they give rise are as
small as possible. This book implies—­and often makes explicit—­how study-
ing art narratives can aid physicians in becoming skilled in recognizing and
consciously dealing with these filters. Our hope is that physicians—­and in-
deed all health care providers—­will use this discussion to occasion a search
for novels, short stories, and poems that might increase their sensitivity to

362  /  the chief concern of medicine

these differences. Our further hope is that a clearer understanding of the
effects of these filters and differences—­and simple checklists in relation to
them—­might make accurate communication more routine between pro-
vider and patient.
We have attempted to demonstrate that the special attention needed by
the physician to listen carefully to a patient’s story is analogous to and can be
practiced by careful reading of stories. This analogy again demonstrates the
important nexus between these two fields and also demonstrates how literary
studies can be used to make doctors better—­in this case, better listeners. In
particular—­in one example—­reading art narratives such as those by Flan-
nery O’Connor can help physicians learn to expect interesting stories and,
more important, to expect and appreciate surprise endings. These surprise
endings are so important in the abductive reasoning that the doctor uses to
make a diagnosis. The surprising fact, as we discussed in relation to logic of
diagnosis, often causes the physician to pause, reflect, and consider several
categories of disease prior to making his final hypothesis or diagnosis.
In this volume, we have focused our medical ethical discussions on virtue
ethics. We started with Aristotle’s Nicomachean Ethics and called on works
by Scott Stroud and David Hilfiker to demonstrate how art narratives can
demonstrate the need for—­and the work of—­ethics in action by the physi-
cian. This moral action is focused on agents of behavior and the active virtues
implicit in behavior. Such virtues are enacted in a doctor’s active attitude to-
ward patients, his general decency. We have presented and supplemented
Hilfiker’s catalog of medical mistakes and argued that prevention of these
errors can largely be effected through the development of narrative skills—­
and that virtues such as compassion, discernment, and trustworthiness can
be recognized and habituated by reflecting on literary narratives and vicari-
ously attending to the behaviors of their characters. When these habits are
brought into the clinic and enacted with real patients, the quality of care and
the satisfaction with the practice of medicine go up for both the patient and
the physician.
In chapter 4, we explored the logic of diagnosis in a rather rigorous man-
ner using the writings of Charles Sanders Pierce and others. We suggested,
as have other writers, that the process doctors use to make a diagnosis, ab-
duction, is significantly different from (even as it is homologous with) the
logics underlying the work of science, induction and deduction. Pierce’s ab-
duction is hypothesis making, while induction begins with a hypothesis and
seeks facts in its support. The hypothesis making of abduction requires—­we
feel we have adequately argued—­not only clarity of thought but competen-

Afterword  /  363
cies we and others have labeled narrative competencies. These skills or
competencies—­which, following Aristotle and Nussbaum, we have called
the technē of narrative knowledge—­can be most efficiently obtained by care-
ful study of narrative combined with application of schemas that have been
used (whether consciously or not) by practicing physicians over the centu-
ries. Because abduction is the induction of characters and characteristics
rather than of facts, the process is most accurately executed by listening care-
fully to the patient’s narrative and applying the narrative skills we have dis-
cussed in The Chief Concern of Medicine. The diagnostic process requires
listening carefully to the patient’s experience of illness, recognizing what is
said and what is not said, reading the text of body language, and imagining
the context of the patient’s symptoms through apprehension of the Social
History. Only then can the physician hope to accurately develop a theory of
illness that might be tested to make a diagnosis. We have argued that diag-
nostic reasoning (abduction) is dependent on the scientific knowledge base
that one gets when studying medicine but that the logical process of diagnos-
tic reasoning is dependent on applying narrative knowledge and skills to ap-
prehend the patient’s experience of illness.
We have discussed Tolstoy’s novella The Death of Ivan Ilych to further
demonstrate the nexus between literature and medicine. We have empha-
sized that the patient-­physician relationship as developed in that novella
can—­in an instance of “case-­based reasoning”—­be reflected on as a bad ex-
ample, a vicarious mistake from which to learn. The example presented by
Tolstoy shows physicians failing to develop rapport with their patient and
failing miserably at listening to his chief concern. Ivan has abdominal pain as
his chief complaint, but the question of whether “this pain is serious” is his
chief concern. Rather than address this, having failed to listen to his concern,
his doctors instead operate out of their own agendas in dealing with his ill-
ness. This narrative also allows us a final look at the ethics of everyday prac-
tice of medicine. We can apply the virtue ethics discussed in chapter 9 to the
behavior of Ivan’s doctors, specifically the schema of virtue ethics embedded
in the heuristic phrase: Doctor Dogood Comforts The Crying Child (De-
cency, Discernment, Conscientiousness, Trustworthiness, Compassion,
Competence). We hope such “applications” can be habituated by the use of
the simple checklists we set forth in appendix 2. But in addition to emphasiz-
ing the ways Tolstoy’s novella represents aspects of medical practices, we also
offer our examination of that narrative to demonstrate the detailed manners
of reading or listening that sophisticated art narrative implies and elicits.
These implications suggest a schematic strategy of attending both to the de-

364  /  the chief concern of medicine

tails of narrative—­its metaphorical language, realistic details, local tactics of
purpose (Tolstoy’s satire), even initial incoherences—­and to its larger narra-
tive structures that reveal the chief concern of any particular narrative. This
combination of knowledge and comprehension, as we call it in our discussion
of The Death of Ivan Ilych, recapitulates the nexus of medicine and
literature—­knowledge of facts, comprehensions of meaning—­bringing to-
gether, as James Joyce suggests tragedy does, the secret cause of human suf-
fering and the particular human sufferer.
Our largest hope is that this volume will provide students of medicine,
medical practitioners, and students of the medical humanities with an en-
hanced way of looking at the practice of medicine—­one that provides more
emphasis on the narrative nature of the health care profession. By attending
to the narrative nature of the practice of medicine and working on what we
are calling “narrative competencies,” we hope that medicine will be experi-
enced with more vigor, more excitement, and overall fulfillment by practic-
ing physicians. We hope that when those who have been practicing for some
time attend to these issues in their practices and explore art narratives to
develop skills, attitudes, and habits in their professional lives, they will expe-
rience a new excitement in their practice that may well prevent the burnout
so common in the profession of medicine. Most of all, we hope that this
volume might help improve the experience of going to the doctor for pa-
tients. It is for them that we strive to improve the experience of doctoring in
the expanded senses of “medical practices” we describe throughout this
book.

Afterword  /  365
Appendix 1
humanities as a discipline

In chapter 1 of this book, we described the resistance, in philosophical prag-

matism, to the claims of positivism in the early twentieth century. That resis-
tance, as we saw, took the form of pursuing a pragmatic conception of phi-
losophy, one that assumed that particular human beings and societies of
human beings need first of all to be understood as engaged in the world—­the
social as well as the natural world—­in terms of evolutionary and day-­to-­day
adaptations. The pragmatists, as we learned from our colleague Seth Van-
natta, were new kinds of “realists” who understood reality not as something
given, once and for all, but as something that could be understood as rela-
tional in the context of the ends of action in the world. At the extreme of the
Aristotelian ethics of phronesis we discussed in chapters 2 and 3, the reality
of value as the end of action could be conceived as something to be deliber-
ated upon and negotiated.
The logical positivists took mathematical physics as the model of compre-
hending reality, and as we suggested in chapter 1, they saw both ordinary
experience and the “extraordinary” experience of humanistic art forms as
shot through with affectivity and “messiness.” Still, contemporaneous with
them in the early twentieth century—­and in many conceptions of the hu-
manities we encounter today—­the humanities were a bit more kindly con-
ceived as the study of unique phenomena, the “singular and meaningful phe-
nomena” that Rita Charon notes patients present to physicians (2005: 9).
This conception is nicely articulated by Louis Hjelmslev, through his system-
atization of Saussurean linguistics, in Prolegomena to the Theory of Lan-
guage, published in 1943. There, he describes a widespread sense of the
“humanistic tradition.” “According to this view,” he writes,

/  367  /
 humanistic, as opposed to natural, phenomena are non-­recurrent and for
that very reason cannot, like natural phenomena, be subject to exact and
generalizing treatment. In the field of the humanities, consequently, there
would have to be a different method—­namely, mere description, which
would be nearer to poetry than to exact science—­or, at any event, a method
that restricts itself to a discursive form of presentation, in which the phenom-
ena pass by, one by one, without being interpreted through a system. In the
field of history this thesis has been held as doctrine, and it seems in fact to be
the very basis of history in its classical form. Accordingly, those disciplines
that may perhaps be called the most humanistic—­the study of literature and
the study of art—­have also been historically descriptive rather than system-
atizing disciplines. (1961: 8–­9)1

Such a view, we suspect, governs the assumption that phronesis is not a

technē and, consequently, cannot be systematically taught, an assumption
suggested in the work of Martha Nussbaum and others. Certainly, such a
view tutored the sense, a generation ago, that there was no need to formally
prepare graduate students in literature to teach literary texts and writing and
that there was no need to formally prepare medical students for the medical
interview and more general engagements with patients. Gerald Graff de-
scribes this sense in his institutional history of literary studies in higher edu-
cation as “the assumption implicit in the humanist myth . . . that literature
teaches itself” (1987: 9). In medicine, there was a parallel assumption that
doctoring teaches itself. In both medicine and the humanities—­particularly
the “most humanistic” art humanities Hjelmslev mentions as engaging with
literature, music, and painting—­it was thought that simply the “experience”
of a great attending physician or a great work of art would itself tutor what
needs to be understood in relation to teaching reading and writing or engag-
ing and diagnosing patients. According to this thinking, the practical reason-
ing (phronesis) of reading or medicine could hardly be taught but was simply
gleaned from long experience.
In these terms, it is interesting to think of the humanities as a discipline
of schematic apprehensions of experience: the experience of art, of narrative,
of meaning itself. In our discussion of phronesis—­particularly our discussion
of the element of “experience” in both phronesis and in narrative—­we cited
Francis Steen’s argument that “our conscious perceptual experience is the
fine-­tuned product of hundreds of millions of years of mammalian evolution,
presenting an orderly world of objects, agents, and events” (2005: 95). In
this, Steen is suggesting that the felt immediacy of experience can be under-

368  /  humanities as a discipline
stood as mediated by means of evolutionary adaptive cognitive “subroutines”
or “subsystems” designed to order recurring patterns of experiential phe-
nomena. On a more local temporal level, we noted Thomas Nickles’s sugges-
tion that schemas and case-­based reasoning mediate the felt immediacy of
experience as well. Elsewhere in this book, we suggested that meaning itself
can and should be thought of as the experience of meaning. The phenomenol-
ogy of meaningful experience is, we suggest, the problem for the humanities
as an intellectual enterprise, and the analysis of phenomenological experi-
ence can be pursued and taught in a disciplined fashion (i.e., not simply as
“mere description,” as Hjelmslev says, but as a systematizing understanding
that implies—­and, indeed, leads to—­procedures and action).2 In the last
century in particular, semiotics has attempted to examine and analyze the
phenomenology of meaning, as a certain strain of linguistics has done, in
terms of the cognitive sense of what a phrase or sentence might mean—­
which we seemingly apprehend as directly (“intuitively”?) as a color or a
taste. Thus Claude Lévi-­Strauss—­studying cultural anthropology, which it-
self falls within Hjelmslev’s definition of traditional humanities—­argues that
he has “tried to transcend the contrast between the tangible and the intelli-
gible by operating from the outset at the sign level. The function of signs, is,
precisely, to express the one by means of the other. Even when very restricted
in number, they lend themselves to rigorously organized combinations which
can translate even the finest shades of the whole range of sense experience”
(1975: 14). Such a range of sense experience includes the felt sense of confu-
sion or bewilderment, of elation or simple contentment, the phenomenal
experience of the failure or the success of grasping a meaning. Thus, semiot-
ics suggests, meaning itself is phenomenal: “it ‘exists’ as the felt sense of its
presence, a signifying whole beyond the limits of the sentence, or the felt
sense of its negated presence, the ‘nonsense’ and ‘bewilderment’ of frag-
mented sense” (Schleifer 1987: xix). Lévi-­Strauss is suggesting that even the
seeming “immediate” experience of sensation or of meaning can be analyzed
in terms of the structures or schemas that condition—­or “mediate”—­its ex-
perience. In this way, experience itself can be more explicitly and systemati-
cally understood and acted upon. In a tradition very different from that of
Lévi-­Strauss, Charles Sanders Peirce attempts to situate and comprehend,
perhaps more basically, the phenomenology of sense experience in his cate-
gory of “icon,” the phenomenology and worldly experience in his category of
“index,” and—­as we saw in chapter 1—­the phenomenology of meaningful
experience in his category of “symbol,” the law that will govern the future.3
A conception of the humanities as a discipline focused on the phenome-

humanities as a discipline  /  369
nology of experience can be seen in the traditional opposition of the hu-
manities and the sciences, which is often taken to be absolute or fundamen-
tal. In these terms, another linguist, Emile Benveniste, has also addressed
the question of the discipline of the humanities in arguing that one should
draw a “fundamental” distinction between two orders of phenomena in the
natural sciences and the humanities. “On the one side,” he writes, there are

physiological and biological data, which present a “simple” nature (no matter
what their complexity may be) because they hold entirely within the field in
which they appear . . . ; on the other side, the phenomena belonging to the
interhuman milieu, which have the characteristic that they can never be
taken as simple data or defined in the order of their own nature but must
always be understood as double from the fact that they are connected to
something else, whatever their “referent” may be. A fact of culture is such
only insofar as it refers to something else. (1971: 38–­39)

Needless to say, we do not take this distinction to be fundamental; as we ar-

gued in chapter 2, the humanities, like physiology and biology, can pursue
systematic understanding. Still, Benveniste’s distinction is instructive. In this
analysis, Benveniste is repeating the distinction we found in Charles Sanders
Peirce between “facts” and “characters” of facts: such characters, he argues
(as we saw in chapter 4), “are not susceptible of simple enumeration like
objects; [rather], characters run in categories” (1992: 140). The province of
such “categories”—­at least when they pertain to experience—­are the provi-
sional schemas we have described throughout this book.
In other words, the schemas posited by cognitive psychology and artificial
intelligence attempt to account for experience beyond the “atomic events”
inherent in the concept of “the passive ideas of the British associationists”
(Nickles 1998: 78) and, indeed, the “atomic events” of the logical positivists.
Moreover, if cognitive psychology posits schemas to explore “larger active
structures” of experience (Nickles 1998: 78), then, we are suggesting, the
humanities as a discipline aim at construing and articulating the “larger
structures” that govern the phenomenology of experience and meaning in
relation to the interhuman milieu, Peirce’s law that will govern the future. In
this sense, pragmatism’s resistance to positivism’s conception of reality is the
assertion, as we have seen, that historical human communities—­a concep-
tion that entails both the tradition and the future of those communities—­
should never be forgotten in relation to conceptions of truth, “atomic” or
otherwise.4 In these terms, the schemes of the humanities are slightly—­but

370  /  humanities as a discipline
significantly—­different from those of cognitive psychology: if cognitive psy-
chology has developed more or less nonprovisional schemas that, as Gureckis
and Goldstone note, allow us “to predict or infer unknown information in
completely new situations” (2011: 725), the humanities develop schemas that
remain more consciously provisional in their analyses, insofar as the meaning
the humanities study, as we have suggested, is more consciously future ori-
ented (Hjelmslev’s “purport”).5
If early twentieth-­century pragmatism resisted the dogmatism of logical
positivism, so did the development of “ordinary language philosophy” in the
mid-­twentieth century, another attempt to take into account the phenome-
nology of ordinary experience. Perhaps the most prominent proponent of
this view was J. L. Austin, who, like the pragmatists, turned to evolutionary
adaptation of language and concept production in examining the ways that
language and philosophy developed in order to produce what Kenneth Burke
(1994) has described as “equipment for living”—­namely, conceptual systems
designed in response to the pragmatic needs to work in the world. In some
way, this might be thought of as a version of “late pragmatism.” “Our com-
mon stock of words,” Austin writes in “A Plea for Excuses,” “embodies all the
distinctions men have found worth drawing, and the connections they have
found worth marking, in the lifetimes of many generations: these surely are
likely to be more numerous, more sound, since they have stood up to the
long test of the survival of the fittest, and more subtle, at least in all ordinary
and reasonably practical matters, than any that you and I are likely to think
up in our arm-­chairs of an afternoon” (1979: 182). In “Three Ways of Spilling
Ink,” Austin distinguishes different functional meanings in three terms that
are often taken to be synonymous: intentionally, deliberately, and on pur-
pose. His point in this essay is to unpack meaning in order to reveal func-
tional distinctions that allow us to more fully attend to both reality and our
interactions with reality. In the introduction and throughout The Chief Con-
cern of Medicine, we have pursued a similar strategy in unpacking the mean-
ings of the concept of health as the alleviation of suffering, the achievement
of well being, and simply “carrying on”—­in John Stone’s words that we often
quoted, “whatever works / and for as long.” Similarly, we have unpacked
conceptions of science as the “formulaic” science of mathematical physics,
the “descriptive” science of evolutionary biology, and the “speculative” sci-
ence of the humanities. We have unpacked the self-­evident fact of narrative
and narrative genres, speculating on the salient features of narrative and the
interacting parts of narrative genres. Most important for the pragmatic ends
of The Chief Concern, we have unpacked species of checklists that Atul Ga-

humanities as a discipline  /  371
wande describes in The Checklist Manifesto, in order to reiterate the func-
tional distinctions we make among skills in listening, skills in interviewing,
and skills in ethical behavior.
Such unpacking in the humanities deals in what Peirce calls categories
rather than the facts of positive science (and, though Peirce does not touch
on this, the processes of evolutionary biological science). In the context of
studying medicine, this process of unpacking might better be described, as
Nickles notes, in terms of cases and the schemas they produce. (In the course
of discussing schemas, we even unpacked the term paradigm [following the
Oxford English Dictionary], under the categories of paradigm as model, as
grammar, and as a Kuhnian horizon of understanding.) Thus, contra
Hjelmslev and Benveniste, this kind of systematic work is what the humani-
ties do: they distinguish categories, assemble cases, and articulate schemas of
understanding and action. But, of course, this is also what the formulaic and
descriptive sciences do as well, though, we would argue, much less self-­
consciously than the “unpacking” humanities, since they focus on facts and
processes rather than on phenomena understood in relation to cases and
schemas. In fact, the significant distinction between our use of schema in this
book and the use pursued by cognitive psychology, as we have already noted,
is that we more fully emphasize the provisional nature of schemas rather
than their empirical reality. Peirce makes this same distinction in his analysis
of the difference between induction and abduction, as we noted in chapter
4. Still, distinguishing categories, assembling cases, and articulating schemas
of understanding and action are the salient features of intellectual discipline:
these are the salient features of intellectual inquiry.
If we are describing intellectual discipline, we should not forget—­as the
pragmatists and the ordinary language philosophers did not forget—­the or-
dinary use of the term discipline to describe pragmatic, practical behavior as
well.6 Atul Gawande notes that “all learned occupations have a definition of
professionalism, a code of conduct . . . [consisting of] three common ele-
ments.” “First,” he notes, “is an expectation of selflessness . . . [which] will
place the needs and concerns of those who depend on us above our own.
Second is an expectation of skill. . . . Third is an expectation of trust-­
worthiness: that we will be responsible in our personal behavior toward our
charges.” He goes on to note that “aviators, however, add a fourth expecta-
tion, discipline: discipline in following prudent procedure and in functioning
with others” (2010: loc. 2532ff.). Although Gawande argues that such disci-
pline is “almost entirely outside the lexicon of most professions, including my
own [medicine]” (loc. 2538), it is clear that the disciplines of the experimen-

372  /  humanities as a discipline
tal sciences (where laboratory work requires prudent procedure and func-
tioning with others) and the disciplines of empirical sciences (e.g., evolution-
ary biology or statistical epidemiology, where accumulations of data are
prudently pursued by teams of investigators) encompass this practical con-
ception of discipline. We suggest that the reason for the absence of such a
pragmatic sense of discipline in many professions is that such professions,
like the humanities as a discipline, are schema-­based and, for that reason,
“feel” like they are based on seemingly immediate, unique, and personal ex-
perience, even while they are mediated and governed by more general sche-
mas and plural or communal action.
Here, then, is our contention: the humanities as a discipline pack and
unpack schemas of experience and action. Moreover, they do so in the man-
ner of Peirce’s abduction, seeking explanation leading to action rather than
classification and formulation. In literary studies, the humanities make the
schemas that govern reading and the experience of reading (or the experi-
ence of a play or a film, a poem or a song) both explicit and habitual. In his-
tory, they make the schemas that govern historical action and those that gov-
ern our apprehensions and understandings of such action both explicit and
habitual. In art studies, they make the schemas by which artworks are cre-
ated and experienced explicit and habitual. In philosophy, the humanities
reflect on schemas that organize and govern more or less systematic modali-
ties of cognition, understanding, and experience and on schemas that ac-
count for the human condition and on how those schemas work. Finally, the
schemas the humanities study are provisional, which means that they are
construed results of speculation that result from deliberation and negotia-
tion. This also means that, like the “performative” work of meaning that Aus-
tin describes, these schemas embody action in the world, within the “inter-
human milieu.” Because of all these things, we believe, the schemas of the
humanities, like the formulas and classifications of biomedical sciences and
evidence-­based medicine, are positioned to contribute in material ways to
the goals and ends of medicine.

humanities as a discipline  /  373
Appendix 2
checklists for skills in listening,
interviewing, and action

The practice of medicine has become a highly complex activity. The facts of
human biology and pathology have exploded to a point that the idea of remem-
bering or knowing it all is clearly unpracticable. The World Health Organiza-
tion has a list of thirteen thousand diseases, syndromes, and accidental trau-
mas; there are in excess of five thousand drugs available; and the list goes on.
The fact that the patient’s story, the History of Present Illness (HPI), is
the most important diagnostic information the patient will give the doctor
complicates this complexity. All stories are unique; however, they are all nar-
ratives that can be understood in certain systematic ways—­by means of what
we have described in this book as schemas. We have argued for a systematic
method of approaching the HPI with patients. We have argued that there are
simple, easy procedures the doctor cannot afford to miss. We have suggested
that simple checklists, when applied consistently, can help a physician avoid
missing these simple yet essential elements in the patient’s narrative and can
increase the quality of the HPI. Dr. Atul Gawande makes this same argu-
ment for complex procedures in The Checklist Manifesto, but he focuses on
medical procedures rather than the patient-­physician interview. We have
further argued that when the narrative is apprehended in the way literary
experts understand stories, the interpretation of them will be more com-
plete, more accurate, and will give the doctor a higher likelihood of making
the correct diagnosis.
Toward that practical goal, we offer the following checklists the doctor
can use when interviewing a patient. Here, we describe the checklists and
then present actual checklists that include check boxes (□). Each checklist

/  374  /
can be
can be put
put onon anan index
index card
card toto be
be filled
filled out
out during
during aa patient
patient interview—­
interview—oorr
before, in
before, in the
the case
case of of self-­
self-aappraisal,
ppraisal, or or after,
after, in
in the
the case
case of of patient
patient engage-
engage-
ment. A
ment. A second
second kind kind of
of checklist
checklist presented
presented here here lists
lists “hot
“hot words”
words” thatthat physi-
physi-
cians can
cians can circle while listening to a patient and then come back to discuss at
the end
the end of—­
of—oorr during
during aa pause
pause in—­
in—tthe patient’s narrative.
he patient’s narrative. This This list
list is
is analo-
analo-
gous to the listed items on the Template for Complete
gous to the listed items on the Template for Complete History, a working History, a working
checklist that
checklist that physicians
physicians use use every
every day day (we
(we present
present this
this template
template in in the
the ex-
ex-
ample of
ample of aa fever
fever ofof unknown
unknown origin
origin in in chapter
chapter 6).6). The
The HPI
HPI is is the
the only
only portion
portion
of the History and Physical Exam that is written as a narrative;
of the History and Physical Exam that is written as a narrative; all the other all the other
sections of
sections of this template for the History and Physical Exam (i.e., Past Medi-
cal History,
cal History, Social
Social History,
History, Family
Family History,
History, Review
Review of of Systems)
Systems) are are check-
check-
lists. We suggest here that “chief concern” be added
lists. We suggest here that “chief concern” be added to the template, in to the template, in the
the
Patient Profile.
Patient Profile.
In appendix
In appendix 3, 3, we
we compile
compile aa list
list of
of schemas
schemas mentioned
mentioned in in The
The Chief
Chief Con-
Con-
cern of Medicine. These are not quite checklists, since it
cern of Medicine. These are not quite checklists, since it is not practicable tois not practicable to
check them
check them off off the
the way
way aa physician
physician can can check
check off
off the
the emotion
emotion aa patient
patient pres-
pres-
ents or as in the category of “accidents” set forth in the Past
ents or as in the category of “accidents” set forth in the Past Medical History Medical History
section of
section of the
the Template
Template for for Complete
Complete History.
History.

6.,//6,1/,67(1,1*

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checklists for
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skills  /  381
/ 381
Appendix 3
a compilation of schemas for
medical practices

In this appendix, we list the schemas of medical practices that have been
described in The Chief Concern of Medicine. They are a series of categories
of (1) narrative structure, roles, genres, and overall meaning and of (2) ac-
tions, particularly the action taking place within the patient-­physician en-
counter of the medical interview (History and Physical Exam). The schemas
of “hot words” and virtues utilized in appendix 2 are not described here.
We set forth these schemas—­tables of interrelated elements and models
for thoughtfulness and action—­in order to make physicians and health care
workers mindful of aspects of humanistic understanding in their interaction
with patients. It is our larger hope that conscious awareness of these schemas
can provide bases for judgment and action. As we mentioned in this book’s
introduction, we hope that such schemas might habituate in physicians acu-
men, judgments, and actions that will so inform the medical encounter be-
tween physician and patient that it will become more informative, more en-
gaging, and more effective in increasing the care of patients and the
fulfillments of doctoring. It is our hope that the explicit articulation of the
schemas outlined here—­growing out of the experience and analyses of The
Chief Concern of Medicine—­move the physician toward engagement with
the patient and avoidance of detachment, enhance the apprehension of the
patient’s story in the patient-­physician interview and therefore improve the
accuracy of the diagnosis, and lead to improved patient satisfaction and de-
crease physician burnout.

/  382  /
I. SCHEMAS INFORMING NARRATIVE COMPREHENSION

A. Narrative Structure (from chapter 3)

Narrative possesses
1. a sequence of events,
2. an end, and
3. recognizable agents;
Narrative also possesses
4. a teller and a listener (i.e., narrative is both articulated and
received),
5. a witness who learns—­who is “concerned”—­about the end
of the narrative (its point or its termination); and
6. its witness learns from experience.
Note: The two parts of this list embody the “two temporalities of
narrative,” the time of the story and the time of its telling.

B. Roles in Narrative (from chapter 8)

Narrative Sentence Medical Roles

hero subject patient (“hero”)
desired object object health (“desired object/condition”)
action verb to purge (to remove the disease)
to purify (to achieve well-­being)
to clarify (to figure out
  whatever works)
helper adverb physician (“helper”)
opponent adverb illness (“opponent”)

C. The Genres of Narrative (from chapters 3 and 8)

  Heroic Melodrama (Epic): a heroic narrative, where the hero

also receives the wished-­for good—­in myth and tradition, the bride
and the kingdom. This is the form of the Russian Wondertale Propp
studied and of many myths and folktales that Lévi-­Strauss studied.
  Tragedy: a tragic narrative, where the helper receives the wished-­
for good, both the storied knowledge of what has taken place on the

a compilation of schemas for medical practices  /  383

 level of the individual destruction of the hero and the promised
reconstruction of the community on the brink of collapse with the
destruction of hero. This last outcome is often accomplished by the
helper (e.g., Creon and Horatio), on the level of the social.
  Comedy: a comic narrative, where the heroine receives the
wished-­for good—­in myth and tradition, the hero as husband and
the estate of marriage.
  Irony: a more or less “modern” narrative, where the opponent
receives the wished-­for good, to destroy it on the level of the indi-
vidual and to transform it on the level of general value.

D. Discerning the Narrative “Meaningful Whole” (from

chapters 4 and 6)

  Attend to the “surprising fact.” When Charles Sanders Peirce

suggests we attend to a “surprising fact” to begin with—­what we
might call some anomaly in a narrative or text—­he is suggesting
that we begin with an element or part that is not self-­evidently
important but that is precisely one that seems to disrupt coherent
wholeness.

II. SCHEMAS INFORMING PATIENT-­PHYSICIAN

INTERACTIONS

A. The Schema of Emotions (from chapter 6)

Primary emotions:
anger
anxiety (fear)
sadness (depression)
disgust
acceptance
Social filters:
cultural background
class

384  /  a compilation of schemas for medical practices

 gender
age
Note: This list of social filters is not exhaustive.

B. Schema for Expressing Empathy (from chapter 5)

1. Attend to the primary emotion of the patient.

2. 
When an emotion is expressed, explicitly acknowledge its
importance.
3. When the patient agrees with the physician’s identification of
the primary emotion, then the physician should legitimize this
feeling and empathize with it.
4. Identify the patient’s “chief concern” as demonstrated by steps
1–­3.
5. Paraphrase the expressed concern to the patient.

With the completion of step 5, the patient will explicitly know that
her concern was heard and understood.

THE QUESTION OF SINCERITY: Such “schematic” responses to

patients are practical and ethical actions that take their place within
schema-­based medicine that might benefit from—­and, we believe give rise
to—­the feeling and understanding (affect and cognition) of empathy. But
the sincerity or intensity of the feelings and understandings they express do
not have to correspond to actual feelings and understanding. Rather, they
are acts arising out of (and an integral part of) engaged narrative; these
acts, in themselves and in the responses they provoke, are “functionally
real” empathy.

C. Schematic Responses to Metaphor and Euphemism (from

chapter 7)

“What do you mean by that?”

“Can you describe that in other words?”
“Why do you describe your illness as a site of warfare?”
“It sounds like your job performance is creating stress.”
“It sounds like you feel guilty about your illness.”
Additional useful responses might be based upon the particular
figurative language a patient uses.

a compilation of schemas for medical practices  /  385

 D. Roman Jakobson’s Analysis of Speech Communication
(from chapter 7)

C ontext

M essage

a ddr esser ------------------------------------------------------------- a ddr essee

C ontaCt

C ode ----------------------- (1987b: 66)

E. Arthur Kleinman’s Questions for “Cross-­Cultural

Medicine” (from chapter 6)

1. What do you call this problem?

2. What do you think has caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does? How does it work?
5. How severe is the sickness? Will it have a short or long course?
6. 
What kind of treatment do you think the patient should receive?
What are the most important results you hope she receives from
this treatment?
7. What are the chief problems the sickness has caused?
8. 
What do you fear most about the sickness? (Fadiman 1998:
260)

III. SCHEMAS INFORMING ACTION AND ETHICS

A. Catalog of Medical Mistakes (from chapter 9)

David Hilfiker describes sources of physician mistakes:

  physicians simply do not know enough medical information to
make an informed decision—­and they do not know that they do not
have enough medical information;
  they do not have the necessary technical skills that are required;
  they are simply careless;

386  /  a compilation of schemas for medical practices

   they suffer from a failure of judgment;
  feeling pressured or rushed, tired, or distracted, they suffer from
a failure of will, even though they know the right thing to do;
   they suffer from failure to conform to basic professional stan-
dards, such as working while drunk, violating patients sexually, and
so on (a source of error Hilfiker does not catalog);
  they do not listen or respond to the patient, a failure to listen (a
source of error Hilfiker narrates but does not catalog).

B. The American Medical Association’s Definition of Patients’

Rights (from chapter 9)

  The right to receive information from physicians and to discuss

the benefits, risks, and costs of appropriate treatment alternatives.
  The right to make decisions regarding the health care that is rec-
ommended by the physician.
  The right to courtesy, respect, dignity, responsiveness, and timely
attention to health needs.
  The right to confidentiality.
  The right to continuity of health care.
  The basic right to have adequate health care. (“Patients Rights,”
http://www.emedicinehealth.com/patient_rights/article-em.htm)

C. The American Medical Association Protocol for Developing

the Goals of Medical Care (from chapter 9)

The steps for developing and articulating the goals of medical care
are
1. creating the right setting;
2. determining what the patient knows;
3. exploring what the patient expects/hopes for;
4. suggesting realistic goals;
5. responding empathically;
6. negotiating a plan and following through on it; and
7. revising the plan as needed. (American Medical Association
1999: 10)
The steps of this protocol correspond, to one degree or another, to
the virtues discussed in chapter 9 and included in checklist 4 in
appendix 2.

a compilation of schemas for medical practices  /  387

 D. The Hippocratic Oath

Modern Version1
 I will abstain in treatment from whatever is deleterious and mis-
chievous.
 I will not permit consideration of race, religion, nationality, poli-
tics or social standing to intervene between my duty and my patient.
 I will give respect and gratitude to those who taught me the Sci-
ence and the Art and will share my knowledge with others.
 I will uphold the integrity and noble traditions of the medical
profession.
  These promises I make solemnly and upon my honor in the pres-
ence of those assembled here today.
  May happiness and good repute be granted me while I keep this
Oath inviolate.

Classical Version (from Hippocratic Oath 1943)

 I swear by Apollo Physician and Asclepius and Hygieia and Pan-
aceia and all the gods and goddesses, making them my witnesses,
that I will fulfill according to my ability and judgment this oath and
this covenant:
  To hold him who has taught me this art as equal to my parents
and to live my life in partnership with him, and if he is in need of
money to give him a share of mine, and to regard his offspring as
equal to my brothers in male lineage and to teach them this art—­if
they desire to learn it—­without fee and covenant; to give a share of
precepts and oral instruction and all the other learning to my sons
and to the sons of him who has instructed me and to pupils who
have signed the covenant and have taken an oath according to the
medical law, but no one else.
 I will apply dietetic measures for the benefit of the sick accord-
ing to my ability and judgment; I will keep them from harm and
injustice.
 I will neither give a deadly drug to anybody who asked for it, nor
will I make a suggestion to this effect. Similarly I will not give to a
woman an abortive remedy. In purity and holiness I will guard my
life and my art.
 I will not use the knife, not even on sufferers from stone, but will
withdraw in favor of such men as are engaged in this work.

388  /  a compilation of schemas for medical practices

   Whatever houses I may visit, I will come for the benefit of the
sick, remaining free of all intentional injustice, of all mischief and
in particular of sexual relations with both female and male persons,
be they free or slaves.
  What I may see or hear in the course of the treatment or even
outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself, holding
such things shameful to be spoken about.
 If I fulfill this oath and do not violate it, may it be granted to me
to enjoy life and art, being honored with fame among all men for all
time to come; if I transgress it and swear falsely, may the opposite
of all this be my lot.

a compilation of schemas for medical practices  /  389

Notes

Introduction
1. While these distinctions might be idiosyncratic to English, the fact that Eng-
lish offers such detailed distinctions—­ much like French elaborates distinctions
among the terms langue, parole, and langage that are not found in English and other
languages—­should be seen as a tool of understanding rather than an accident of Eng-
lish. We note in appendix 1 how “ordinary language philosophy” assumes that distinc-
tions embodied in the ordinary usages of language present useful distinctions honed
by the functional adaptiveness of linguistic distinctions. Such distinctions, we suggest,
can be “unpacked” and schematically described in ways that can make people—­and,
in the context of The Chief Concern, physicians and health care workers—­more self-­
conscious and efficient in their work. The definitions of “health” we are describing
here present an instance of such linguistic “unpacking.”
2. In Narrative Medicine, Rita Charon notes that “facing one’s desires vis-­à-­vis
one’s texts may be something more aptly and expertly done in the department of
medicine than the department of English. It may be an area in which narrative med-
icine can make original contributions to literary studies” (2006a: 126). Human suffer-
ing and the causes of human suffering are implicit in Joyce’s definitions of pity and
terror in terms of the human sufferer and the “secret cause” we quoted earlier.
3. In an earlier draft of The Chief Concern of Medicine and in earlier essays (see
Schleifer and Vannatta 2011; Schleifer 2012), we had begun to discuss this concept
under the designation of “paradigm-­based medicine.” While we hope that our exposi-
tion of schema-­based medicine will allow readers to notice why we thought this ear-
lier term useful—­including its various definitions we will describe and its relation to
the work of Thomas Kuhn—­we have come to see that the term paradigm too easily
lends itself to misunderstanding. Moreover, the term schema lends itself more readily
to the practical work of checklists that fulfills our practical goals in this book; and in-
sofar as discussions of phronesis have regularly described it as a skill that grows from
experience, it is notable that schemas in cognitive psychology were developed to ac-
count for the seeming immediacy of “experience” itself. Still, one reason we began
with the concept of “paradigm” is because it is our contention that paradigms (or the

/  391  /
larger, inclusive set of schemas) are the building blocks of the humanities taken as
intellectual disciplines, just as, it could be argued, mathematics is the methodological
basis of physics, and just as the concept of natural selection is the basic explanatory
schema of evolutionary biology. But in this regard, “schemas”—­particularly as a more
precise description of paradigms in commentators concerned with Kuhn’s work
whom we cite here—­are similarly useful in isolating the disciplinary “building blocks”
of the humanities. We set forth a description of the humanistic disciplines in appen-
dix 1.
4. In The Right Mind, a study of the right brain in relation to the left brain, Rob-
ert Ornstein offers a possible neurological and physiological account of the intellec-
tual and experiential phenomenon of global apprehension. He notes that “both halves
of the brain are needed for the two elements of everyday language. The left side looks
after the basic text, the conventional features of language: choice of words, syntax,
and literal meaning. But taking part in a conversation requires a lot more than using
the right words in the right order and knowing what individual sentences mean. To
understand fully what someone is saying, you have to be able to interpret his or her
tone of voice, apply the conventions of polite conversation, follow a narrative, under-
stand gestures, and so on. You need to know when sentences don’t have their usual
function and be able to fathom the speaker’s purpose” (1997: 113). All of these expe-
riences of “full” understanding, although Ornstein does not use the term, are condi-
tioned by provisional schemas of understanding and experience. Thus it is significant
that his catalog includes the experience of “following a narrative,” an example of great
importance in our argument. Throughout his book, one chief example of this rela-
tionship between the hemispheres of the brain is the narrative example of “getting” a
joke. (In a very different tradition, this is A. J. Greimas’s initial starting point in his
examination of the “meaningful whole” of discourse in his study of semantics [1983:
79ff.].) People with right-­brain damage, do not get jokes, and both Ornstein and
Greimas argue that jokes function by suggesting one provisional schema of apprehen-
sion and subsequently “exploding” it with another. (Like Ornstein, Greimas also does
not use the term schema in his analysis.) Ornstein goes on to argue that “the right
hemisphere decodes the external information that we use to compute context; it
helps assemble the whole field of view to create an overall understanding of a scene”
(1997: 101). In one example, he describes the way that “people with right-­hemisphere
damage . . . can’t update their understanding in the light of new information” (109).
When someone tells you, he notes, that Sally brought pen and paper when she met a
movie star, “immediately, and unconsciously, the sentence activates possibilities for
what is going on.” In our terms, we are suggesting, it activates a schema. But Ornstein
explains that when an additional sentence “fleshes out the situation” by noting that
Sally is writing an article about famous peoples’ opinions on nuclear power, while
most people would conclude Sally is a journalist, “right-­hemisphere patients, how-
ever, find it very difficult to process this sort of change, and when they retell the se-
quence, stick with their first, autograph hunter, interpretation” (109). Throughout
The Right Mind, Ornstein offers interpretations by patients with right-­hemisphere
damage of a painting by Norman Rockwell that depicts three people anxiously wait-

392  /  note to page 16
ing in a physician’s waiting room. Patients with right-­hemisphere damage variously
describe the painting as people at a baseball game (“they all seem so interested” [11]),
people at an unexciting boy scout meeting (26), a young man “calling on his girl’s
parents” (43), veterans in a church pew (63), brothers watching television (80), or
people at the movies (87). One patient simply lists the elements of the painting—­
position, clothing, faces—­without suggesting any “larger” meaning (97). “If you were
to look at a scene like the one in our Norman Rockwell painting of the doctor’s office,”
Ornstein concludes, “and you couldn’t tell what it was, what the purpose of the room
was, or why the people were waiting, then you might have difficulty deciding how to
act, what to do. . . . And what might you think of someone walking into the room with
a scalpel? You might respond as you would when attacked” (117; see Schleifer 2009a:
114–­15 for a discussion of this passage in relation to narrative). What is striking here
is that brain-­damaged observers almost all fail to interpret the image narratively, in
terms of “why the people were waiting”; they fail to follow a narrative. Precisely the
speculative provisional construal of context—­and in the specific case of narrative,
speculative provisional construal of narrative endings—­is accomplished by schemas.
Ornstein’s study suggests that there is a neurological basis for these skills.
5. The provisional nature of both schemas and paradigms is closely related to
their practical functioning, their connection to action. Thus Joseph Rouse, studying
Thomas Kuhn’s conception of science, argues that “accepting a paradigm is more like
acquiring and applying a skill than like understanding and believing a statement”
(cited in Nickles 1998: 57). This argument contributes to our sense, developed in Part
1, that the schemas we present are closely related to Aristotle’s sense of the practical
technē of science, understanding, and ethics. That provisional hypotheses, especially
when they are conceived as acts, can give rise to rigorous mathematical accounts and
retrospective explanation is the burden of Peirce’s abductive logic, examined in chap-
ter 4.
6. Later, Nickles notes that case-­based reasoning “is not a magical logic of discov-
ery that solves every problem at the frontier, although it can aid such discovery”
(1998: 73). We examine the “logic of discovery”—­Peirce’s abduction—­in chapter 4.
Nickles also notes that case-­based reasoning “is much faster than [rule-­based reason-
ing], but schema-­mediated processes are even faster. Study of the cases, perhaps with
external guidance, produces both small schemas that are operationalized cases and
larger, organizing schemas (paradigms) that amount to similarity metrics (producing
prototypical effects) and the corresponding indexing and retrieval systems. On this
interpretation of his work, Kuhn’s heroic attempts to disentangle the meanings of
‘paradigm’ still did not go quite far enough. He should have distinguished exemplars
from schematized exemplars. Actually, schema instances have a similar twofold na-
ture, functioning both as memory stores and as procedures for applying that knowl-
edge” (1998: 79).
7. Indeed, we were using this term in a late draft of this book. See also two arti-
cles that contributed to this book: Schleifer and Vannatta 2011; Schleifer 2012.
8. See also, Stanley Harris’s description and references of the “function” of sche-
mas: “Schemas serve as mental maps which enable individuals to traverse and orient

notes to pages 16–19  /  393

themselves within their experiential terrain (Louis 1983, Weick 1979a) and guide in-
terpretations of the past and present and expectations for the future. As Neisser
(1976) and Weick (1979b) observed, schemas guide the search for, acquisition of, and
processing of information and guide subsequent behavior in response to that infor-
mation. Lord and Foti (1986) note that ‘schemas help reduce the information-­
processing demands associated with social activities by providing a ready-­ made
knowledge system for interpreting and storing information about others’ (p. 38).
Summarizing research in the area, Taylor and Crocker (1981) identified seven func-
tions of schemas: They (1) provide a structure against which experience is mapped,
(2) direct information encoding and retrieval from memory, (3) affect information
processing efficiency and speed, (4) guide filling gaps in the information available, (5)
provide templates for problem solving, (6) facilitate the evaluation of experience, and
(7) facilitate anticipations of the future, goal setting, planning, and goal execution”
(1994: 310; see our bibliography for Harris’s references).
9. In chapter 4, we discuss Peirce’s productive distinction between facts and cat-
egories, what he calls “characters” or “characteristics.” “Hypothesis [abduction],”
Peirce writes, “has been called an induction of characters. . . . [C]haracters are not
susceptible of simple enumeration like objects; [rather], characters run in categories”
(1992: 140). The categorical nature of schemas—­the fact that they are “device[s] for
structuring a complex situation or set of inputs into an organized whole,” as Nickles
says (1998: 78)—­distinguishes them from the mathematical certainties of physics and
the retrospective certainties of evolutionary biology. Moreover, as Nickles suggests,
they share with narrative the function of structuring complex situations into an orga-
nized whole. In chapter 3, we examine such narrative structuring in detail.
10. The Oxford English Dictionary offers four definitions of paradigm, three of
which we recount here as instructive in understanding the ways in which we are using
the term schema in The Chief Concern of Medicine:

1. A pattern or model, an exemplar; (also) a typical instance of something, an

example.
2. a. Grammar. In the traditional grammar of Latin, Greek, and other in-
flected languages: a pattern or table showing all the inflected forms of a
particular verb, noun, or adjective, serving as a model for other words
of the same conjugation or declension . . .
3. Rhetoric. A figure of speech in which a comparison is made by resem-
blance; = paradigma n.1 rare.
4. A conceptual or methodological model underlying the theories and prac-
tices of a science or discipline at a particular time; (hence) a generally ac-
cepted world view.

The fourth definition in the OED explicitly references Kuhn’s work. While neither
Gureckis and Goldstone nor Nickles include the third rhetorical definition in the
features of a schema—­as we have seen, they do suggest the modeling effect of a
schema (e.g., the “classroom” example), its “predictive” function, and, of course, its
relation to Kuhn—­we should note that a comparison by resemblance might well gov-

394  /  notes to page 19
ern Aristotle’s use of the medical term katharsis (most likely encountered from his
father, who was a physician) to make sense of the experience that tragedy provokes in
its audience, and we have already suggested that these three translations of katharsis
“resemble” the three definitions of health we have presented (and return to): the
“purging” of a disease, the restoration of well-­being from sickness, and the profound
gift of the possibilities of simply carrying on in the face of illness. Moreover, this rhe-
torical use of paradigm to mean “resemblance” might well govern the connections
between medicine and narrative—­or, more specifically, medicine and literature—­
that govern our discussion as a whole. Schema, however, does not suggest a rhetorical
resemblance in its analytic uses in cognitive psychology or artificial intelligence. Still,
the second definition of schema in the OED is “a diagrammatic representation,”
which does suggest resemblance.
11. In The Cognitive Structure of Scientific Revolution, Hanne Andersen, Peter
Barker, and Xiang Chen note that “within linguistics the term ‘paradigm’ is used to
denote conjugation patterns, such as the pattern displayed by the Latin verb amo,
amas, amat, amamus, amatis, amant. Kuhn claimed that the procedure by which sci-
ence students are supposed to model novel problems on exemplary problems is simi-
lar to the procedure by which language students learn conjugations by extracting
patterns from examples. He adopted the term ‘paradigm’ to denote standard exam-
ples in science teaching; thus, that term first entered Kuhn’s work prior to the publi-
cation of The Structure of Scientific Revolutions to denote standard scientific prob-
lems, or exemplars, used in teaching” (2006: 20).
12. Later in his book, Gawande describes the “unmanageable” nature of medi-
cine: “Over the course of a year of office practice—­which, by definition, excludes the
patients seen in the hospital—­physicians each evaluated an average of 250 different
primary diseases and conditions. Their patients had more than nine hundred other
active medical problems that had to be taken into account. The doctors each pre-
scribed some three hundred medications, ordered more than a hundred different
types of laboratory tests, and performed an average of forty different kinds of office
procedures—­from vaccinations to setting fractures” (2010: loc. 318).
13. In appendix 2, we provide concise “checklists” based on schemas—­schema-­
based medicine—­for the patient-­physician encounter, and in appendix 3, we suggest
several algorithms of care (e.g., “if you notice anger, say ‘you seem angry’”). But other
schemas in appendix 3 (e.g., the schema of narrative grammar) call not for algorithms
but, rather, for a certain kind of attention.

Chapter 1
1. A recent literature review by Ousager (2010) demonstrates this bias in favor of
quantifiable “evidence.” In this review, the author searched for empirical evidence of
the value of humanities courses in medical education. The methodology required
outcome studies. Such studies, while common in the biomedical research world, are
decidedly uncommon in the study of narrative, because of the nature of the subject
matter and because the effects of humanistic education in narrative largely lend

notes to pages 20–36  /  395

themselves to qualitative study—­their effects are seen in students’ approaches and
“attitudes” toward patients and practices, a sense of “ends,” “goals, and “values” as we
describe them in chapters 2 and 3—­and are thus more difficult to measure quantita-
tively. The vocabulary used in the review also reveals a bias against narrative studies:
categories labeled as “pleading the case” and “holding the horses” imply that even as
recent as 2010, advocates of courses in the medical humanities have been reduced to
begging to be accepted into the curriculum.
2. As we note in the following chapters, the avoidance of both of these fallacies is
a function of the nature of narrative itself. The “result” of narrative, its “end” or
“point,” is, in its nature, the gathering up—­and therefore the reconception—­of the
seeming “antecedent” features of narrative that precede it, and thus an understanding
of narrative prevents the first of these fallacies. Moreover, since the features of narra-
tive are necessary but not sufficient, mindfulness of this fact should caution prudence
in the attribution of generalizing biomedical knowledge to the “singular” subject of
narrative, its patient-­speaker, whose unique features affect the “results” as well.
3. This is a paraphrase of a pragmatic maxim coined by Peirce: “Consider what
effects, that might conceivably have practical bearings, we conceive the object of our
conception to have. Then, our conception of these effects is the whole of our concep-
tion of the object” (1992: 132). Moreover, as we note later, Peirce strikingly claims
that the function of meaningful symbols is to establish “the being of law that will
govern the future” (1931–­58: 1.23); see Schleifer 2009a (esp. 26–­33) for an analysis of
Peirce’s claim in relation to “scientific knowledge.”
4. Strictly speaking, this is true only in mathematical physics, since evolutionary
biology, of necessity, cannot function with those vocabularies (for a detailed analysis
of this, see Gould 1989).
5. Evolutionary biology, as we argue in the following chapter, is organized around
the sufficient but not necessary truths of the historical development of biological
systems. Its details, while sufficient, are organized in relation to what Stephen Jay
Gould (1989) calls “contingency” rather than “necessity.” That most physicians sub-
scribe to these evolutionary “truths” about biology, even when they do not present the
nomological “evidence” of evidence-­based medicine, should allow them to entertain
alternative vocabularies—­particularly that of narrative knowledge—­governing differ-
ent aspects of their practice.
6. Misplaced concreteness is, according to Alfred North Whitehead, the fallacy
of treating abstract outcomes of inquiry as concrete. Misplacing concreteness in the
clinic allows a physician to ignore that which is most concrete, the actual experience
and concern of the patient. In chapter 3, we note that the neurology term modular—­
rather than, say, operational cognitive subsystem—­is another form of misplaced con-
creteness; and in chapter 4 (n. 5), we note, following Bogan and Woodward, that the
fallacy of misplaced concreteness can be understood as mistaking “data” for “phe-
nomena.”
7. As we mentioned in the introduction, Thomas Nickles notes that schema the-
ory resists this assumption of “atomic events” (1998: 78).

396  /  notes to pages 37–43

 8. See chapter 2 for an evolutionary understanding of the cognitive functioning
of narrative “experience.” See Steen 2005: 92–­95 for an evolutionary account of “the
architecture of sensory consciousness.” Schleifer (2009a) examines the nature of con-
scious experience in relation to the seeming immediate intuition of “meaning” and
the linguistic and semiotic structures that condition that felt phenomenology of intu-
ition. See Schleifer, Davis, and Mergler 1992: 11–­21 for a discussion of “objectivity”
in relation to Quine, Rorty, Bernstein, and others.
9. This account of Peirce, beginning with doubt, takes the form of narrative. As
we argue in chapter 2, for Aristotle, practical reasoning, or phronesis, likewise mani-
fests itself in a narrative that results in habits of action, as do his “virtues” that we
discuss in chapter 9.
10. For a congruent argument from a tradition very different from that of Peirce,
see Hayles 1991.
11. Moreover, Aristotle, as we see in the next chapter, asserts that the practical
reasoning of phronesis is focused on the “ends” of action, in which the end is both a
“point” and a “future consequence.” Precisely the temporal sense of “end,” like the
“future” Peirce describes, ties both semiotics and phronesis to narrative. It also ties
the pragmatism we are describing here to narrative. Finally, it is most clearly instanti-
ated in the practices of medicine, whose aims always seek particular, pragmatic fu-
ture ends.
12. Meir Sternberg (2001) argues that narrative also begins in “living doubt”; see
chap. 3, n. 11, in the present volume.
13. Peirce’s use of “aesthetics” here is broad and corresponds to its origins in
Greek. Its origin is the Greek aesthēsis, “sensuous perception,” and thus it incorpo-
rates more than theoretical reflections on artistic creation. Sensuous perception, for
Peirce, here translates as “feeling,” and aesthetics is the normative science of how we
ought to feel. The object of these feelings is the ideal purpose to which our conduct
is directed. In chapter 2, we touch on a similar use of aesthēsis in understanding Ar-
istotle’s conception of phronesis.
14. In this chapter, we have discussed measuring outcomes or consequences of
phenomena, particularly the quantitative measurements used in the sciences. How-
ever, we do not want to create the impression that outcomes and consequences of
literary studies (or other humanistic studies such as art, history, or ethics) in medical
education cannot and should not be measured. Rather, it is possible to “measure”
outcomes and consequences without necessarily having to quantify those “results.” In
other words, qualitative as well as quantitative measurement is possible, even when
those measurements do not lend themselves to mathematical analysis or formulas.
Recently, at the University of Oklahoma College of Medicine faculty who teach the
humanities to medical students have developed a “Community of Inquiry” using
Qualitative Research Techniques designed to define and measure the consequences
of teaching these subjects to medical students. Such measurement, like the Apgar
score we discussed in chapter 3 (see particularly n. 17), is as functionally real as the
seeming infallible formulas of mathematical physics.

notes to pages 44–56  /  397

Chapter 2
1. See Falkum 2008 for an overview. Nussbaum notes that “to judge from my
own work and to the consensus of philologists, there is, at least through Plato’s time,
no systematic or general distinction between epistēmē and technē” (2001: 94).
2. In his description of the discovery of “mirror neurons,” aptly titled Mirroring
People: The Science of Empathy and How We Connect with Others, Marco Iacoboni
suggests what might well be the neurological—­and even physiological—­basis of the-
ory of mind and empathy, the latter of which, as we suggest throughout the present
book, is of great importance to practices of medicine. Iacoboni only mentions theory
of mind once, in passing in a discussion of autism, but he describes the functioning of
mirror neurons in a manner that suggests they are the neurological basis of theory of
mind and empathy. Mirror neurons fire both when the subject performs certain ac-
tivities and when that subject perceives a fellow creature performing that activity.
Thus Iacoboni notes, “Given that our own actions are almost invariably associated
with specific intentions, the activation in my brain of the same neurons I use to per-
form my own actions when I see other people performing these actions may also al-
low me to understand the intentions of the other people” (2009: 30).
In an essay examining the basis for theory of mind in mirror neurons and citing
Iacoboni, Sarah Swenson notes that “experiencing the lives of others and learning
from these experiences is known as a vicarious experience, but Iacoboni claims that
‘“vicarious” is not a strong enough word to describe the effect of . . . mirror neurons.
When we see someone else suffering or in pain, mirror neurons help us to read her
or his facial expression and actually make us feel the suffering or pain of the other
person’ (Iacoboni 2009: 209:4).” “Importantly, however,” Swenson goes on, “the abil-
ity of mirror neurons to respond to another’s personal experience is not limited to
visual stimuli. Listening to laughter, for example, activates motor neurons required
for smiling (Iacoboni 2009: 105). Furthermore, according to a study performed by
psychologist Lisa Aziz-­Zadeh, ‘areas in the brain known to control the movements of
particular body parts (i.e., the hand or the mouth) were activated not only when sub-
jects watched the movement on video but also when subjects read sentences about
the movement’ (Iacoboni 2009: 94)” (Swenson 2011).
The whole of Iacoboni’s description of the discovery and functioning of mirror
neurons is apposite for The Chief Concern of Medicine. As he suggests early in his
book, he is pursuing “holistic interpretations of brain functions, in which motor cells
are concerned with the goal of an action” (2009: 15), and he goes on to describe his
work as “neurophysiological phenomenology” that aims at “realizing that perception
and action are a unified process in the brain” (17). In this chapter, we are pursuing
Aristotle’s concern with the goal of actions, and throughout this book, we are con-
cerned with the overriding goals of medicine. See also Cassell 1991.
3. In her preface to the revised edition of The Fragility of Goodness, Nussbaum
uses the term flourishing rather than the flowering forth we put forward here, de-
scribing “a good person . . . managing to live a flourishing human life, a life promi-
nently including virtuous activity. (The ‘goodness’ of the title [of my book] should be

398  /  notes to pages 59–63

understood as ‘the human good’ or eudaimonia, rather than as ‘goodness of charac-
ter.’)”; later, she describes “the elements of a life that make for flourishing or eudai-
monia” (2001: xiii, xiii, xiv). In using flourishing, she is following J. D. Cooper (see
2001: 6 n. 1 for a full discussion of the term). We use flowering forth because we think
it is a more emphatically self-­conscious metaphorical term than flourishing (whose
metaphorical nature seems to us almost erased) and, thus, that it more fully implies
the narrative aspect of eudaimonia. (The Oxford English Dictionary offers the first,
obsolete definition of flourish as “to blossom, flower; to throw out leaves and shoots.”)
4. For a thorough discussion of the aesthetics of improvisation, see Hamilton
1990 and Schleifer 2011: 145–­50.
5. In this description, Bernstein is criticizing such positivistic science. As Edward
Slingerland notes, “Richard Bernstein, who celebrates the philosophical hermeneu-
tics movement of Martin Heidegger and Hans-­Georg Gadamer and the ‘neo-­
pragmatism’ of Richard Rorty in his Beyond Objectivism and Relativism (1983), is
right about the fact that these thinkers are clearly struggling to get away from the
dualist ‘Cartesian anxiety,’ and what he sees as a turn back to Aristotelian phronesis or
‘practical wisdom’ would certainly constitute a step in the right direction” (2008: loc.
2458–­63).
6. Needless to say, the “general rule” of natural selection does seem applicable to
each new case, but the controversies within evolutionary biology (as opposed to the
politics that surrounds it) have to do with, first, what constitutes the “case,” whether
it be, in Stephen Jay Gould’s discussion, “gene, cell lineage, organism, deme, species
and clad” (2002: 73). In Intangible Materialism, Schleifer reduces this list to “gene,
organism, and species (i.e., Dawkins’s ‘selfish gene,’ Darwin’s ‘individual,’ and Gould’s
‘punctuated equilibrium’)” (2009a: 198 n. 22), corresponding to the “levels” of phys-
ics, biology, and semiotics that he examines in that book and that we are touching on
in this chapter. The “general rule” also has to be understood in relation to the external
“accident” that Gould describes in punctuated equilibrium, which corresponds, willy-­
nilly, to the “luck” that Nussbaum explores in The Fragility of Goodness: Luck and
Ethics in Greek Tragedy and Philosophy.
7. For a discussion of these assumptions in relation to evidence-­based medicine,
see the section titled “Narrative Phronesis: Schema-­Based Medicine” in chapter 3.
8. In this, she is following Wiggins, who translates this passage “we deliberate
(bouleuometha) not about ends but what is towards ends” (1980: 225). (Although we
are citing the 2001 edition of The Fragility of Goodness, it was originally published in
1986 and was “updated” with a new preface twenty-­five years later.) Even earlier, in
her first book, Aristotle’s “De Motu Animalium” (particularly in “Essay 4”), Nussbaum
also notes that “the entire notion that Aristotelian deliberation is concerned only with
instrumental means to an end, and not also with components of the end, was based on
misreading and mistranslation and should by now be buried” (1978: 170). In a note,
she adds that “the phrase ta pros to telos is understood by [many, including the trans-
lator of the Nicomachean Ethics, W. D. Ross] . . . to refer only to external means to the
end. . . . Wiggins and [J. M.] Cooper both argue convincingly that ta pros to telos can
cover reasoning about constituents as well as about means” (1978: 170 n. 13).

notes to pages 63–65  /  399

 9. This is the burden of Schleifer’s argument in Intangible Materialism (2009a:
esp. 48–­63), but it is also “formally”—­but not quite “formulaically”—­worked out in
his essay “The Semiotics of Speculation” (2009b). In his powerful, 2005 study of nar-
rative as a form of evolutionary cognition, Steen argues that narrative “construes”
endings.
10. In this chapter, we discuss the “formulas” of mathematical physics, but such
formulation includes the quantification we described in chapter 1. We use this wider
term because the “formulas” are not necessarily quantitative in some cases (e.g., the
deontological formula “do no harm”). Still, as we noted earlier, the “strongest” scien-
tific formulas are quantitative, mathematical formulations.
11. Wittgenstein’s meditation on experience and its “aspects” that go beyond sim-
ple sense impressions nicely chimes with Nussbaum’s analysis of Aristotle: it is no
accident that she prefaces her essay “The Discernment of Perception: An Aristotelian
Conception of Private and Public Rationality” in Love’s Knowledge with an epigraph
from Philosophical Investigations (Wittgenstein 2001: 2.xi). In Mirroring People, Ia-
coboni notes that Wittgenstein says, “We see emotion . . . We do not see facial contor-
tions and make the inference that he is feeling joy, grief, boredom. We describe a face
immediately as sad, radiant, bored, even when we are unable to give any other de-
scription of the features.” “Mirror neurons,” Iacoboni continues, “seem to explain
why and how Wittgenstein and the existential phenomenologists were correct all
along” (2009: 262).
12. Wittgenstein’s related example is the “perception” of sadness: “I can only see,
not hear, red or green,—­but sadness I can hear as much as I can see it. Think of the
expression, ‘I heard a plaintive melody.’ And the question is: ‘Does he hear the
plaint?’” (2001: II.xi, p. 178). For him, however, the salient feature is at the heart of
“perception” in such a way that perception itself, however immediate it feels, must be
more than simple sensation. (Even though the attribution of sadness might perhaps
be associated with the isolatable “feature” of a minor modality of music, this attribu-
tion still leaves open the question of what makes this modality of music “sad.”) The
“salient feature” in medicine—­particularly when it answers Nussbaum’s category of
the “concern with explanation,” which we explore in a moment—­more explicitly ties
together perception and practical reason insofar as the practiced physician (or phron­
imos) seems simply and immediately “to perceive” what is important, even though, as
we are arguing, such perception is mediated, in some sense, by perceptual and con-
ceptual schemas.
13. In Time and Narrative, Paul Ricoeur describes the comprehension accom-
plished by “the narrative operation”—­but also by comprehension in general—­by
quoting Louis Mink: “Comprehension in the broad sense is defined as the act ‘of
grasping together in a single mental act things which are not experienced together, or
even capable of being so experienced, because they are separated by time, space, or
logical kind. And the ability to do this is a necessary (although not a sufficient) condi-
tion of understanding’” (1984: 159; Mink 1970: 547; see also Schleifer, Davis, and
Mergler 1992: 10–­11). Such “grasping,” we are suggesting, depends on necessary but
not sufficient schemas. Moreover, the mental act of “grasping” does not distinguish,

400  /  notes to pages 66–68

as the logical positivists do—­and Nussbaum sometimes suggests—­between scientific
and nonscientific reasoning.
14. J. Hillis Miller describes the demand for interpretation because of what he
calls “the terror or dread readers may experience when they confront a text which
seems irreducibly strange, inexplicable, perhaps even mad” (1985: 20). For a discus-
sion of Miller’s analysis of this phenomenon—­and the domestication—­of “mad” nar-
rative, particularly in relation to formal “speculation,” see Schleifer 2009b. This is
particularly apposite to physicians confronted with incoherent patient narratives. Un-
der the term general, in this passage, Nussbaum seems to be describing the function-
ing of schemas as well.
15. For a discussion of technē in relation to contemporary evidence-­based medi-
cine, see the section entitled “Narrative Phronesis: Schema-­Based Medicine” in
chapter 3.
16. In The Conscious Mind (1996), David Chalmers argues that the “iconic” con-
sciousness of qualities (he does not use Peirce’s term) is, in fact, a separate and dis-
tinct faculty and the defining quality of experience itself (and hardly the dysfunctional
simultagnosia Sacks describes). In this, he seems to assume, unlike Sacks—­and un-
like the schema theory of cognitive psychology—­that the felt immediacy of experi-
ence is not, in fact, mediated by structures or schemas of perception. For an extended
discussion of Chalmers, see Schleifer 2009b: chap. 1.
17. For a thoroughgoing analysis of evolutionary science as historical and not
quantifiable, see, particularly, Stephen Jay Gould’s Wonderful Life (1989) and The
Structure of Evolutionary Theory (2002). The schemas that analyze experience are
founded on necessary but not sufficient narrative “structures,” as Sacks calls them,
which inform (in very different ways) both narratology and evolutionary cognition.
18. In chapter 4 (n. 5), we note the distinction that James Bogan and James Wood-
ward make between “data” and “phenomena,” which is relevant to our discussion of
science and its methods in this chapter. They argue that “data” are the products of
controlled experiments and therefore always “observable,” while phenomena—­a ver-
sion of the “experience” we are discussing here—­“are not idiosyncratic to particular
experimental contexts” but nevertheless “have stable, repeatable characteristics
which will be detectable by means of a variety of different procedures, which may
yield quite different kinds of data” (1988: 317). Two such procedures, we are suggest-
ing, are schema-­based reasoning and case-­based reasoning.
19. In this section, we focus on the evolutionary basis of narrative; earlier, we used
the notion of “speculation,” which corresponds to Steen’s notion of the “evolved
mode of construal”—­both of which can be understood in relation to the deliberations
of phronesis. “Speculation,” we noted earlier, more readily captures the provisional
nature of narrative knowledge. The catalog of salient features of narrative presented
in the next chapter, we are suggesting, can help us delineate the narrative structure
that Steen posits.
20. In a study of “narrative empathy,” Suzanne Keen notes that “the human capac-
ity for primitive empathy, or the phenomenon of spontaneously matching feelings,
suggests that human beings are basically similar to one another, with a limited range

notes to pages 70–78  /  401

of variations. Psychologist Martin Hoffman, for instance, believes that the structural
similarities in people’s physiological and cognitive response systems cause similar
feelings to be evoked by similar events” (2006: 212). In recent years the postulation
of “mirror neurons” that respond to both an individual’s behavior and that of its con-
specific—­a chimpanzee, for instance, “firing” these neurons when it eats and when it
sees another chimp eating—­lends physiological evidence to Keen’s description of
“matching feelings” (see Iacoboni 2009). Neurological evidence of mirror neurons
suggests the physiological and evolutionary bases for theory of mind we mentioned
earlier. It is odd, we think, that the contestation of basic human similarities should
have taken on such a political edge in the humanities in recent years.
21. In his conclusion, Boyd unsystematically catalogs most of the features of nar-
rative we describe in chapter 3: its aim “to direct the attention of others” (witness), its
“particular individuals, situations, or actions” (recognizable agents; sequence of
events), “a storyteller hold[ing] our interest” (articulated and received), “its import”
(end) (2009: 382–­84). (Earlier, he explicitly excludes the last feature we mention, ex-
perience, asserting that narration is different from “experience” [2009: 159]). But it is
his marshaling of evidence from cognitive science and evolutionary cognition in what
follows—­evidence, as we note, that is not educed for the purposes of defining
narrative—­that most supports our isolation of six salient features of narrative in chap-
ter 3.
22. The style in this passage is characteristic of Boyd’s study as a whole, with an
assertion followed by citations that are rarely discussed, either in relation to the
book’s other explicit and implicit assertions—­including its ubiquitous first-­person
plural pronouns—­or in relation to the other citations in particular notes. The equa-
tion of preschool experience and adult experience in this passage is not even brought
up, even though a later citation (and the text itself) distinguishes between memory
function at different ages.
23. Meir Sternberg (2003a; 2003b) describes, in powerful detail, how cognitive
studies of narrative have systematically refused to acknowledge and benefit from the
literary and narratological studies of narrative and narrative forms. As we have al-
ready mentioned, this imputation of modularity is an example of the fallacy of mis-
placed concreteness.
24. Slingerland consistently argues against a “blank slate” understanding of hu-
man cognition. For instance, he argues, “The evolutionary psychologists John Tooby
and Leda Cosmides have been in the forefront of a movement arguing against blank
slate views in favor of what they term an ‘evolutionary Kantian’ position: that human
cognition could simply not get off the ground without the existence of a robust set of
evolutionarily designed and species-­typical categories of understanding” (2008: loc.
3206); and he notes that “the theoretical necessity for built-­in structure goes by vari-
ous names in different fields—­it is the ‘frame problem’ in AI, the ‘poverty of stimulus’
in linguistics, the problem of ‘referential ambiguity’ in semantics, the need for ‘con-
straints on induction’ in developmental psychology, or the problem of the underde-
termination of ‘stimulus array’ interpretation in the psychology and neuroscience of

402  /  notes to pages 79–81

perception—­but all of these fields converge in demonstrating that a blank slate would
simply remain blank” (loc. 3211–­16).

Chapter 3
1. It is instructive, we think, to compare our focus on the “chief concern” of a
patient’s narrative with Charon’s lucid discussion of the “desire” that inhabits encoun-
ters with narrative. Such desire, she notes, “is both the most obscure and the most
accessible” aspect of engaging with narrative: “What appetite is satisfied by virtue of
the reading act? What hunger seems to have been fulfilled in the teller . . . ? These
questions do not pertain to the desires of the characters in the work or of the flesh-­
and-­blood author behind the work as much as to the desires of the narrator and the
reader themselves” (2006a: 124). Charon concludes this section of her book by noting
that “facing one’s desires vis-­à-­vis one’s texts may be something more aptly and ex-
pertly done in the department of medicine than the department of English. It may be
an area in which narrative medicine can make original contributions to literary stud-
ies” (126). She writes that focusing on desire—­on what she calls “fulfilled” need,
“obtained” drive, “achieved” bliss (124)—­and “asking readers to articulate the desires
awakened by a text” have “been, in my teaching, a reliable method of guiding them to
the heart of their encounter with the text” (125). Here, though, we are focusing on
patient anxiety rather than desire, which might also lead physicians to the heart of
their patients’ stories.
2. As we have seen, construal is the term that Francis Steen employs in his argu-
ment that there is “a generic and universally understood narrative structure” that is
“made possible by a complex suite of well-­established and tested adaptations with a
deep biological history” whose function “is an evolved mode of construal, a systematic
method for predicting what agents will do” (2005: 88–­89).
3. In his discussion of narrative rhetoric, Phelan nicely catalogs terms that com-
plement our use of deliberation: “There are various metaphors, all somewhat inade-
quate, that might be applied to this relationship between author, text, and audience:
interaction, exchange, transaction, intercourse” (1996: 18). Such listing—­both by
Phelan and by us in quoting him here—­enacts the act of deliberation that both we
and Phelan describe in relation to narrative. Charon also presents a fine “meta-
phor . . . from child psychology” for this deliberate activity, which describes the dif-
ference between “parallel play” that infants, before they “develop the intersubjective
capacity to respond to one another,” engage in and “collaborative play, that is playing
with instead of simply playing next to” (2006a: 32). Narrative, she argues, encourages
such intersubjective collaborations.
4. Francis Steen (2005) offers a strongly detailed framework for understanding
the human capability of grasping narrative wholes, and Patrick Colm Hogan, in his
study of the relationship of prototypical stories to human emotion, examines “univer-
sal” narrative formations in fine detail, arguing, at one point, that storytelling helps
articulate and achieve Aristotle’s notion of eudaimonia (2003: 222–­24), what he de-

notes to pages 85–91  /  403

scribes, in narrative terms, as “a transcendental goal or telos” (224). In addition, the
evolutionary adaptiveness of narrative is more fully described in discussions of the
evolutionary origins of religious formations in human communities, which argue that
the particulars of religious belief are closely related to the features of narrative—­
particularly the ascription of agency to events (see Schleifer 2009a: 140–­45). Evolu-
tionary accounts of religion offer a fine sense of the connections between practical
reason and narrative formations: Pascal Boyer, in one telling example, describes the
“narrative drive” animating the adaptive social formations of religious beliefs and in-
stitutions (2001: 204). As we have seen, Brian Boyd, in On the Origins of Stories:
Evolution, Cognition, and Fiction, compiles a richly detailed survey of the findings of
experimental psychology and evolutionary cognition in relation to narrative.
5. As we have seen, Nussbaum emphasizes that the recognition of “the salient
features of a complex situation” (1990: 74) is at the heart of phronesis. The impor-
tance of salient features here, as in phronesis more generally, is ultimately practical:
they lend themselves to the creation of systems of understanding—­schemas, check-
lists, algorithms—­that physicians can implement in their interaction with patients in
order to facilitate the grasping of narrative knowledge. Rather than attempting a
definition of narrative (or the “narrativity” that Ryan discusses in the citation with
which we began this chapter), we are proposing practical procedures based on a
“schematic” understanding of narrative analogous to the evidence-­based procedures—­
compilations of information, such as the “clinical evidence” we discuss in the intro-
duction, or algorithms of action, such as the evidence-­based guidelines we discuss
later in this chapter—­that are taught and practiced in medicine.
6. Chekhov’s comment, which he repeated in a number of letters, is discussed by
Simmons (1962: 190). Hogan provides the empirical evidence of psychological ex-
periments that substantiate the particular power of literary narratives, “direct em-
pirical research on literary response that supports this analysis” (2003: 66ff.). Our use
of the term art narrative as opposed to popular narrative is analogous with the dis-
tinction between art music and popular music in musicology. One of the distinguish-
ing features of popular music is the fact that it is woven into the actions of everyday
life, work music, dance music, and so on. In this sense, the HPI of the patient-­
physician encounter is a form of “popular” narrative. Art music—­which one commen-
tator has compared to “the ‘museum art’ ethos that dominates the world of Western
art music” (Hamilton 1990: 325)—­is separated from everyday life and calls on and
provokes certain kinds of attention, including an emphasis on the aesthetics of experi-
ence. In Narrative Medicine, Charon devotes significant sections of her discussion of
the work of physicians to the analyses of art narrative, particularly Henry James. A
good example of the virtues of analyzing accomplished “aesthetic” storytelling can be
found in Phelan’s rhetorical analysis of Katherine Anne Porter’s story “Magic” at the
beginning of Narrative as Rhetoric, where he reads the literary narrative with great
attention to detail. In one instance, he notes that two powerful women in the story,
Ninette’s “madam” and Madame Blanchard, are situated in parallel positions: “Since
Ninette’s madam asserted her power over her employees by beating them with bottle,
Madame Blanchard’s clicking her own perfume bottle shut at this moment suggests

404  /  notes to page 91
that she feels some need to remind herself—­and the maid—­of her power” (1996: 7).
In this, Phelan is following Chekhov’s aesthetic insight. Moreover, throughout her
work, Charon demonstrates the close relationship between the aesthetics of narrative
knowledge and the shape of the action following from that knowledge.
7. Brian Boyd, working in a very different tradition, agrees with Miller’s observa-
tion, arguing that “our capacity to comprehend events, many facets of which we share
with other animals, underlies our capacity for story but should not be confused with
narrative, with telling events, an effortful process we undertake only to direct the at-
tention of others to events real or imagined” (2009: 382). In this emphasis on the ac-
tual telling of stories, he situates himself against what Martin Kreiswirth calls “narra-
tive naturalists,” researchers who “want to see story as a going all the way down,
beyond language and textuality, into mental activity or basic cognitive processes”
(2000: 305). Kreiswirth cites Mark Turner as his chief example of this (306).
8. We are borrowing the term meaningful whole from A. J. Greimas’s Structural
Semantics, where he refers to “the still very vague, yet necessary concept of the
meaningful whole set forth by a message” (1983: 59). Such a concept, he argues, is at
the heart of semantics. We discuss the concept at some length in chapters 4 and 6 in
the present book.
9. This definition also governs Sternberg 2001 (see n. 10 in the present chapter).
The opposition between the temporal action of the telling and the temporal action of
the story itself is articulated in a formal analysis of narrative based on the work of
Greimas, in which Greimas’s “category, sender vs. receiver, articulates the situation of
linguistic activity, whereas the other actantial categories [e.g., hero vs. opponent, ob-
ject (or sought-­for good) vs. helper, categories we examine later in this chapter] help
describe semionarrative relationships within a message” (Schleifer, Davis, and Mer-
gler 1992: 73).
10. Although Meir Sternberg describes “the undisputed narrative essentials [as]
character and event” (2001: 15) and claims that “narrativity lives between the pro-
cesses uniquely run together by the genre: actional and communicative, told and
telling/reading sequence” (117)—­three of the salient features we are describing here
(event, character, articulation/reception)—­he focuses on the phenomenology of nar-
rative, the fact that in encountering narrative we are “always faced with effects
only . . . [that] we have to work back to the probable causes” (119). This is the burden
of the following chapter, where we examine Peirce’s logical formalization of working
from effects to causes, the “abductive” logic of diagnosis. More to the point here is
Sternberg’s phenomenological analysis of narrative, his isolation of “the three univer-
sal narrative effects/interests/dynamics of prospection, retrospection, and
recognition—­suspense, curiosity, and surprise” (117). These last responses to narra-
tive correspond to the “concern” (suspense), “sequence” (curiosity), and “end” (sur-
prise) of narrative we are describing, which he describes as “narrative master
forces . . . [that] narrativize everything else in the text, by assimilating it willy-­nilly to
their dynamics of lifelike development and/or artful disclosure” (117). Moreover, his
description of “plot” nicely comports with the situation of the patient-­physician en-
counter, beginning, as it does, in the patient’s not knowing: “a plot thus hinges on the

notes to pages 92–93  /  405

uncertainties of a word’s bearing, a speaker’s authority, a trait’s fixity, or a reality-­
model’s, which it ambiguated to begin with” (117). He includes in his analysis the
ambiguity of the “forked judgment” (121) concerning the narrative’s end or point, the
provisional nature of the end of a not-­yet-­completed story.
11. Kathryn Montgomery Hunter describes this nicely in her discussion of narra-
tive, literature, and phronesis in relation to medicine: “Whether it is an individual’s
life story which is essential to moral understanding or the political history of a nation,
narrative explores the way cause and effect are entangled with the variables of human
character and motivation, and with luck and happenstance” (1999: 306).
12. Speaking of novels, Frank Kermode describes this strong version of narrative
as creating “world models” (1967: 52). In his account of “narrative and knowledge in
the human sciences,” Martin Kreiswirth describes those who subscribe to this ac-
count as “narrative naturalists,” researchers who “want to see story as a going all the
way down, beyond language and textuality, into mental activity or basic cognitive
processes” (2000: 305). “Viewed in this way,” he writes—­he is particularly discussing
the work of Mark Turner—­“story making seems to operate somewhere between per-
ception and cognition, conflating what is being represented and its representation.
Indeed, at this conceptual depth, the issue of representation itself is at issue. Is an
apprehension (for Turner, a small spatial story) a representation? And can it accu-
rately be called a narrative, when what is posited is the perceptual and cognitive activ-
ity of combining and chaining, of locating sequence, of putting together spatiotempo-
ral constructs, not communicating them (even to oneself) via the dynamic interactions
established between the construct conveyed and the process of its conveyance?”
(306). These discussions—­particularly Kermode’s “world models”—­seem to call up
Kuhn’s “paradigms.” Moreover, Kreiswirth’s account of Turner’s argument that narra-
tive operates “somewhere between perception and cognition” denies our claim—­and
that of much cognitive theory—­that schemas provide provisional cognitive organiza-
tions rather than the very “shape” of experience as such. In any case, in chapter 9,
following the work of Scott Stroud and others, we examine more fully the phenome-
non of vicarious experience as it arises in narrative. For a detailed analysis of the ways
that “aesthetic” or “art” narrative (as we called it in n. 6 in the present chapter) in
particular “simulates” experience, see Stroud 2008: 30–­31.
13. The provisional nature of schemas and of medical phronesis collapses the ab-
solute opposition between science and narrative to which the logical positivists,
among others, subscribe.
14. In fact, there is likely a neurological basis for narrative comprehension. Neu-
rologists have identified a condition they describe as “discourse-­level aphasia” as a
“distinct syndrome” that Merlin Donald describes as follows:

Spoken language would remain fluent and word finding would not be im-
paired. There would be no reason to expect difficulty with repetition or with
limited comprehension and production of single words and short, highly over-
practiced stock sentences and phrases. Mimetic uses of vocalization would
likewise remain unaffected. But narrative discourse-­level uses of language

406  /  notes to pages 94–95

 would break down; symbolically based thought would be selectively impaired;
and the comprehension of linguistically encoded ideas would be destroyed.
Moreover, linguist invention would be lost. . . .
 . . . The closest thing in the existing literature to discourse-­level aphasia
might be the deficit in the recall of stories shown by some left temporal-­lobe
epileptics (Milner, 1965). These patients have difficulty recalling the details of
narrative material, even very short narratives. They have difficulty in attribut-
ing agency and action; if asked about the content of a story, they have difficulty
even with major aspects of the plot and the major characters. The deficit is
made worse (although the epileptic symptoms are usually relieved somewhat)
by neurosurgery of the diseased areas. This is a very specific cognitive loss, not
attributable to aphasia in the normal sense, or to dementia, intellectual loss, or
sensory loss.
Frisk and Milner (1990a, 1990b) have shown further that this deficit is not
due to a reduction in immediate working memory capacity, or in the rate at
which verbal information can be processed. The deficit is characterized by loss
of narrative information after a short delay (even overlearned material is lost
in 20 minutes) and is made worse in proportion to the amount of left hippo-
campal tissue removed in the surgery. (1991: 266–­67; see our bibliography for
Donald’s references)

15. One example of such a guideline is the American College of Cardiology and
the American Heart Association’s 2007 “Guidelines on Perioperative Cardiovascular
Evaluation and Care for Noncardiac Surgery” (Fleisher et al. 2007), which sets forth
“tables and algorithms [to] provide quick references for decision making.” These
guidelines are designed for “physician and nonphysician caregivers who are involved
in preoperative, operative, and postoperative care of patients,” and they set forth a
precise “if-­then” series of actions based on “a comprehensive review of the literature
relevant to the perioperative cardiac evaluation published since that last publication
of these guidelines in 2002.” They include a “schema of classification of recommen-
dations and levels of evidence.”
16. It is notable that in the example of the “Guidelines on Perioperative Cardio-
vascular Evaluation,” the writing committee is comprised of twelve coauthors, eleven
of whom are MDs and one of whom is a registered nurse (Fleisher et al. 2007).
17. Gawande describes the remarkable transformation in childbirth in the United
States after the introduction of the Apgar test. In the mid-­1930s, he notes, “one in
150 pregnancies ended in the death of the mother,” and for newborns, “one in thirty
still died at birth—­odds that were scarcely better than they were a century before”
(2007: 184–­85). But “in the United States today [after the Apgar test was developed
and in widespread use],” he reports, “a full-­term baby dies in just one childbirth out
of five hundred, and a mother dies in less than one in ten thousand” (187). “There’s a
paradox here,” Gawande concludes: “Ask most research physicians how a profession
can advance, and they will tell you about the model of ‘evidence-­based medicine’—­
the idea that nothing ought to be introduced into practice unless it has been properly

notes to pages 97–99  /  407

tested and proved effective by research centers, preferably through a double blind,
randomized controlled trial. But in a 1978 ranking of medical specialties according to
their use of hard evidence from randomized clinical trials, obstetrics came in last”
(188). In obstetrics, says Gawande, “they just went ahead and tried it [without “re-
search trials”], then looked to see if results improved. Obstetrics went about improv-
ing the same way Toyota and General Electric went about improving: on the fly, but
always paying attention to the results and trying to better them” (189).
18. In chapter 8, we also describe another element of medical practices, Rita
Charon’s development in her students of a narrative “parallel chart”—­parallel, that is,
to the nonnarrative patient chart kept for all patients—­that pursues a narrative
“schema” writ large by encouraging the narrative understanding of the experiences of
patients and the practices of doctoring themselves. These parallel charts articulate
the student-­physician’s and the patient’s “concern” and, we suspect, what Charon
describes as the “desire” of narrative (see n. 1 in the present chapter).
19. Steen’s argument that the perceptual processing of sensory input—­the medi-
ated fact of conscious experience—­is the base on which narrative structures function
(2005: 99) suggests a neurological foundation for the contention that narrative ap-
proximates experience.
20. For an account of Greimas’s analysis, see Schleifer 1987: 87–­110.
21. The folktales and wondertales analyzed by Lévi-­Strauss and Propp can be con-
sidered art narratives (rather than popular narratives) precisely because their telling
is isolated from everyday life, and they call for the particular forms of attention we are
calling aesthetic. They may profitably be contrasted with proverbs and proverbial say-
ings, which are the “everyday” expression of narrative, often folkloristic narrative.
22. This generic account—­relationally described in this analysis (and thus neces-
sary but not sufficient)—­is compatible with Hogan’s empirical description of the
common form of prototypical narrative genres in The Mind and Its Stories (2003).
Hogan’s prototype of “Romantic tragi-­comedy” encompasses the genre of comedy
that Greimas’s analysis suggests; his prototype of “Heroic tragic-­comedy” encom-
passes melodramatic epic; and his prototype of “Sacrificial tragic-­comedy” encom-
passes tragedy. Irony, we would argue, is a relatively late narrative form, a “logical”
possibility in Greimas’s schema, but one that was rarely realized before social forma-
tions that arose with Enlightenment individualism. Moreover, when we suggest that
Hogan’s empirical prototypes “encompass” Greimas’s more abstract formulations, we
are suggesting that the necessary but not sufficient nature of the structuration of nar-
rative we are describing in Greimas’s actantial terms is realized in Hogan’s (sufficient)
empirical examples.
23. For a more detailed account, see Schleifer, Davis, and Mergler 1992: esp.
chap. 2, “Structures of Meaning: The Logic of Narrative and the Constitution of Lit-
erary Genres.” That chapter presents a full, “formal” account of narrative, suggesting
necessary but not sufficient features, including the argument that literary genres de-
fine themselves in general terms in relation to the syncretized “receiver”-­actant in
narrative. The chapter is based on earlier work (Schleifer and Velie 1987).

408  /  notes to pages 99–104

Chapter 4
1. Nussbaum notes that “Aristotle does hold that the desires and reflections of a
rational agent form some sort of system, and that the practical syllogism can help us
elucidate this system” (1978: 209). Peirce, as we demonstrate, describes the system-
atic nature of hypothesis formation.
2. The following is the “Bean Bag analogy” as it appears in Peirce’s essay “Deduc-
tion, Induction, and Hypothesis” (1992: 134). We are following this “translation”:
“beans” =­“children”; “bag” =­“class”; “white” =­“measles.” We have also modified
“Abduction” to reflect the connection between “case” and “rule” in relation to the
“result,” which, in medicine, is the presentation of the symptom(s).

deduction
Rule—­All the beans in this bag are white.
Case—­These beans are from the bag.
∴Result—­These beans are white.

induction
Case—­These beans are from this bag.
Result—­These beans are white.
∴Rule—­All the beans from this bag are white.

abduction
Rule—­All the beans in this bag are white.
Result—­These beans are white.
∴Case—­These beans are from the bag.

(Since this essay is a thorough early description of “hypothesis” or “abduction,” we are

citing an easily accessible source. The essay also appears in Peirce 1931–­58, vol. 2.)
3. We should note that the two “courts” of the logical positivists we mentioned in
chapter 1 as judging “truth value”—­the court of empirical observation and the court
of logic—­correspond to induction and deduction. For the positivists, there was no
room for abduction (hypothesis).
4. Ilkka Niiniluoto notes that “inference to the best explanation”—­a twentieth-­
century description of abduction (see n. 7 in the present chapter)—­“is always re-
stricted to a set of historically given or formulated hypotheses” (1999: S447). Deduc-
tion, induction, and abduction so conceived also encompass the “state of affairs” of
rigorously tested evidence-­based medicine (“preferably [accomplished] through a
double blind, randomized controlled trial” that Gawande describes [2007: 188]); the
less strictly controlled “evidence” of “matters of past fact,” as in the Apgar score; and,
finally, the future-­oriented speculations and construals of schema-­based medicine.
5. For a thoughtful discussion of accounting for phenomena that are not—­and
often cannot be—­observed, see James Bogan and James Woodward 1988, especially
the distinction those authors make between “data” and “phenomena,” between “what
is uncontroversially observable (data)” and “what theories explain (phenomena or

notes to pages 113–18  /  409

facts about phenomena)” (314). Instances of phenomena, they note, “can occur in a
wide variety of different instances or contexts. This, in turn, is closely connected with
the fact that the occurrence of these instances is (or is plausibly thought to be) the
result of the interaction of some manageably small number of some causal factors,
instances of which can themselves occur in a variety of different kinds of situa-
tions. . . . Data are, as we shall say, idiosyncratic to particular experimental contexts,
and typically cannot occur outside of those contexts. . . . Phenomena, by contrast, are
not idiosyncratic to particular experimental contexts. We expect phenomena to have
stable, repeatable characteristics which will be detectable by means of a variety of
different procedures, which may yield quite different kinds of data” (317). This dis-
tinction, implicit in Peirce’s conception of abduction—­especially, as we shall see, in
his conception of the “character” or “characteristics” of phenomena on which abduc-
tion focuses—­might help to clarify the distinction between “symptoms” and “illness”
in medicine. It also clarifies Whitehead’s notion of the fallacy of misplaced concrete-
ness discussed in chapter 1. The source of this fallacy can be seen in the mistaken
apprehension of “data” as “phenomena.”
6. This is why the essays collected in The Sign of the Three, edited by Umberto
Eco and Thomas Sebeok, consistently focus on the relationship between Peirce’s
semiotics—­especially his sense of abduction—­and the narratives of Sherlock Holmes.
In a techno-­philosophical analysis of abduction, Ilkka Niiniluoto also notes that “a
historically interesting application of abduction as a heuristic method can be found in
classical detective stories” (1999: S440). Throughout Doctors’ Stories: The Narrative
Structure of Medical Knowledge, Kathryn Montgomery Hunter describes the parallel
structure of medical diagnosis and detective fiction. “The medical case,” she writes,
“the central narrative account of the study and diagnosis of disease in an individual
patient, developed along with that most modern of Western literary forms, the detec-
tive story” (1991: 21). She goes on to say that Sherlock Holmes’s “method requires the
retrospective construction of a hypothetical narrative in order to work out the relation
of the clues to one another within an acceptable chronology. Within the published
story written by Arthur Conan Doyle and told by Watson, the action ends with
Holmes telling the story he has constructed. Holmes’s story is diagnostic, a narrative
reconstruction that aims to recapture lost time and unobserved deeds. . . . The diag-
nostic skill that is the focus of a physician’s education bears striking similarities. Like
Sherlock Holmes’s narrative reconstruction of the crime, the physician’s medical ver-
sion of a patient’s story is the narrative embodiment of a diagnostic hypothesis, the
reconstruction of what has gone wrong” (24). See also Montgomery 2000 for a discus-
sion of clinical practices and detective stories.
7. This catalog is suggested in many post-­Peircean studies of abduction and ex-
planation. For instance, in their discussion of the nature of explanation—­especially
scientific explanation—­in “Saving the Phenomena,” Bogan and Woodward are careful
to describe explanation as entailing “detailed causal stories” as well as the “classical
deductive-­nomological model” of mathematics (1988: 324). Their example of a story
or narrative explanation is an account of the cause of Parkinson’s disease, and they
claim that the deductive model often entails “idealizations and approximations”

410  /  notes to page 119

(324n). Gilbert Harman, in an earlier discussion of “inference to the best explana-
tion” (1965)—­his description of the logic of abduction (88)—­argues that “enumera-
tive induction” is a special case of abduction (“inference to the best explanation”). For
a thoroughly Peircean examination of the homologies of the formulaic science of
mathematical physics, the explanatory science of evolutionary biology, and the “spec-
ulative” science of semiotics, see Schleifer 2009a.
8. Kathryn Montgomery Hunter describes the parallel between the process of
reading and the “practical reason” of the clinician: “like reading itself,” she writes,
“the exercise of practical reason is an act of interpretation”; it is a “process inter-
twined with history, identity, culture, and life-­meaning” (1999: 307). Describing the
“logic” of abduction, Ilkka Niiniluoto also suggests parallels between reading narra-
tive and the differential diagnosis: “For example, suppose we are looking for an expla-
nation of the death of a certain person, and there are available several possible causes,
H, H′ . . . of her death. However, if the case is given a fuller description, including
facts about her life and the symptoms in her body, it may be that many of the potential
hypotheses fail to give a causal explanation any more. In the limit, it may happen that
only one of the potential hypotheses is left, and this is then certainly the ‘best’ expla-
nation in this situation” (1999: S444). It is striking that Niiniluoto’s example—­in a
highly techno-­philosophical paper—­is, in effect, the problem of both a detective
story and a medical diagnosis.
9. In Doctors’ Stories (1991), Kathryn Montgomery Hunter has closely studied
the relations—­and parallels—­between the activities of detectives and physicians.
Here, we are triangulating these parallels with Peirce’s logic. The key question, as
Arthur Burks noted many years ago, is “can there be a logic of discovery? For are not
discovery and invention the work of genius, and hence the proper subject matter of
psychology rather than of logic? Can the process of arriving at an hypothesis (rather
than of justifying it) be called inference or argument? Peirce does not lack historical
precedent for such a view, of course, for induction has often been regarded, not as an
evidencing process, but as a logic of discovery” (1946: 302). The self-­conscious pur-
suit of the connection between the Case and the Rule of abduction—­especially in the
context of the connections between Rule and Result in deduction and Case and Rule
in induction—­calls for physicians (and others, such as detectives) to attend to phe-
nomena more fully. Accomplished experienced physicians follow this “method”
habitually—­the “practical reason” of phronesis is, after all, “practiced” the way one
practices a piano—­but its conscious pursuit, we believe, makes it teachable as well.

Chapter 5
1. The neurologist Antonio Damasio has persuasively argued in a series of stud-
ies and books—­most notably The Feeling of What Happens (1999)—­that ordinary
thinking (as opposed to the focused attention to logic and formulas) is the product of
the neurological combination of cognition and affect.
2. As we noted in chapter 2, Marco Iacoboni has reported that “according to a
study performed by psychologist Lisa Aziz-­Zadeh, areas in the brain known to control

notes to pages 127–60  /  411

the movements of particular body parts (i.e., the hand or the mouth) were activated
not only when subjects watched the movement on video but also when subjects read
sentences about the movement” (Iacoboni 2009: 94).

Chapter 6
1. Descartes’s belief in the materialist mechanical nature of the body is a re-
sponse, in large part, to the assumption of “vitalism” that governed much thought in
the late Middle Ages. Vitalism is derived from Aristotelian thought, which governed
much of classical medicine. It assumes that vitality is an immanent property of mate-
rial stuff, so that living matter is caused and sustained by a vital force that is distinct
from physical and chemical forces. Descartes opposed this doctrine with a “mechan-
ical” worldview, which assumes that all the phenomena in the universe can ultimately
be explained in terms of matter moving in accordance with mathematically formula-
ble laws of nature. (Descartes believed life was a divine gift, but later versions of
mechanical science believed that life itself can be explained by mechanical material-
ism.) Such a worldview assumes that scientific explanation is measured by canons of
simplicity (the simplest explanation is the best), generalizability (an explanation that
explains more than one phenomenon—­especially when it is able to predict phenom-
ena—­is the best), and accuracy (the explanation that does not contradict but, rather,
accounts for empirical phenomena is the best). As such, a mechanical worldview is
essentially reductive: it explains the whole of a phenomenon in terms of its constitu-
ent parts. (Simplicity, generalizability, and accuracy are often taken by philosophers
of science to be the criteria by which to judge scientific explanation. For an extended
discussion of this, see Schleifer 2000 and 2009a. These categories are congruent with
the features of science described by Martha Nussbaum in her study of Aristotle,
which we discussed in chapter 2.)
2. Thus neurological psychologist Merlin Donald has noted that

procedural memory involves the storage of the algorithms, or schemas, that

underlie action. Sherry and Schacter (1987) have observed that in terms of its
storage strategy, procedural memory is the opposite of episodic memory.
Whereas episodic memory preserves the specifics of events, procedural mem-
ory preserves the generalities of action, across events. . . . Thus, learning a
procedure . . . involves setting parameters and forming general rules. . . .
Episodic and procedural memory involve different neural mechanisms, as
can be shown in birds, who will lose their songs (a procedural memory system)
if lesioned in one nucleus, and their ability to hide and relocate food (an epi-
sodic memory system) if lesioned in another. The same distinction exists in
humans, as seen in amnesics. In the famous case of H. M., followed by Milner
and her associates (1966, 1975) for over twenty years, the patient developed
catastrophic anterograde amnesia following neurosurgery. He retained a ca-
pacity for acquiring new procedural memories, that is, he could still learn new
motor skills. But his capacity for new episodic memories was destroyed; he

412  /  notes to page 176

 could not record any new events in his life. . . . Both episodic and procedural
memory systems seem to be present in a variety of animals, including mam-
mals and birds. Sherry and Schacter (1987) reasoned that episodic memory
evolved separately from procedural memory for the very good reason that
their storage strategies are mutually incompatible. Whereas procedural mem-
ories generalize across situations and life events, episodic memory stores the
specific details of situations and life events. Thus, one memory system stores
the generalities and discards the specifics; the other system, the episodic,
stores the specifics but does not generalize. (Donald 1991: 150–­51; see our
bibliography for Donald’s references)

The algorithmic schemas of procedural memory are not provisional in the way of the
schemas of humanistic understanding—­or, for that matter, the classroom schema Gu-
reckis and Goldstone describe; the if-­then schemas of algorithmic read-­do checklists
remain provisional insofar as the “if” remains provisional.
3. This analysis of Williams is based on a discussion of Williams in relation to
popular music in Schleifer 2011: 63.

Chapter 7
1. In a fascinating discussion of patient-­physician interactions, Malcolm Gladwell
cites studies of hundreds of recorded conversations between a group of physicians,
half of whom had never been sued, and their patients. One study found a clear differ-
ence between the sued and unsued physicians in terms of interview behavior (e.g.,
unsued physicians spent three minutes longer with patients, tended explicitly to leave
time for questions, and engaged in active listening), though Gladwell reports “no dif-
ference in the amount or quality of information they gave their patients” (2005: 42).
A second study cited by Gladwell culled surgeon-­patient conversations from these
recordings, chose four ten-­second clips of each of the surgeons talking, and removed
the high-­frequency sounds from speech so that listeners could not understand par-
ticular words but still encountered “intonation, pitch, and rhythm.” Gladwell reports
that third-­party listeners were then asked to judge “for such qualities as warmth,
hostility, dominance, and anxiousness, and [the researcher] found that by using only
those ratings, she could predict which surgeons got sued and which ones didn’t”
(420). All that the listeners “were using for their prediction,” Gladwell notes, “was
their analysis of the surgeon’s tone of voice.” He concludes that malpractice “in the
end . . . comes down to a matter of respect, and the simplest way that respect is com-
municated is through tone of voice” (43).

Chapter 8
1. In his history of American medical education in the twentieth century, Time to
Heal, Dr. Kenneth Ludmerer offers an extended and impassioned discussion of the
importance of taking time—­for reflection, relationship, and understanding—­in med-

notes to pages 182–252  /  413

ical practice and medical education. Here is his short description of the increasing
loss of such time in medicine: “As medical technology became more sophisticated,
life on the wards became more hectic. Many new surgical procedures were much
more complex than older operations. For example, kidney transplantation, usually
listed as one operation, in fact required two operating teams, two operating rooms,
and a total of about 14 hours. Powerful new drugs, such as corticosteroids and various
cancer chemotherapies, carried an increased risk of toxic reactions and side effects.
The development of technologies like mechanical ventilators (artificial lungs), extra-­
corporeal circulatory pumps (heart-­lung machine), hemodialyzers (artificial kidneys),
and cardiac pacemakers imposed more work on the medical staff and required the
cooperation and assistance of highly trained supporting personnel. The development
of complex electronic equipment, particularly machinery for monitoring the electri-
cal impulses of the heart, led to the creation in the 1960s of intensive care units. With
sicker patients, more things to do, and a greater turnover of patients, house officers
and students were busier than ever, and time for study and reflection became scarcer”
(1999: 176–­77).
2. Her great novel Middlemarch focuses in part on a physician, Dr. Lydgate, who
through a series of small compromises gives up his youthful dreams of medical re-
search. In The Call of Stories, Robert Coles discusses Middlemarch, and how his
student, Gerard, describes the narrator, George Eliot, as a “helper” in a narrative in
which he is the “hero.”

Novels and stories are renderings of life; they can not only keep us company,
but admonish us, point us in new directions, or give us the courage to stay a
given course. They can offer us kinsmen, kinswomen, comrades, advisers—­
offer us other eyes through which we might see, other ears with which we
might make soundings. Every medical student, law student, or business school
student, every man or woman studying at a graduate school of education or
learning to be an architect, will all too quickly be beyond schooling, will be out
there making a living and, too, just plain living—­that is, trying to find and offer
to others the affection and love that give purpose to our time spent here. No
wonder, then, a Dr. Lydgate or a Dick Diver can be cautionary figures to us,
especially to us doctors, can be spiritual companions, can be persons, however
‘imaginary’ in nature, who give us pause and help us in the private moments
when we try to find our bearings. . . .
A former student, Gerard, described that kind of self-­searching to me five
years after graduation from medical school, his residency training in surgery
by then completed: “I’m not ashamed to say that I can talk to that Dr. Lydgate.
He’s someone I know. I’ve forgotten the ‘imagery’ in Middlemarch, and I don’t
know anymore the English history [Eliot] worked into the novel, and some of
the minor characters have disappeared from my head. It’s not social respect I
want; it’s the end of this long, long apprenticeship. I’m finally through, but I
don’t know quite what to do. Dr. Lydgate warns me I might become a society
doc, and with my debts, why not? But I can’t quite go down that road, as
tempting as it is. . . .

414  /  note to page 265

 “There are days when I think of George Eliot and her Lydgate, and I come
to the conclusion that lots of us doctors fool ourselves very easily, and that’s
what Middlemarch has to say to me now. . . . But maybe there’s hope. . . . Well,
maybe my friend Lydgate will help me turn to corner—­go after what I think is
right for me to do. . . . I’d hate to end up a driven, driven ‘success,’ who is
bored by what he does, but is always postponing any moral confrontation with
himself!” (1989: 159–­62)

3. Many of the following literary examples follow those of Schleifer, Davis, and
Mergler 1992: chap. 2 and, earlier, Schleifer and Velie 1987.
4. It might seem that the detective, like a physician, is a helper aiding the hero-­
victim, but in many of the Holmes stories, the victim is not of central concern, and
Holmes’s “help” to the police is usually negligible. If fact, precisely the “heroic” na-
ture of stories like those of Holmes and Dupin—­as well as melodrama epic—­suggests
that physicians, “detecting” the villainous ailments of patients, are the heroes of med-
icine.
5. The fact that the physician can also assume the role of opponent in the tragic
conception of the narrative of medicine is nicely suggested in Eric Cassell’s book The
Nature of Suffering and the Goals of Medicine. There, Cassell describes patient suf-
fering and the (avoidable) ways physicians can contribute to it. Without explicitly
discussing narrative or narrative genres, he also suggests that the comic conception of
the narrative of medicine we describe here is accomplished when physicians assume
the role of helper.

Chapter 9
1. While a number of these virtues—­particularly compassion and conscientious-
ness—­do not appear in the Nicomachean Ethics, they are nevertheless part of the
Aristotelian tradition of focusing discussions of ethical issues on the agents of ethical
action rather than on abstract, analytic principles. Aristotle remains a reasonable
starting point for our discussion of virtue ethics, for his discussion in the Nicoma-
chean Ethics is certainly an important text for ethics in our society, including the
ethics of medicine. We are concentrating on the virtue ethics of everyday medical
practices that by definition include the virtues of common decency by which we at-
tempt to live our lives as well as compassion, both of which are not mentioned in the
Nicomachean Ethics. Other virtues could be added to our list as well. Rather than
being exhaustive in our list of ethical behaviors, habits, and characteristics that a phy-
sician should possess, we have chosen a few that are central to ethical practices of
everyday medicine. In any case, the study of literary narratives—­in drama and poetry
as well as fiction—­helps clarify the nature and function of these virtues.
2. The virtue of the checklist procedures we describe in appendix 2—­following
Gawande’s more extensive description in The Checklist Manifesto (2010)—­is the
manner in which they create provisional procedures “before the fact” of a practical
activity that are developed by means of “after the fact,” retrospective understanding
of possible failures of one sort or another.

notes to pages 270–94  /  415

 3. The actions embodying discernment include recording and remembering the
patient’s name, noting the emotion the patient brings to the patient-­physician en-
counter, the patient’s chief complaint, and the patient’s chief concern. The actions
embodying conscientiousness include recording the chief complaint and the chief
concern. The actions embodying trustworthiness include acknowledging to the pa-
tient his chief complaint and his chief concern. The actions embodying compassion
include acknowledging to the patient her emotion and her life situation (as it is pre-
sented, explicitly or implicitly, in the History of Present Illness, in the chief com-
plaint, and in the chief concern).
4. For a powerful examination of such denial, see Becker 1973.
5. In 1847, the American Medical Association’s first code of medical ethics
stated, “The life of a sick person can be shortened not only by the acts, but also by the
words or the manner of a physician. It is, therefore, a sacred duty to guard himself
carefully in this respect, and to avoid all things which have a tendency to discourage
the patient and to depress his spirits” (chap. 1, sec. 3). This is as true today as it was
in 1847—­the manner in which a physician presents the information to his patient,
particularly if the information is negative, can set the stage for any future therapeutic
encounters. What is perhaps different today than in 1847 is that many patients, at
least in the United States, want to know the status of their health so that they may
actively participate in the health care decision-­making process.

Chapter 10
1. “Satire” is a literary form that emphasizes and often mocks the failings of par-
ticular behaviors. It presents, so to speak, a subschema of narrative that inflects nar-
rative meaning. In Kinds of Literature (1982), Alasdair Fowler offers a wonderfully
nuanced analysis of literary genres, describing generic “form” (e.g., comedy) and ge-
neric “kinds” (e.g., comic). Such an analysis, however, while useful to literary scholars,
might not be particularly useful to practicing physicians. If they note the expression
of satire in a patient’s story—­usually conveyed through sarcasm and disdain—­it is
enough to apprehend anger as a primary emotion and acknowledge its presence in
the patient’s attitude and story. In Fowler’s terms, Ivan Ilych presents satirical realism
rather than an out-­and-­out satire. We are suggesting that it presents tragic realism as
well.
2. In an ethical analysis of The Death of Ivan Ilych, F. M. Kamm notes, “For ex-
ample, [Ivan] was an incorruptible judge. This should count for something positive,
at least if the laws he applied had any justice in them” (2003: 202).

Appendix 1
1. In the early twentieth century, linguistics was particularly well situated to re-
evaluate the significance and goals of the humanities, since it was undertaking the
task of transforming the almost purely descriptive study of language into a discipline
that attempted formulate its systematic study.

416  /  notes to pages 295–368

 2. Some areas in the study of both literature and art do not move us to action but
simply increase the beauty in our lives. Nevertheless, such studied “appreciation,”
even when it seems simply mere description, traffics in schemas of experience of one
sort or another. Even when we “appreciate,” say, Cole Porter’s use of major seventh
chords in “Night and Day” or W. B. Yeats’s strategic uses of polysyllabic words in his
lyrics, we are implicitly developing a schema for experience whose engagement with
“experience,” now understood as an active engagement, can be understood as an ac-
tion. Austin’s speech act theory and Kenneth Burke’s notion of literature as “equip-
ment for living” (1994) focus on the ways that humanistic understanding encom-
passes implications of action, but schema theory more generally assumes that it is
misleading to understand experience in any of its forms—­including the contemplative
or aesthetic experience of art—­as simply passive.
3. For a thoroughgoing account of the “phenomenology of experience,” see
Schleifer 2009a, where Peirce’s three categories are studied in relation to the “iconic”
physiology of Tourette’s syndrome, the “indexical” evolution of the human hand, and
the “symbolic” nature of human pain. Moreover, that book offers an extended discus-
sion of the “phenomenology of meaning” (4), particularly in its discussion of David
Chalmers’s philosophical study The Conscious Mind. “For Chalmers,” Schleifer
writes, “consciousness—­including, by implication, the experience of meaning—­is im-
mediate and unanalyzable,” possessing “a certain feel” that can be understood “in
terms of meaning” (3). But if “experience”—­particularly experience as it is depicted
by a philosopher who describes its immediate, unanalyzable givenness—­is under-
stood in terms of “meaningfulness,” it can and should lend itself to further analysis
than that of its seeming immediacy. Two forms of such further analysis are the sche-
mas of cognitive psychology we present in this book and the schema-­based analyses—­
the discipline—­of the humanities more generally. (Even Chalmers’s analysis is orga-
nized around schemas of analytic philosophy.) It is a small but significant step from
Hjelmslev’s formulation of the “mere description” of the humanities to the discipline
of case-­based reasoning and schema-­based analysis.
4. In fact, even the atomic events by which the positivists understood truth are
themselves situated in the “milieu” of deliberation and negotiation, the construals
and speculations embodied in the schemas and paradigms the humanities articulate.
This can be seen and felt in the very contentiousness of their arguments (e.g., the
rhetoric of “messiness”).
5. Another philosopher, Charles Taylor, focusing on language like Hjelmslev and
Benveniste (but not a linguist as such), also touches on the provisional nature of hu-
manistic understanding, in his focus on language’s future working. “Language,” he
writes, “may be viewed as a structure of rules, or of possible formations and transfor-
mations. But . . . [particular speech acts] are not in a simple relation of subsumption
with the rule to which they are submitted. They may be in conformity with it, or they
may deviate. . . . Languages live only through successive renewals, each of which is a
risk, for it runs the risk of not coming through this renewal unharmed” (Taylor, Carr,
and Ricoeur 1991: 176). The schemas of cognitive psychology may be revised or even
renewed, but the deliberations, often communal (as in Kuhn’s scientific paradigms),

notes to pages 369–71  /  417

that condition such revisions are not a constituent part of how those schemas func-
tion. As we have seen, such deliberation is a constituent part of narrative and practical
reasoning (phronesis).
6. As part of his speech act theory, Austin coined the term performative language
for referring to the work or action particular uses of language accomplish in the
world. Any utterance conveys meaning, but it also enacts human relationships, and
when confronting speech or engaging in dialogue, one can provisionally choose one
or the other of these aspects of language as the framework for understanding. The
humanities as a discipline pursue disciplined performance in the sense of Austin’s
idea of the performative aspect of language. Note that Roman Jakobson’s schema
analyzing speech communication (which we presented in chapter 7), although grow-
ing out of an intellectual tradition (namely, structural linguistics) very different from
Austin’s engagement with analytic philosophy, nevertheless also engages the pragmat-
ics of discursive events as action in the world.

Appendix 3
1. Adapted from the original Oath of Hippocrates and the Declaration of Geneva
by M. Dewayne Andrews, M.D., and adopted by the University of Oklahoma College
of Medicine Faculty Board, 1997.

418  /  notes to pages 372–88

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Index

Note: In this index, we have included definitions of technical terms right af-
ter the headings so that the index will function as a glossary as well as an in-
dex.

abduction, 66, 122, 124 goals of medical care by, 100, 322
definition of, 1, 20, 92, 114 on patients’ rights, 27, 300, 302
connection of with narrative knowledge, anagnorisis
53, 59, 118, 123 definition of, 250
connections of effects and cause in, 119–­ as ethical element, 303
20 as narrative recognition, 5, 259, 261
difference of from induction and deduc- See also narrative; salient features of nar-
tion, 115–­16 rative
and executed by listening to patients, 364 analogical reasoning
logic of, 27 definition of, 347
narrative elements of, 115 Anatomy of Hope, by Jerome Groopman,
Peirce’s theory of logic of, 111, 132 242
relationship of to practical reason, 116 An Anthropologist on Mars, by Oliver Sacks,
role of in hypothesis formation, 117–­18, 140
124, 251, 363 Apgar, Dr. Virginia, 99
use of in detective fiction, 119, 127, 129–­ Apgar score
30 benefit of, 100
use of in making diagnosis, 40, 89 as form of evidence-­based medicine, 14,
use of technē in, 113 98–­99
workings of, 121 as means-­end explanation, 101
See also Peirce, Charles Sanders; specula- Aristotle, 50, 52, 55, 120, 233, 272, 276, 298,
tion 302, 347, 397n9
Abse, Dannie, 277 on achieving eudaimonia (well being), 4,
After Virtue, by Aladair MacIntyre, 58 62–­63, 93, 102, 286, 302, 317
age analysis of tragedy by, 218, 260–­61, 271,
as narrative filter, 208–­10 303–­4, 329, 342
Agee, James, 254 on completion of practical reason through
See also Death in the Family action, 15, 59, 65–­66, 91, 101, 116–­
Allison, Dorothy, 11, 13 17, 120, 162, 359
See also Bastard Out of Carolina concept of karthasis of, 5–­6, 13, 90,
American Medical Association, 387 395n10

/  429  /
Aristotle (continued)
concept of phronesis by, 8, 27, 29, 47, 73,
82, 84, 98, 288, 314, 322, 358
concept of practical reason by, 1, 56–­58,
63–­64, 69–­70, 77, 93
concept of practical syllogism by, 111
concept of virtues in action by, 28
definition of virtues by, 295
on elements of narrative, 267, 277
on emotions of pity and terror in tragedy,
148, 344
and ends and goals of practical reason,
75
ethics of phronesis defined by, 295, 367
on focused action as ethical category, 257,
397n11
on grasp of practical reason through expe-
rience, 67, 81
and habitual behavior as expression of be-
liefs, 31
list of virtues of moral agent by, 290, 294,
315, 349, 363
medical connections to writings of, 17, 41,
277
on pity for human sufferer, 343, 353
on reality of death, 339
on recognition of the meaningful whole,
250
study of narrative and medicine by, 7, 41,
45, 259, 277
on technē, 71, 364, 393n5
and use of logic of discovery, 27, 37
and use of perception by in practical rea-
son, 67–­68
on virtue of ethics, 100, 290, 346
See also Metaphysics; Nicomachean Eth-
ics; Poetics
“Art as Technique,” by Viktor Shklovsky, 350
artificial intelligence, 370
“The Artificial Nigger,” by Flannery
O’Connor, 154
achievement of empathy in, 161
example of literal paternalism in, 146–­47
as heroic narrative, 270–­71
shifting of character position in, 148
use of communication elements in, 218
Aspects of the Novel, by E. M. Forster, 262
“Atrium: October 2001,” by Richard Selzer,
155–­56
Austin, J. L., 371
See also “A Plea for Excuses”; “Three
Ways of Spilling Ink”
430  /  index
Autobiography, by William Carlos Williams,
224, 282
Awakenings, by Oliver Sacks, 140, 279
Ayurveda (traditional Hindu medical text),
259
Baker, David, 163
Bastard Out of Carolina, by Dorothy Alli-
son, 11, 13
Bell, Joseph, 172, 186
Beloved, by Toni Morrison, 154–­55, 157,
161, 238, 362
use of to teach empathy, 166
Benjamin, Walter, 107, 109
definition of a story by, 77
on essence of story, 61, 331
on source of narrative power, 114
on structure of storytelling, 141, 335
Bentham, Jeremy, 65
Benveniste, Emile, 370, 372
Bernstein, Richard, 63–­65
biomedical knowledge, 50, 358
as domain of competence, 307
fallibilism of, 36–­37
medical profession preference for, 47
vocabulary of, described, 39–­40
See also evolutionary science; nomological
science
Blythe, Ronald, 209–­10
See also The View in Winter
Boyd, Brian, 80–81
on cognition narrative, 61–­62
description of memory by, 79–­80
description of narrative by, 100
on evolutionary adaptiveness of narrative,
78
on one-­sided monism, 98
on role of narrative in patient-­physician
relationship, 138
on telling events of narrative, 149, 219,
291
See also The Origins of Stories
Boyd, Kenneth
on modes of unhealth, 4–­6, 11–­13, 140,
179
British Medical Journal, 22
Brody, Dr. Howard, 289, 342
Brooks, Peter, 261
The Brothers Karamazov, by Fyodor Dosto-
evsky, 254
Broyard, Anatole, 335
description of illness by, 145
 examination of power differential in
patient-­physician relationship by,
139–­40
on importance of narrative in medicine, 7
on need of rapport in patient-­physician
relationship, 151
See also Intoxicated by My Illness
“Brute,” by Richard Selzer, 315
confrontation of death and dying in, 316
example of abuse of power in patient-­
physician relationship in, 144–­45
as example of emotional response, 223,
224
as example of failure of will, 311
shifting of character position by, 148
use of violence in, 337
Bulgakov, Mikhail, 277
Burke, Kenneth, 371
Burks, Arthur, 116
Byock, Dr. Ira, 317, 326
The Call of Stories, by Robert Coles, 247,
252
Cambridge Encyclopedia of the Language
Sciences, 16
Campo, Dr. Rafael, 141, 231
as physician/writer, 277
poem of as example of shared experience
of illness, 194–­95
poem of on empathy, 164–­65
realistic details in narrative of, 339, 349
on relationship between poetry and medi-
cine, 163, 243–­44, 282
story of on physician-­assisted suicides,
319–­21
See also “The Couple”; The Desire to
Heal; “Doctor Kevorkian”; “Manuel”;
“What I Would Give”
Camus, Albert
ambiguity in narrative form of works of,
315
on code of morals, 290, 293
on decency as virtue, 314–15
dramatic narrative of about medical prac-
tice, 274
quote from work of, 284
use of work of to teach empathy, 166–­67
See also The Plague
“The Cardboard Box,” by Arthur Conan
Doyle, 129
Carnap, Rudolph, 43
case-­based history
index  /  431
as narrative to discern meaningful whole,
279
use of in study of humanities, 372
case-­based reasoning, 393n6
definition of, 17–­18
role of narrative in, 150, 152
as seen in The Death of Ivan Ilych, 335,
354, 364
use of narrative knowledge in, 32, 237
use of vicarious experience in, 201
Cassell, Eric
on personhood, 86–­87, 242, 244
See also The Nature of Suffering and the
Goals of Medicine; personhood char-
acteristics
Charon, Dr. Rita, 141, 194
on chief concern in narrative, 93, 172
as creator of parallel charts, 277–­79
definition of empathy by, 160
definition of narrative knowledge by, 77,
95–­96, 170
definition of narrative medicine by, 38,
77, 83
on ethics of acting, 285
on focused action in narrative, 219, 255
on honoring life in story, 348
on importance of narrative medicine, 77,
83, 248–­49, 358
on motive of stories, 269, 359
on narrative communication, 12, 103
on physician’s duty to act, 311
on role of narrative in medicine, 17, 35,
39–­40, 125, 163, 170, 232–­33, 251,
367, 391n2
on role of salient features, 91
on Russian formalists, 350
on understanding meaningful whole, 180,
250
on use of salient features of narrative, 91,
101
See also Narrative Medicine
The Checklist Manifesto, by Atul Gawande,
26, 372
checklist models in, 24, 374
on purpose of checklists, 303
checklists, 28, 97, 191
and American Medical Association’s rights
of patients, 27
analysis of, 371–­72
as based on schemas, 21–­22, 31
and The Death of Ivan Ilych, 329
development of, 26
checklists (continued)
examples of, 375–­80
importance of, 19, 23–­24, 32, 303
Kleinman’s questions similar to, 202–­3
as method of pause and reflection, 184
use of in History of Present Illness, 186,
374
for virtue ethics, 364
Cheever, John, 276
See also “The Housebreaker of Shady
Hill”
Chekhov, Dr. Anton, 106, 109, 155, 259
and aesthetics of art narrative, 91, 299
chief concern in story of, 269
fiction writing of, 141, 282
narrative events of, 210
as physician/writer, 277
on schema of narrative roles, 276
story of as example of gender narrative fil-
ters, 205–­7
story of as example of marital trouble, 237
use of irony in works of, 273
vicarious experience acquired from story
of, 235
See also “The Lady with the Pet Dog”
chief complaint
and diagnosis, 9, 25, 45, 48, 261
difference of from chief concern, 12, 359
examples of, 22–­23
inclusion of in History of Present Illness,
38, 85, 112, 186
role of in patient-­physician relationship,
141
use of Kleinman’s question in discerning,
203
use of schema-­based medicine to diag-
nose, 25
chief concern, 111
in achieving “a good death,” 317
causes related to
employment, 238
marital troubles, 236–­37
personal finances, 238
as contained in narrative, 93, 172, 217
discerning of in patient’s narrative, 21, 25,
38, 45, 109, 169, 210, 215, 219, 239,
251, 358, 377, 378, 379
as end of narrative, 261–­62
examples of, 5, 22–­23, 87–­89
failure to attend to, 308
and goals of patient’s medical care, 3, 21,
86, 321–­22
432  /  index
importance of in making diagnosis, 12,
359–­61
importance of in patient-­physician rela-
tionship, 27, 141
inclusion of in History and Physical Exam,
2, 4, 39, 85, 90, 162, 163, 375
inclusion of in History of Present Illness,
112, 222
as meaningful whole in narrative, 174
as portrayed in The Death of Ivan Ilych,
334, 336, 338, 341–­42, 349, 362,
364–­65
use of character roles in discerning, 130,
266
use of ethical virtues to determine, 29
use of Kleinman’s questions in discerning,
203
use of narrative details to discern, 214,
242
use of narrative knowledge to determine,
9, 32, 36, 48, 105, 181
Clinical Evidence Concise, 22–­24, 26, 27
Cochran, Archie, 36
cognition narrative. See narrative cognition
cognitive psychology
use of schemas in, 370–­71, 391n3
cognitive science
and explanation of storytelling, 78
studies of memory in, 79–­81
use of schemas in, 74
Coles, Robert, 276, 281
as physician/writer, 277
quote of, 247
on stories that create reflection, 252
on use of art narratives to teach other
fields, 244
See also The Call of Stories
comedy, 108, 269, 274
definition of, 103, 270–­72
Aristotle’s study of, 259
See also narrative genres
communication, act of
contact as element of, 219–­20
six elements in, 214–­18
competence
two domains of, 307–­8
Conrad, Joseph, 298–­99
See also Heart of Darkness
“A Conversation with My Father,” by Grace
Paley, 277
analysis of as art narrative, 106–­10
Coulehan, Jack, 277
“The Couple,” by Rafael Campo, 244, 321
as example of shared experience of illness,
194–­95
on reality of death, 339
Crime and Punishment, by Fyodor Dosto-
evsky, 254
cultural differences
as narrative filters, 200–­202
Dante, 139
death and dying
application of virtue ethics in, 315–­17,
325–­26
denial of in medicine, 339–­40
ethical drama portrayal of, 322–­24, 334,
339
need for discussion of, 320–­21
Death in the Family, by James Agee, 254
The Death of Ivan Ilych, by Leo Tolstoy, 28,
330, 333
on alternatives of dying, 321–­22
chief concern of character of, 334, 361
listening as portrayed in, 340–­42
as modern classical tragedy, 329
as nexus of literature and medicine, 364,
365
as patient’s story, 349–­55
portrayal of ethics in, 345–­49
provoking of vicarious experience in, 353–­
55
on reality of death, 339
as study of patient-­physician relationship,
335–­40
summary and re-­storying of, 331–­35
use of narrative of to teach empathy, 161,
166
use of pity in, 344
use of realistic details in, 350–­53
decency, 322
as a virtue ethic, 314
deduction
difference of from induction and deduc-
tion, 115–­18
logical understanding of, 119
logic of abduction as complement to, 27
as method of systematic understanding,
20
as used by Sherlock Holmes, 129
use of in science, 363
deontological ethics, 65–­66
Descartes, René, 16, 43, 51
concept of science by, 35
index  /  433
use of scientific knowledge by, 175–­76
See also “Description of the Human
Body”; “Formation of the Foetus”;
“The Passions of the Soul”; “Treatise
of Man”
“Description of the Human Body,” by René
Descartes, 176
The Desire to Heal, by Rafael Campo, 282
detective fiction, 170
attention to detail in, 349
as example of diagnostic listening, 212–­
14, 228
examples of meaningful whole of narra-
tive in, 119, 172, 173
as related to abduction, 113, 123–­25, 127,
128–­31
roles of characters in, 264, 269
use of hypothesis formation in, 114, 184–­
85, 251
use of narrative skills and logico-­scientific
methods in, 175
Dewey, John, 50
on fallacy of Greek discourse on struc-
ture, 47
philosophy of language of, 46
pragmatism of concepts of, 22, 47
on use of nonreductive empirical method
in medical clinic, 45
view of moral and scientific concepts by,
54
diagnosis, 214
attention to detail in, 349
and comprehension of “end” of story, 121,
131, 180
and development of a hypothesis, 192
elements of, described, 113–­14, 121–­24
History of Present Illness as most impor-
tant tool of, 362
role of empathy in, 161, 163
role of listening in, 364
role of narrative knowledge in, 127, 133,
214, 307, 359
role of patient’s narratives in, 126, 169,
220, 211, 262, 374
diagnostic listening, 244
as abduction, 364
attending to the parts of, 214
causes of failure of, 221–­24
denial in recognizing, 228–­29
emotional response, 223–­24
failure of will, 224–­25
failure to teach properly, 225–­26
diagnostic listening (continued)
lack of time, 226–­27
medical specialties, 220–­23
decline in skills of, 225–­26
by Sherlock Holmes, 212–­13
results of failure of, 220–­22
See also listening
discipline
need for in medicine to follow prudent
procedure, 25
use of, 372–­73
Divine Comedy, by Dante, 139
“Doctor Kevorkian,” by Rafael Campo, 319–­
20
Doctor’s Stories, by Kathryn Montgomery
Hunter, 232
The Doctor Stories, by William Carlos Wil-
liams, 281
Dostoevsky, Fyodor, 254
Doyle, Arthur Conan, 113, 122, 341
classic detective story of, 127–­28
misapprehension of evidence in story by,
191
narrative of case histories by, 280
use of abduction in stories of, 129
use of diagnostic listening in stories of,
213, 223
use of hypothesis formation in stories of,
185
use of knowledge by characters of, 123,
172
See also “The Cardboard Box”; “The Resi-
dent Patient”
Doyle, Roddy
ethical medical behavior acquired from
story of, 296–­97
example of paternalism in novel of, 142–­
43, 145
moral element in stories of, 300, 301
narrative of on cultural differences, 204
story as example of experience of marital
trouble, 237
story as example of physician’s failure to
listen, 227
vicarious experience created in story of,
299
See also The Woman Who Walked into
Doors
drama of medical practice
mechanisms of, 262–­63
in relation to ethics, 308
role of good judgment in, 309
434  /  index
virtue ethics in, 292, 326
Dunbar, Robin
on theory of mind, 60–­62
on use of language to forge relationships,
149
Dupin, Auguste (character)
description of, 127–­28
diagnostic listening by, 214, 215
as example of meaningful whole of narra-
tive, 173–­74
identification of narrative actors by, 264
as melodramatic hero, 275, 303
on misapprehension of evidence, 191
reasoning skills of, 113
and recognizing missing narrative ele-
ments, 250
Sherlock Holmes based on, 172
use of abductive reasoning by, 119, 129–­
33
use of depth of knowledge by, 123
use of hypothesis formation by, 125, 184–­
86, 193
use of provisional understandings by, 275
Eco, Umberto
on the meaningful whole of narrative, 120
on understanding of narrative, 92–­93, 123
on workings of abduction, 121
Eddy, David
on systematic review of research, 108
and use of evidence-­based guidelines, 97–­
98
Edelman, Gerald
on neurological categories to understand
experience, 75–­76
Edson, Margaret, 104
example of negotiating care in play of,
322–­24
See also Wit
Eliot, George, 265
empathy
definition of, 157, 159, 161, 344
in The Death of Ivan Ilych, 339–­40
as defined by Dr. Charon, 160
as a domain of competence, 307
example of need for, 294
importance of in medical practice, 41,
163–­65, 308–9, 359
as important part of phronesis, 162
pity as form of, 347
and recognition of meaningful whole, 250
recognition of role switching in, 267
 role of in patient-­physician relationship,
161
role of narrative in, 53, 143, 146, 157–­59,
161, 231, 253, 362
understanding of in humans, 159–­60
use of art narrative to achieve, 179, 232,
234–­35, 254
use of schemas in narrative to achieve, 99,
162, 166, 249
empirical evidence, 124
bias for, 395n1
and means-­end explanation, 101
in relation to schemas of patient-­physician
relationship, 22
use of in evolutionary science, 20
use of in medical practice
as related to patient’s experiences, 44,
45
use of in schema of narrative, 21
empirical understanding
as used in induction, 119
Enormous Changes at the Last Minute, by
Grace Paley, 110
epic. See heroic narrative; narrative genres
“Epiphany,” by Ferrol Sams, 315
as example of narrative competence, 239
as example of rapport, 151–­52
as story of failure of judgment, 309
use of empathy in narrative of, 159
episodic memory
definition of, 176
and characteristics of personhood, 86
epistēmē
definition of, 71
practical reason as systematic skill of, 84
and practical wisdom, 67
as systematic understanding, 63
use of evidence-­based guidelines in, 97
use of in scientific reason, 65
See also scientific reason
ethical behavior
description of, 296
disruption of by failure of will, 311
importance of in medical practice, 359
narrative as examples of, 326, 347, 363
and physician-­assisted suicides, 318–­21
schemas to follow, 386–­89
as seen in Leo Tolstoy’s The Death of Ivan
Ilych, 334
successes of, 313
ethical practice
of health care, 326
index  /  435
as seen in The Death of Ivan Ilych, 331
and setting overall goals of care, 322–­25
ethics, 55, 66
definition of, 284–­85, 295
of action, 4, 13
as casuistical-­based, 294
of everyday
in death and dying, 315–­17
and individual values, 301–­2
in medicine, 29, 315
framework of, 284–­85
as narrative-­based
creation of vicarious experience in, 258,
296, 348
role of in medical practice, 292
narrative portrayal of failure of, 323–­26
normative principles of, 285–­86
as portrayed in The Death of Ivan Ilych,
345–­49, 364
as principle-­based
definition of, 286–­88
addressing of patient suffering in, 325
difference of from virtue ethics, 289,
294
limitations of, 304–­5
as relational
difference of from virtue ethics, 289
use of casuistical reasoning in, 288
as shown in Philoctetes, 302
as technē, 73
use of in The Death of Ivan Ilych, 348
as virtue
definition of, 288–­89
competence in performing, 307
example of need for, 293–­94
list of, 290–­91
schema of, 295
use of in medical practice, 292
use of narrative to develop, 289
See also narrative-­based ethics
eudaimonia
definition of, 4, 21, 41, 62–­63
achieving of, 302
integrity as moral agent for, 291
as issue of medical practice, 284
in patient-­physician relationship, 89
as related to ethics, 13, 286
as seen in narrative, 110
translations of, 298
euthanasia
definition of, 318
Evans, Marianne. See Eliot, George
“Everything Is Going to Be All Right,” by
Derek Mahon, 272–­73
evidence-­based guidelines
features of, 97–­98
formulas as means and ends of, 66
to maintain biomedical competence, 307
use of as checklists, 24
as way to algorithms of behavior, 99
evidence-­based medicine
definition of, 14
examples of, 99
importance of, 21–­22, 56
pursuit of as quantifiable, 35–­36
schema-­based medicine homologous to,
100
use of evidence-­based guidelines in, 97
use of formulas in, 101
vocabulary of nomological knowledge of,
40
and why dominates medical practice, 47,
90
evidence-­based science
use of in medicine, 37
evolutionary science, 35, 100, 396n5
costs and benefits of, 66
importance of scientific narrative in, 49
means-­end explanation of, 101
schemas of, 392n3
use of determinate ends in, 65
use of historical knowledge of in medi-
cine, 40
use of induction in, 117
use of in medicine, 37
vocabulary of, 39
See also biomedical knowledge
experience
definition of, 369
as gained from narrative, 91, 93–­94, 101,
109–­10, 133, 217, 253, 279
global apprehension of, 392n4
as learned from poetry, 182
as organized in schemas of language, 236
as part of technē, 90
of patients, 358
phenomenology of, 369
as provider of ethical successes, 313
purport or meaning of symbols of, 74–­75
as seen in The Death of Ivan Ilych, 338
teaching of in diagnostic skills, 124, 127
as a technē, 73
understanding of in neurological terms,
75
436  /  index
experience, vicarious, 18
dismissal of in evidence-­based medicine,
77
ethics acquired from, 296, 348
and examples of physician’s failure to lis-
ten, 224
as part of gaining empathy, 161, 166
as provided by art narrative, 49, 226, 234–­
35, 297, 300, 362
as provided by narrative, 13, 18, 41, 53,
99, 150–­52
as provoked in The Death of Ivan Ilych,
334, 353–­55
use of in medical practices, 99
use of schemas to gain, 299
Fadiman, Anne
example of transcultural medicine in
works of, 201–­2
on Kleinman’s questions, 203
See also The Spirit Catches You and You
Fall Down
fallibilism, 51
Fanthrope, Ursula, 277
film narrative, 219
Fitzgerald, F. Scott, 271, 310
See also Tender Is the Night
“Formation of the Foetus,” by René Des-
cartes, 176
Forster, E. M., 262, 339, 360
See also Aspects of the Novel; Howards
End
Foucault, Michel, 279
The Fragility of Goodness, by Martha Nuss-
baum, 93
definition of technē in, 71, 98
discussion of katharsis in, 6
Frankfurt, Harry, 114
Freud, Sigmund, 7, 280, 310
functional realism
definition of, 37
assertions of, 122
of competence of physician, 294
as derived from humanities, 26
of narrative as empathy, 163
narrative fulfillment of, 362
use of nomological knowledge and narra-
tive knowledge in, 40
Galileo Galilei, 35
“Gaudeamus Igitur,” by John Stone, 272
Gawande, Atul
 on acquisition of medical skills, 7, 307
checklist models of, 22, 26, 97, 186, 371–­
72, 374
on checklist of Apgar score, 99
on default virtues of medical practice,
291, 295
evidence-­based medicine described by, 14
on importance of checklists, 19, 23–­25,
42, 184, 303
melodramatic villains in work of, 275
memoirs of, 280
on nature of medicine, 395n12
on physician’s failures, 224
on professional code of conduct, 311, 372
See also The Checklist Manifesto; “When
Good Doctors Go Bad”
gender
as narrative filters, 205, 207
Gilman, Charlotte Perkins, 234
roles of characters in narrative of, 267
work of as example of marital trouble, 237
See also “The Yellow Wallpaper”
goal-­oriented care
narrative on failure of, 323–­26
Goldstone, Robert
on definition of paradigm, 394n10
definition of schema by, 16, 18, 20
on nonprovisional schemas of cognitive
psychology, 371
on provisional nature of schemas, 17
on salient features in schema, 182
Golovin, Ivan Ilych (character)
See Ilych, Ivan (character)
Goodside, I., 110
Graff, Gerald, 368
Greenhalgh, Trisha
on discord between sciences and art nar-
rative, 42–­43
Greimas, A. J.
on “actants” of narrative, 69, 91, 101–­3,
196, 215
on gaining meaningful whole in narrative,
172
on the meaningful whole of narrative,
118, 172–­73, 392n4
on nature of narrative, 45, 90
on receiver and sender in narrative, 138,
148
on roles of narrative actors, 263
schematic account of genre by, 108–­9
Groopman, Dr. Jerome
on failure of physicians to understand pa-
index  /  437
tient’s narrative, 242–­43
memoirs of, 280
on soul of patients, 244
See also Anatomy of Hope
Gureckis, Todd
on definition of paradigm, 394n10
definition of schema by, 16, 18, 20
on nonprovisional schemas of cognitive
psychology, 371
on provisional nature of schemas, 17
on salient features in schema, 182
Hamlet, by William Shakespeare
narrative of compared to other works,
275
role of characters in, 269
view of as tragedy, 119, 172, 271
Hardy, Thomas
poem of as example of age narrative fil-
ters, 208–­9
See also “I Look into My Glass”
Hawkins, Anne Hunsaker, 289, 295
Healing the Wounds, by Dr. David Hilfiker
as systematic look at medical mistakes,
304
health
definitions of, 4–­5, 13, 55, 181, 262,
272, 317, 371
abstract concepts of, 90
as defined by Dr. John Stone, 274
as goal of practice of medicine, 58, 84
as learned from poem, 178–­79
maintenance of, 284
meaning of katharsis in, 6
use of in medicine and narrative, 259
Heart of Darkness, by Joseph Conrad
contrast of with “popular” narrative, 298–­
99
“He Makes a House Call,” by Dr. John
Stone (poem)
definition of illness in, 6
description of patient-­physician relation-
ship in, 145, 195
on improvisation of health, 63
narrative knowledge analyzed in, 176–­79
religious imagery in, 231
roles of characters in narrative of, 148,
266–­67
use of communication elements in, 218
Hemingway, Ernest, 254, 277
Henry V, by William Shakespeare (play)
as heroic narrative, 270
heroic narrative
definition of, 103
on death and dying, 316
description of character roles in, 270–­71
as genre of dramatic narrative in medical
practice, 274
See also narrative genres
Hilfiker, Dr. David
on carelessness in medical mistakes, 308
on failure of judgment in medical mis-
takes, 308–­10, 324
on failure of will in medical mistakes,
311
on lack of competence in medical mis-
takes, 307
memoirs of mistakes by, 280
narrative form of story of, 315
as physician/writer, 277
systematic look at medical mistakes by,
304–­6, 386–87
on virtue ethics, 363
See also Healing the Wounds
Hippocrates, 286–­87, 388–89
History and Physical Exam
examples of components of, 191
inclusion of chief concern in, 2, 4, 26, 39,
85, 163, 202, 210
use of with History of Present Illness,
186, 262, 375
review of systems use in, 15
History of Present Illness
action of described, 86
The Death of Ivan Ilych as example of,
349
examples of, 187–­88
gender differences in narrative of, 205
impact of narrative filters on, 196–­97,
199, 200
importance as diagnostic tool, 8, 38–­39,
112–­13, 121, 127, 213, 220, 222
importance of social background in, 194
as a narrative event, 38, 185–­86, 375
need for changes in, 85
patient narrative in, 137, 210, 216, 234,
242–­43, 238–­39, 248, 262, 306, 358,
362
procedural guide for, 26
use of analysis and medical knowledge in,
114, 133, 359
use of logic of abduction with, 118
use of modal orders in, 124
use of schemas in, 99, 162, 275, 374
438  /  index
HIV-­AIDS patients
avoidance of by health care workers, 230–­
32, 240–­41
judgmental views of, 241–­42
physician memoirs about, 280
Hjelmslev, Louis, 369, 372
conception of humanities articulated by,
367–­68
on purport of symbols of experience, 75
See also Prolegomena to the Theory of
Language
Hogan, Patrick Colm, 100, 103
Holland, John, 124
Holmes, Sherlock (character)
apprehension of meaningful whole by,
174, 264
description of, 128
diagnostic listening by, 212–­13, 223
as example of narrative case histories, 280
in heroic narratives, 270, 275, 303
origins of character of, 172
recognizing missing narrative elements
by, 250
use of abduction by, 113, 129–­33
use of hypothesis formation by, 125, 184–­
86
use of knowledge by, 123, 234
homology
structure of, 98
“The Housebreaker of Shady Hill,” by John
Cheever, 276
Howards End, by E. M. Forster, 339
humanistic knowledge. See humanities
humanistic science. See humanities
humanistic understanding. See humanities
humanities
as applied in History of Present Illness,
362
building blocks of, 392n3
as discipline focused on schematic appre-
hensions of experience, 368–­70, 373
importance of in medicine, 21, 30–­31
lack of in sciences, 41–­42, 45
law of provisional truth of, 15–­16, 64
narrative as mode for, 251, 258
narrative knowledge derived from, 26,
357
relationship of with nomological sciences,
27
role of in medical education, 7, 43
schemas of as teaching tool, 7–­8, 20, 26,
372, 382
 as speculative science, 371
as study of unique phenomena, 182, 367–­
68
systematic understanding of, 370
technē of skills of, 59, 326
use of memory store in, 155
use of to understand the meaningful
whole, 249–­50
Hunter, Kathryn Montgomery, 28
on morality of medicine, 41
on “re-­storying” a patient’s story, 140, 232
See also Doctor’s Stories; Montgomery,
Kathryn
Husserl, Edmund
on crises of lack of humanity in sciences,
41–­42, 45
hypothesis formation
definition of, 184
category of acts in, 180
by Charles Sanders Peirce, 56
as a domain of competence, 307
importance of in diagnosis, 113–­14, 121–­
22, 124, 192
as presented in detective stories, 127–­28,
133
process of, 184
relation of to narrative discourse, 127
role of abduction in, 116, 117, 124, 363
role of narrative in, 248–­49, 251
technē of, 111
use of observation of human behavior in,
130
use of patient’s narrative in, 126, 132
See also abduction; diagnosis; logic of di-
agnosis
Iacoboni, Marco, 235, 398n1
illness
definition of, 4, 6
example of as mode of unhealth, 11
overcoming of to be healthy, 13
Illness and Metaphor, by Susan Sontag
on use of metaphors to describe illness,
239
“I Look into My Glass,” by Thomas Hardy
as example of age narrative filters, 208–­9
Ilych, Ivan, 144 (character)
chief concern of character of, 361
on palliative care in story of, 255
story of, 331–­33
“Imelda,” by Richard Selzer
narrative form of, 315
index  /  439
use of narrative in to form vicarious iden-
tification, 311–­13
induction
difference of from abduction, 115–­18,
120, 122, 132
logic of abduction as complement to, 27
and use by August Dupin, 129
use of by police in detective stories, 130
use of in science, 363
inquiry
into effects of concepts, 52
order of norms for, 55
Peirce’s theory of, 50
use of narrative in, 51–­53
intellectual practice of medicine, 26–­27
“The Interior Castle,” by Jean Stafford
confrontation of death and dying in, 316
as dramatic narrative, 263
on ethical failure of trustworthiness in
story of, 308–­9
as example of failure of judgment, 311
as example of power and paternalism in
story of, 145–­47
intellectual arrogance of character in,
270–­71, 337
role of characters in, 265, 267
Intoxicated by My Illness, by Anatole Bro-
yard, 7, 139, 335
irony
definition of, 104, 273
as genre of drama narrative in medical
practice, 274
as used in Paley’s story, 109
See also narrative genres
Jakobson, Roman, 350
on literature as kind of attending, 212
on one-­sided pluralism, 96
six elements of speech of, 99, 215–­19,
227, 236, 238, 240, 250, 337–­38
James, Henry, 38
James, William, 61
Jefferson, Thomas, 302
Johnson, Ian
on meaning of eudaimonia, 62–­63
Johnson, Steven
on empathetic understanding, 159–­60
Joyce, James, 263
definition of pity by, 261
on human suffering, 2, 254, 391n2
on recognition of the meaningful whole,
250
Joyce, James (continued)
study of tragedy by, 329, 344, 365
and understanding of katharsis, 6
See also A Portrait of the Young Artist as
a Young Man; Ulysses
Kamm, F. M., 338
Kandel, Eric, 80
Kant, Immanuel, 51, 65
katharsis
definitions of, 5–­6, 260–­61, 395n10
action of definition of health, 13
in Aristotle’s study narrative of tragedy,
259
in narrative, 315
pity at heart of, 347
Keats, John, 277
Keen, Suzanne, 157
Kennedy John
sequence of events of assassination of,
119
as a tragedy narrative, 172
use of schemas to understand similarities
to other narratives, 275
Kermode, Frank
power of narrative endings, 69
on speculative endings, 66–­67
See also The Sense of an Ending
King Lear, by William Shakespeare
use of schema to understand ending of,
275–­76
Klass, Perri, 277
Kleinman, Arthur
on importance of narrative medicine, 358
memoirs of, 280
questions by to elicit patient model,
202–­3
Klushf, George, 46
knowledge base
as element in diagnosis, 113, 124, 126–­27
use of in detective stories, 128–­29
Kuhn, Thomas
and building blocks of humanities, 392n3
definition of paradigm by, 18–­19, 391n3,
393n5, 393n6, 394n10
schema models of, 21
use of paradigm by, 94, 100
“The Lady with the Pet Dog,” by Anton
Chekhov, 259
with chronological narrative, 233
example of gender narrative filters in,
440  /  index
205–­7
“The Lady with the Pet Dog,” by Joyce
Carol Oates, 259
example of gender narrative filters in,
205–­7
as example of marital trouble, 237
with nonchronological narrative, 233
“The Lame Shall Enter First,” by Flannery
O’Connor, 148
on learning from successful listening,
250–­51
portrayal of arrogance in, 149, 337
surprise ending of, 276
use of communication elements in, 218
language
pragmatic view of, 46–­47
structure of, 74
The Last Gentleman, by Walker Percy, 254
“Let’s Talk About It,” by David Rinaldi
poem on physician-­assisted suicides, 318–­
19
Lévi-­Stauss, Claude, 102–­3, 369
listening
causes of failure of, 221–­26
from denial, 237
separation from patient, 241
decline in skills of, 225–­26
discerning chief concern through, 238,
242
importance of in nonchronological se-
quenced plot, 233–­34
as important skill, 211–­12, 237, 247
to patient’s story, 363–­64
as portrayed in The Death of Ivan Ilych,
340–­42, 364
in relation to medical ethics, 308
as teachable skill, 232, 234
See also diagnostic listening
literary narrative. See narrative, “art”
logical positivism
definition of, 367
dismissal of narrative knowledge by, 43–­
44
fallacy of, 46–­47
and nontheistic metaphysical belief, 94
resistance to, 367, 370–­71
role of in medical education, 142
theory of truth by, 44–­45, 63, 174
use of scientific reasoning by, 65
view of reality of facts by, 89, 113, 122,
370
view of social interaction by, 54
logic of diagnosis, 37, 68
and need to discover end, 82
as related to literary narrative, 53, 59, 112
role of surprise facts in, 363
as type of understanding, 247
use of abduction in, 363
use of technē in, 113
See also abduction; diagnosis
logic of discovery, 393n6
See also abduction
logico-­scientific reasoning
and empathy, 159, 164, 166, 241
methods of, 175, 212, 231
as seen in The Death of Ivan Ilych, 354
The Lord of the Rings, by J. R. R. Tolkien,
91
Love in the Time of Cholera, by Gabriel
Garcia Márquez, 226, 237
Love’s Knowledge, by Martha Nussbaum,
67, 97
Lowbury, Edward, 277
Ludwig, Dr. Alfred, 253
MacIntyre, Alasdair, 358
on History of Present Illness narrative, 8
on place of tradition, 58–­60, 67, 70
See also After Virtue
“Magic,” by Katherine Anne Porter, 106,
404n6
Mahon, Derek
comedy in poem of, 272
as physician/writer, 277
See also “Everything Is Going to Be All
Right”
malfeasance
as cause of medical mistakes, 308
“Manuel,” by Raphael Campo, 231
The Man Who Mistook His Wife for a Hat,
by Oliver Sacks, 140, 170
Marinker, Marshall, 4
Márquez, Gabriel Garcia, 226
work as example of marital trouble, 237
See also Love in the Time of Cholera
Mates, Susan Onthank, 277
mathematically forumulated laws
as form of evidence-­based medicine, 14–­
15
mathematical physics
definition of, 35
See also evidence-­based guidelines; no-
mological science
Maude, Aylmer, 344, 345
index  /  441
Maude, Louise, 344, 345
Maugham, Somerset, 277
McCarthy, Joseph, 314
meaningful whole of narrative
apprehension of, 171–­72, 179
examples of in detective stories, 173
examples of regarding death and dying,
325
failure of understanding of, 224, 309
organization of plot leading to, 262
as part of humanistic understanding, 258,
294
as seen in The Death of Ivan Ilych, 339
use of art narrative for apprehension of,
173
use of episodic memory in, 176
use of in medicine, 249–­50
use of schemas to understand, 183, 382
use of technē to understand, 252
mediation
definition of, 73–­74
in form of case-­based reasoning, 17
use of in understanding experience, 74
medical education, 7
biomedical knowledge presented in, 48,
217
conception of science in, 63, 174
on developing rapport with patient,
149
discounting of narrative medicine in, 44,
53
importance of narrative knowledge to, 30,
148
importance of vicarious experience in, 53,
73, 110
lack of teaching History of Present Illness
skill in, 112
need for empathy training in, 146, 164
need for training of narrative medicine in,
46, 48–­49, 280
paternalism as consequence of methods
of, 142
role of in inversion of relationships to sci-
ences and humanities, 43
teaching of diagnostic listening skill in,
225, 244
teaching of medical humanities and narra-
tive knowledge in, 36, 49, 123, 148,
248, 258, 358
teaching of phronesis in, 84
use of logico-­scientific language in, 240–­
41
medical mistakes
causes for, 306
carelessness, 308
failure of judgment, 308–­10
failure of will, 311–­12
lack of competence, 308
lack of knowledge and skill, 306–­7
prevention of with study of narrative,
303–4, 363
schemas for, 386–87
systematic look at, 303–­5
medical practice
definition of, 29
attitude in as seen through Tolstoy’s The
Death of Ivan Ilych, 334
confrontation of death and dying in, 316–­
17, 321
as dramatic narrative, 270
as relates to comedy, 271–­73
as relates to heroic narrative, 270–­71
as relates to tragedy, 271
written by doctors, 276
duty to act in, 311
ethical practices in, 284, 285, 295, 313
failure of judgment in, 315
importance of discernment of patient’s
chief concern in, 358
learning about through memoirs, 280
negotiating with patient in, 359–­60
principle-­based ethics in, 286
re-­storying patient’s narrative in, 331
rewards of, 355
medical schools
courses on human behavior in, 130
development of skill of rapport in,
149–­50
discounting of narrative medicine by, 44
lack of History of Present Illness skills in,
112
need for empathy training in, 164
need for narrative schemas in, 359
preference for biomedical knowledge in,
47
role of in inversion of relationships to sci-
ences and humanities, 43
skills taught in, 30
teaching skill of diagnostic listening in,
225
and use of patient’s story in diagnosis, 48
medicine
as Aristotle’s chief example of phronesis,
60, 84
442  /  index
connection of The Death of Ivan Ilych to,
342
and definitions of katharsis, 261
health as goal of, 58, 66, 84
morality of, 41
structure of in narrative terms, 261
as technē, 71, 72
melodrama. See heroic narrative; narrative
genres
memory
types of, 80
Merchant of Venice, by William Shake-
speare, 272
“Mercy,” by Richard Selzer, 319
metaphors
creating new realities with, 239–­41
importance of in listening, 243
use of, 311
use of by Leo Tolstoy in The Death of
Ivan Ilych, 334, 352
use of by patients, 242
use of to describe illness, 268
metaphysical beliefs, 94
Metaphysics, by Aristotle, 71
methodical skill
narrative knowledge as, 49
Middle Ages, 51
Miller, J. Hillis
on structure of narrative, 92–­93
mirror neurons
definition of, 398n1
neurological evidence of, 400n11,
402n19
and recognition of role switching, 267
response to others’ pain and suffering
from, 235
role of in empathy, 160, 235, 267, 398n2
misapprehension of systems, 191
“Misery,” Anton Chekov
analysis of chief concern of, 269
analysis of schema of narrative in, 276
use of for vicarious experience, 235
use of irony in, 273
Montgomery, Kathryn, 331
See also Doctor’s Stories; Hunter, Kathryn
Montgomery
Moore, G. E., 43
Morrison, Toni, 154
use of stories to teach empathy, 166
See also Beloved
Much Ado about Nothing, by William
Shakespeare, 272
“The Murders in the Rue Morgue,” by Ed-
gar Allen Poe, 119, 123
as example of apprehension of meaningful
whole of narrative, 173–­74
as example of diagnostic listening, 214–­
15, 222
misapprehension of evidence in, 191
use of abduction in, 133
use of hypothesis formation in, 128–­29,
131, 184–­85
use of provisional understandings in, 275
Musicophilia, by Oliver Sacks, 75
My Own Country, by Abraham Verghese,
186
as example of avoidance of HIV-­AIDS pa-
tients, 230
as a memoir, 280
quote from, 211
narrative
action as feature of, 101–­2, 163
act of communication in, 215–­17
analysis of, 259, 371
Aristotle’s study of tragedy in terms of,
259
benefits of teaching schemas of, 166
and characteristics of personhood, 86
as connected to phronesis, 60, 64–­65, 70
as connected to practical reasoning, 59,
78, 103, 119
to convey vicarious experience
of pain and suffering, 195
as seen in The Death of Ivan Ilych,
354–­55
creation of empathy with, 157, 362
creation of vicarious experiences through,
67, 77, 237, 297–­99
definition of by Rita Charon, 95
in detective stories, 128
different mediums of, 219
elements of, 277
and end of narrative, 81–82, 93, 121
as ethical drama of death and dying, 322
ethics portrayed in, 291, 307, 312, 317
evolutionary adaptiveness of, 81
focused attention ability from, 255, 257
as functional reality, 362
function of, 78, 396n2
gaining of insight to self through, 229
genres of used to understand medical
practice, 269–­72, 274
in hypothesis formation, 125, 132, 251
index  /  443
importance of in patient-­physician rela-
tionship, 61
importance of knowledge of, 247, 374
learning from experience in, 94, 127
limits and scope of, 261
listening as part of, 212, 222–­23, 363
medical profession bias against use of, 47
as mode for humanistic understanding,
26, 83, 258
nature of, 79, 83–­84
ordinary language of, 267–­68
of patients
and chief concern, 359
The Death of Ivan Ilych as, 349–­55
importance of, 89, 168–­69, 357–­58,
374
physicians attracted to as writers, 277
plots of, 233–­34, 261–­63
in poetry, 183
portrayal of alternatives of dying in, 322
portrayal of ethics in, 258, 284, 190, 313
realistic details in, 352
and recognition of same story, 258, 331
role of episodic memory in, 81, 176
role of in achieving empathy, 160–­61
role of in diagnosis, 53, 111–­13, 127, 210,
213, 226
role of in medicine, 1, 7, 37–­38, 99, 248–­
49, 253, 258
role of in patient-­physician relationship,
149, 154, 157, 179, 357
role of in recognizing negative paternal-
ism, 144
role of katharsis in, 260–­61
roles of characters in, 254, 263–­73, 275
salient features of, 91, 95, 98, 105, 191,
193, 262
schemas and technē of, 12, 39, 45, 50, 68–­
69, 71, 82, 96, 101, 105, 166, 172,
226, 227–­28, 232, 250, 267, 276, 358,
373, 382–­84
sequence of events of, 233, 262, 335, 338
speculation in, 66
structure of, 74, 91–­93, 104, 267, 279, 311
systematic review of in, 108, 251, 273
as teaching tool, 97, 292, 330, 347, 359
technēs for understanding of, 113, 252,
303
techniques of “defamiliarization” in, 350–­
51
and theory of mind, 60
two temporalities of, 147, 182, 207, 233
narrative (continued) use of to understand other social classes,
understanding of meaningful whole of, 204
69, 77, 95, 118–­19, 120, 172–­74, 210, narrative, “popular”
226, 228–­29, 249–­55, 263, 325 as contrasted to “art” narrative, 298–­99
use of abduction in, 119 discerning salient features in, 105
use of clichés in, 254–­55 putative goals of, 106
use of in History of Present Illness, 38–­39 roles of narrative actors in, 264
use of pity and terror in, 345 narrative actors, 263–­64
vocabulary of, 39–­40 narrative agents
narrative, “art,” 170 definition of, 101–­2
aesthetics of, 91 role of in narrative, 91
analysis of Paley’s story as, 110 narrative-­based ethics
articulation of chief concern by, 5 role of in medical practice, 292
attention to realistic details in, 349 narrative cognition
as contrasted to “popular” narrative, 298–­ evolutionary adaption of, 76
99 evolution of structure of, 141
cultural filters in, 203 and salient features of narrative, 208
The Death of Ivan Ilych as, 334, 342–­45, and theory of mind, 61
353 and understanding of experience, 77
discerning salient features in, 105, 106, use of in practical reasoning in medicine,
109–­10 56
on ethical dilemma of physician-­assisted narrative competence, 238
suicide, 318–­21 definition of, 232
examples of ethical behavior in, 145, 295– as technē of narrative knowledge, 364
96, 303, 313, 326, 334, 362–­63 narrative elements
personal and societal assumptions in, of death and dying, 320
242 use of in logic of abduction, 115
provoking reflection by, 252 See also schema of elements
role of in achieving empathy, 161–­62 narrative filters
roles of characters in, 264–­65 definition of, 196
structure of, 112 age as, 207, 209, 210
use of in patient-­physician relationship, cultural differences as, 200–­201, 203
361 and failure to listen, 220, 226
use of in phronesis, 71 gender as, 205, 207, 228
and use of schemas, 183 of patient’s narrative, 362
techniques of “defamiliarization” in, 350–­ primary emotion as, 196–­200
51 use of to discern chief concern, 239
use of as teaching tool, 148, 226, 229 narrative genres, 253
to achieve empathy, 157 analysis of, 371
for communicative skills, 215, 220 comprehension of meaningful whole of,
for discerning chief concern, 238, 242 118–­19, 268
for listening skills, 232–­34, 244, 363 determination of type of, 270, 310
for rapport, 151–­52, 155 everyday ethics in, 315
use of for vicarious experience, 150–­51, identification of by receiver, 264
201, 232, 234–­35, 334, 362 kinds of
use of in hypothesis formation, 251 comedy, 108
use of in narrative medicine, 1, 40, 247 description of, 103–­4
use of in patient-­physician relationship, detective story as, 127
137–­38 heroic, 270–­71
use of to address stereotypes, 231 ironic, 273
use of to understand meaningful whole, tragedy, 108, 271
174, 249–­50, 254 number of, 258

444  /  index
 as part of narrative knowledge, 27
systematic ambiguities of, 268–­69, 275–­76
use of hypothesis formation in, 251
and use of schema to develop narrative
skills, 40, 269, 275, 382
narrative knowledge
definition of, 77, 83, 95–­96, 176, 247
abduction connection with, 118
as applied in History of Present Illness,
362
development skills of, 48, 61, 279, 303
dismissal of by logical positivism, 44
as a domain of competence, 294, 307, 309
gaining of through narrative, 1, 150, 229
and genres of narrative, 258
importance of in medicine, 8, 30–­32, 35,
37, 39, 84–­85, 113, 247, 248–­49, 307,
361
lack of as cause of medical mistakes, 306
learn pause and reflection from, 184
listening as constituent part of, 212
methods of, 28
and patient’s narratives, 168–­69, 207, 355
role of in diagnosis, 9–­12, 213
as source of virtues, 347
as supplement to scientific knowledge, 27,
175, 225, 358
understanding of experience with, 77, 82
use of in The Death of Ivan Ilych, 330,
335, 337
use of in deliberation and negotiation, 114
use of in diagnosis of chief concern, 186,
226
use of in ethical practices, 285, 291, 300
use of in patient-­physician relationship,
138, 275
use of poetry to teach discernment of, 181
use of schemas to understand, 40, 77, 80,
180, 282–­83
use of technē in, 59, 98, 113, 364
use of to create empathy, 166
use of to gain vicarious experience, 201,
288
use of to understand meaningful whole,
172, 297
ways conveyed in art narrative, 106
as way to provide humanistic understand-
ing, 357
narrative medicine
definition of, 38
goal of to integrate humanity into medi-
cine, 35–­37, 42, 46
index  /  445
importance of knowledge of, 48, 55–­56,
248–­49, 358
issues emphasized in, 41
narrative knowledge used in, 83
origins of biases against, 44
patient’s experience as starting point of,
45
Peircean realism as defender of, 47
resistance to, 43
technē of, as seen in Tolstoy’s The Death
of Ivan Ilych, 335
use of “art” narratives in, 40–­41
use of pragmatic continuity in, 45–­46
use of schemas and checklists in, 97
Narrative Medicine, by Rita Charon
definition of narrative in, 95
on parallel charts, 277, 279
narrative roles
ambiguity of in different genres, 270–­71
in ironic narrative, 274
as part of narrative knowledge, 27
use of schema for understanding of, 275,
382
narrative schemas
benefits of use of, 13
use of in medical practice, 180–­81
See also schemas
narrative virtues, 27
The Nature of Suffering and the Goals of
Medicine, by Eric Cassell, 86
Neff, D. S.
analysis of Grace Paley’s story by,
107–­9
neural modules
definitions of, 78
Newton, Isaac, 35, 43, 54
Nickles, Thomas
on case-­based reasoning, 17–­18, 152, 176,
354, 372, 393n6
on definition of paradigm, 394n10
definition of schema by, 19, 114
on schema and case-­based reasoning, 92,
369
on schemas as memory stores, 152, 155,
234
on understanding abstract concepts, 29
Nicomachean Ethics, by Aristotle
action of practical reason in, 91, 116
concept of practical reasoning in, 4, 57,
60, 64
description of practical syllogism in, 111
ethics defined in, 295, 363
Nicomachean Ethics (continued)
medicine as example of practical reason
in, 84
mistranslations in regarding the end, 65
on virtue of ethics, 290, 294
nominalism
definition of, 49–­50
arguments by against realism, 51
fallibility of, 53
view of relation as particular by, 54
nomological science
commensurability of replacing particular-
ity of experiences, 42
difference of to narrative knowledge,
175
Nussbaum’s assumptions about, 98
principle-­based ethics analogous to, 286,
287
relationship of with humanities, 27
use of determinate ends in, 65
use of Plato’s theoretical reasoning in, 93
vocabulary of, 39
See also biomedical knowledge
normative ethics
definition of, 285–­86
Nussbaum, Martha, 8
on action as conclusion of practical syllo-
gism, 116
on Aristotle’s conception of the ends, 65,
66, 358
comparison of scientific reason to practi-
cal reason by, 59, 63–­64, 97–­98
on deliberation as goal of practical reason,
81
distinction by between phronesis and
technē, 76
on ends of health care, 3
on improvisation of phronesis, 63, 69–­70,
101, 102
on nature and function of practical rea-
son, 62, 69
on phonesis as set of skills, 17
and salient features of narrative, 89
on science being commensurable, 64
on teaching phronesis, 368
on technē, 70–­73, 85, 90, 98, 105, 364
on unanticipated occurrences in narrative,
93
on use of experience in practical reason,
67, 82
on use of hypothesis by Aristotle, 111
on use of katharsis, 6
446  /  index
on use of perception in practical reason,
67–­68, 70, 71
use of salient features of narrative by, 17,
20
See also The Fragility of Goodness; Love’s
Knowledge
Oates, Joyce Carol
story of as example of gender narrative fil-
ters, 205–­7
story of as example of marital trouble, 237
telling of same story as Chekhov, 259
See also “The Lady with the Pet Dog”
O’Connor, Flannery
attention to realistic details in narrative
of, 349
intellectual arrogance of character of, 337
on need for rapport, 149
stories of as represented situations, 150
stories of as teaching tools, 252
story of as example of missing narrative
elements, 250–­51
story of as example of paternalism, 146–­
47
story of as example of physician’s failure
to listen, 227, 363
structure of stories by as teaching tools,
148–­49
surprise endings in story of, 276
use of communication elements in stories
of, 218
use of heroic narrative by, 271
use of narrative by to achieve empathy,
155, 161
use of religious themes by, 145, 166
use of story of to establish rapport, 154
See also “The Artificial Nigger”; “The
Lame Shall Enter First”
Odyssey, by Homer, 270
Oedipus, by Sophocles
as example of tragedy, 271
use of narrative schemas to understand
similarities to other works, 275
use of to understand meaningful whole,
249
“Old Doc Rivers,” by William Carlos Wil-
liams, 263, 275
The Old Man and the Sea, by Ernest
Hemingway, 254
On Doctoring, by Richard Reynolds and
John Stone, 273, 277
The Origins of Stories, by Brian Boyd, 76
Ornstein, Robert, 81, 392n4
See also The Right Mind
Paley, Grace, 149
father of, 281
medical connections of to writings of,
277
role of characters in narrative of, 269, 349
story by as art narrative, 105, 106–­10
use of narrative by to create relationship,
155
See also “A Conversation with My Fa-
ther”; Enormous Changes at the Last
Minute
paradigm
definition of, 18, 100, 372, 391n3,
393n6, 394n10, 395n11
provisional nature of, 391n5
use of to understand schema operations,
19–­20, 395n10
parallel chart
definition of, 277–­78
Parker, Charlie, 101
“The Passions of the Soul,” by René Des-
cartes, 176
paternalism
as described in Tolstoy’s The Death of
Ivan Ilych, 344
in negative form, 144
as obstruction in medicine, 142–­43
patient-­physician relationship, 123
definition of, 91, 137
consequences of emotional response in,
223–­24
deliberations and negotiations in, 86, 89
developing of rapport in, 149, 151–­53,
161, 361, 362
elements of communication in, 215–­17,
219–­20
as emphasized in narrative medicine, 41
and goals of medical care, 323–­26
impact of narrative filters on
anger, 197–­98
fear, 198–­99
sadness, 200
importance of chief concern in, 87–­89
importance of humanities in, 31
importance of narrative knowledge in, 32,
317
importance of patient’s narratives in, 168–­
69
knowledge needed in, 307
index  /  447
as mechanism in drama of medical prac-
tice, 262–­63
nature of conversation in, 70
paternalism as obstruction in, 139, 142,
143–­44, 214–­15
as portrayed in The Death of Ivan Ilych,
331, 335–­41, 344, 364
power of narrative and practical reason in,
61, 158, 252
reflective attention in, 253
role of empathy in, 159, 161, 163, 164,
347
as scene narration, 149
schema of interaction in, 382, 383–­85
as a shared enterprise, 140–­41
temporalities in narrative of, 92
understanding cultural differences in,
200–­204
use of “art” narratives in, 138, 145–­46,
154
use of checklists in, 374
use of ethical virtues in, 29, 285, 314, 326
use of History of Present Illness in, 85,
382
use of listening skills in, 211, 232, 237–­38
use of narrative knowledge in, 39, 56, 179,
247, 357
use of schema and technē of narrative in,
21, 22, 99, 162, 249
patients’ rights
definition of, 300
patient’s story. See narrative
Peirce, Charles Sanders
on analyzing experience, 76
on anomaly in narrative, 174
on categories of characters, 370, 372,
394n9
concept of abduction by, 1, 59, 66, 81–82,
92, 111, 113, 117–­18, 120–­21, 123,
129, 132, 363, 393n5, 393n6
conceptual model of for use of narrative,
37, 54
on connection of phronesis with litera-
ture, 397n11
defense of narrative medicine, 47
on fallibism of science, 51
and habitual behavior as expression of be-
liefs, 31, 289
on kinds of characteristics in logic of diag-
nosis, 114–­15
on law of provisional truth, 15–­16, 20, 192
on logic as norm in inquiry, 55
Peirce, Charles Sanders (continued)
on logic of discovery, 27
on mediation of experiential modalities,
75
on phenomenology of sense experience,
369
as pragmatist realist, 22, 52, 54
on role of abduction in forming hypothe-
sis, 56, 116, 180, 288
schema of logical inferences of, 124
on speculation of ends and benefits of
practical reason, 66
on symbolic function of signs in experi-
ence, 74–­76, 396n3
theory of inquiry of, 50
on use of knowledge in abduction, 122,
307
use of narrative in theory of abduction,
50, 127, 397n9
use of perception in formulation of ab-
duction, 68
and whole meaning of concepts, 55
Pellegrino, Edmund
on health as goal in medicine, 58
on moral good in medical practice, 300,
311
perception
in phronesis, 67–­68
as a technē, 73
Percy, Walker, 254
See also The Last Gentleman
peripeteia
failure of principle-­based ethics to ad-
dress, 325
narrative examples of, 304
personhood characteristics, 86–­87, 89
Phelan, James
on act of narrative, 91, 101
analysis of story by, 106
on narrative as rhetoric, 86
on schematic understanding of a story,
110
phenomenology of meaning, 369
Philadelphia (film), 242
example of contact of communicative act
in, 219
Philoctetes, by Sophocles
confrontation of death and dying in, 316
narrative form of, 315
use of to recognize mistakes, 303
use of to understand everyday ethics,
301–­2
448  /  index
Philosophical Investigation, by Ludwig Witt-
genstein
on practical reason use of experience, 67
philosophy
failure of in twentieth century academics,
47
fallibility of in science, 45–­46
quest for certainty in, 51
schemas used in, 373
See also logical positivism
Philosophy and the Mirror of Nature, by
Richard Rorty, 47
phronesis
definition of, 1–­2, 247
clinical knowledge of, 257
diagnosis as skill in, 111, 113
dismissal of in evidence-­based medicine,
77
empathy as important aspect of, 162
focus on action by, 84
habitual feature of, 290
importance of use of in medicine, 84
intellectual virtues of as related to medi-
cine, 288, 290–­91, 314
as means to well-­lived life, 62
narrative knowledge as skill to achieve,
64–­65, 303, 308
Nussbaum’s discussion of, 97
physician’s development of, 359
pursuit of the end by, 73, 82, 95, 367
systematic understanding of practical rea-
son of, 60, 85, 114, 252
as a technē, 71
translation of as practical reason and prac-
tical wisdom, 107
use of deliberation in, 105, 110, 169
use of experience in, 67, 81, 82
use of improvisation in, 101–­2
use of in apprehending meaningful whole
in narrative, 174, 325
use of in patient-­physician relationship,
61, 89
use of narrative in, 93
use of patient narrative in, 112
use of perception in, 70
use of provisional schemas in, 183, 391n3
use of salient features in, 115
use of speculation in, 66
use of technē to teach, 124, 314, 368
See also practical reasoning
physician-­assisted suicide
as major ethical dilemma, 318–­21
physician/writer
of case-­based histories, 277–­78
fiction writing of, 281
memoirs of, 280
of parallel charts, 279
poetry of, 282
physics, 15–­16, 20
The Plague, by Albert Camus
on code of morals, 290
confrontation of death and dying in, 316
decency as virtue in, 315
as example of dramatic narrative in medi-
cal practice, 274, 315
quote from, 284
use of narrative of to teach empathy, 166–­
67
Plato, 65, 70, 71
on nontheistic metaphysical belief, 94
theoretical reasoning concept of as com-
pared to Aristotle, 93
use of epistēmē in time of, 63
“A Plea for Excuses,” by J. L. Austin, 371
Poe, Edgar Poe, 113, 341
detective stories of, 127, 172
knowledge used by character of, 123
misapprehension of evidence in story of,
191
role of narrator by, 265
on romantic notion of melancholy, 239
story of as diagnostic listening, 214
use of abductive reasoning in stories of,
119
See also “The Murders in the Rue
Morgue”
Poetics, by Aristotle, 5, 13, 233
on recognition of the meaningful whole,
250
study of tragedy in terms of narrative in,
259–­60, 301
use of medicine in study of narrative in,
259
poetry, 71 155, 235
close analysis of, 181–­84
defamiliarization of language in, 351
importance of in learning to listen, 231–­
32, 243–­44
language of, 218, 233
relationship of with medicine, 282
role of implicit narrative of in knowledge,
140, 172
shared pain and suffering portrayed in,
194–­96
index  /  449
training in interpretation of, 48
Valéry’s definition of, 257
use of to teach empathy, 157, 165
as written by physicians, 141, 176
A Portrait of the Artist as a Young Man, by
James Joyce, 6
positivism. See logical positivism
practical reasoning
definition of, 1, 13
Aristotle’s development of, 47, 57, 59, 98
completion of through action, 15, 41, 58,
64–­65, 91, 116
as composed by virtues, 29
deliberation on goals of health care by, 1,
17, 65, 66, 81–­82, 84, 95
development of, 31
importance of in patient-­physician rela-
tionship, 61
as method to systemic understandings of
science, 59
Peircean realism as defender of, 47
place of tradition in, 59, 60
role of narrative in, 27, 53, 56, 59, 78, 98,
103, 368
as set of skills, 17, 90
systematic understanding of, 114
as translation of phronesis, 107
and understanding ethical practices in
medicine, 307
use of experience in, 67, 76, 252
use of schemas in, 68–­69, 93, 183
use of technē in, 59, 100
practical syllogism
and abduction, 59
action as conclusion of, 116, 117, 120, 162
Aristotle’s description of, 111
use of in The Death of Ivan Ilych, 337
use of technē in, 113
practical wisdom
achievement of, 49
as composed by virtues, 29
and determining patient’s chief concern,
111
development of, 31
empathy as important part of, 162
and goal of well-­lived life, 62
moral concepts used in, 54
physicians reaching state of, 90
as translation of phronesis, 107
use of experience in, 67, 252
use of narrative to achieve, 103
use of physicians, 85
practical wisdom (continued)
use of theatrical improvisation in, 69
See practical reasoning
pragmatic realism, 124
pragmatic skills
definition of, 21
use of schemas in teaching of, 20–­22
pragmatism
definition of, 367
Charles Sanders Peirce as initiator of, 50
concept of science in, 51
resistance to logical positivists, 370–­71
use of discipline in, 372–­73
use of method in, 113
primary emotions
anger, 197–­98
fear, 198–­99
as narrative filters, 196–­99
sadness, 199–­200
Prolegomena to the Theory of Language, by
Louis Hjelmslev, 367
Propp, Vladimir, 102–­3
rapport
development of, 149, 152, 160
example of lack of, 297
need for in patient-­physician relationship,
149, 151–­52
role of empathy in creation of, 159, 161,
361–­62
role of narrative in teaching skill of, 150,
154–­58, 166
realism
definition of, 50
concepts and laws in, 52
nominalist arguments against, 51
Peirce’s concept of, 50–­51
as produced by scientific laws, 52
“The Red Wheelbarrow,” by William Carlos
Williams
as teaching tool to discern chief concern,
181–­84
reflection
as element in diagnosis, 114, 123, 124
experience in use of, 127
as technē in narrative understanding, 252
use of narrative clichés to create, 255
as way of reasoning, 128
as way of understanding meaningful
whole, 253
“The Resident Patient,” by Arthur Conan
Doyle, 123, 129, 131
450  /  index
as example of diagnostic listening, 212–­
13, 222
misapprehension of evidence in, 191
police in as example of failure to listen,
223
use of abduction in, 132
retrospective comprehension
discussion of, 92–­93
Reynolds, Richard, 277
Ricoeur, Paul
on configuration mode of understanding,
121
on narrative comprehension, 92, 93
on use of narrative to understand the
whole, 249
See also Time and Narrative
The Right Mind, by Robert Ornstein, 81
Rinaldi, David
as physician/writer, 277
poem on physician-­assisted suicides, 318–­
21
See also “Let’s Talk About It”
Rorty, Richard
on failure of academic philosophy, 47
as nominalist, 49, 51
on status of moral virtues, 54
See also Philosophy and the Mirror of
Nature
Rouse, Joseph, 393n5
Rovere, Richard, 314
Rudrum, David, 83
Russell, Bertrand, 43
Russian formalism, 96, 350
Ryan, Marie-­Laure
criteria of narrative by, 83
on nature of narrative, 83–­84
Sacks, Oliver
as case historian, 141
on modalities of experience, 75
on patient’s narrative knowledge, 170
story of example of his relationship with
patients, 140
on structure of language and thought, 74,
102
use of case histories of, 255, 277
use of neurological terms to understand
experience, 76
See also An Anthropologist on
Mars; Awakenings; The Man Who
Mistook His Wife for a Hat;
Musicophilia
salient features of narrative, 253, 371
definition of, 17, 91
as actions of phronesis, 101
as contained in History of Present Illness,
193
as conveyor of experience of narrative,
216–­18
in The Death of Ivan Ilych, 338, 354
in descriptive accounts, 45
gaining of vicarious experience through,
125, 201, 298
importance of in listening, 243
importance of in narrative structure, 191
in medical narratives, 138
and narrative cognition, 79, 208
in Paley’s story, 109–­10
as part of narrative knowledge, 27, 80,
170
and perception, 68
presentation of in narratives, 49
recognition of, 89, 95, 105, 232
as structure of narrative, 101, 104, 262
systematic understanding of, 73, 182
use of in abduction, 114, 121
use of in narrative, 21, 39, 80, 83, 85
use of schema to discern, 98–­99
See also schemas of narrative
Sams, Dr. Ferrol
narrative form of story of, 315
as physician/writer, 141, 277, 282
story of as example of development of
rapport, 151–­52
story of as example of narrative compe-
tence in, 239
story of failure of judgment by, 309–­10
use of empathy in story of, 159
See also “Epiphany”
schema-­based disciplines, 373
schema-­based ethics, 290
schema-­based guidelines, 99
schema-­based medicine, 37
definition of, 27
approach to using technē, 100
benefits of use of, 2–­3, 22, 26, 163
as complement to evidence-­based medi-
cine, 14
goal of to integrate humanity into medi-
cine, 46
importance of patient-­physician relation-
ship in, 25
and narrative cognition, 81
narrative knowledge as vehicle for, 8
index  /  451
Peircean realism as defender of, 47
systematic understanding of experience
in, 77
as teachable concepts and terms, 31
use of narrative knowledge in, 308
use of speculation discerning ends and
benefits in, 66
vocabulary of narrative knowledge in, 40
schema-­based reasoning, 285
schema guidelines, 108, 247, 269
schema of elements, 196
in language, 337–­38
schemas, categorial
description of, 180
schemas of medical practices
summarized, 382–­89
schemas of narrative
definition of, 16–­17, 19, 64, 100
of action and ethics, 236
application of, 364
of arrogant judgmental power, 148
as basic building block of humanistic un-
derstanding, 20
of cognitive psychology, 338, 371
of communicative language, 215–­17
creation of with technē, 101
in The Death of Ivan Ilych, 329–­30, 335,
338, 354
as defined by Thomas Nickles, 18, 19, 114
of dramatic narrative, 270
function of, 393n8
of genres, 270
as guide to deliberation, 105
of language, 235–­36, 239–­42, 268
for medical interview, 236
as memory stores, 155
as method to understand abstract con-
cepts, 29
of narrative events, 261–­62
in narrative medicine, 97, 248
of narrative structure, 263, 267–­68
in perception, 68
provisional nature of, 16, 50, 183–­84, 370,
372, 392n4, 393n5
recognition of components of, 249
and salient features of narrative, 215–­16,
338
as teachable tools, 18, 46, 93, 236, 244,
358–­59
as techne for practical reason, 100
technē of to determine roles of characters,
266
schemas of narrative (continued)
as tool in use of narrative medicine, 53
training of in medical education, 46, 48–­
49
of two temporalities of narrative, 147
to understand meaningful whole, 305–6
and use of in case-­based reasoning, 393n6
use of in checklists, 99, 391n3
use of in cognitive science, 74
use of in patient-­physician relationship,
22, 26, 56, 145, 243
use of in study of humanities, 372–­73
use of in study of narrative knowledge, 98,
236
use of in understanding “health,” 179
use of models of in interviewing, 21
use of narrative skills of apprehension,
175, 232, 238, 250
use of narrative structure in, 243, 251
use of paradigm to understand operations
of, 19
use of to address stereotypes, 150–­51, 231
use of to develop empathy, 162
use of to discover chief concern, 21
use of to gain experience, 18, 39, 45, 75,
124, 201, 234, 237, 248, 298–­99,
369–­70
use of to learn from mistakes, 303
use of to teach pragmatic skills, 20–­21, 27,
166
use of to understand narrative, 12–­13, 40
use of to understand salient features, 105,
182
of virtues, 295
See also narrative filters
schema theory
description of, 92
and systematic understanding of experi-
ence, 73
and use of experience, 67
schematic narrative
analysis of The Death of Ivan Ilych, 338
features of, 108
roles of in medical practice, 273
summary of, 274
schematic narrative roles
and failure of judgment, 310–­11
schematic understanding
examples of benefits of, 110
science, evolutionary, 35, 372
definition of, 52, 371
as distinguished from evidence-­based
452  /  index
medicine, 14–­15
importance of scientific narrative in, 49
as part of systematic understanding, 20
plausible retrospective laws of, 16
use of schemas and cases in, 372
science, formulaic
definition of, 371
use of schemas and cases in, 372
science, nomological, 27
scientific knowledge
definition of, 175
analysis of as reductive, 180
narrative knowledge as complement to,
358
as used by Descartes, 175–­76
scientific positivism. See logical positivism
scientific reason
Aristotle’s comparison of with practical
reason, 59
and conception of means and ends, 65
Selzer, Dr. Richard
attention to realistic details in narratives
of, 349
as physician/writer, 141, 277, 282
shifting of character position by, 148
stories of on abuse of power in patient-­
physician relationship, 144–­45
stories of on creation of rapport, 149,
155–­56, 161, 361
stories of on everyday ethics, 302
stories of on failure of will, 311
stories of on failure to listen, 223
story on physician-­assisted suicides, 319,
321
on use of empathy training, 165
works of, 316
See also “Atrium: October 2001”; “Brute”;
“Imelda”; “Mercy”; “Whither Thou
Goest”
semiotic and information theory, 52, 75
definition of schemas of, 64
and analysis of phenomenology of mean-
ing, 369
in human sciences, 65
and understanding of narrative, 92
and understanding of phronesis, 60
use of as technē, 76, 77
use of “necessary but not sufficient” to
reach ends in, 65
use of speculation discerning ends and
benefits in, 66
value of, 54–­55
Seneca
quote by, 137
The Sense of an Ending, by Frank Kermode,
69
Shakespeare, William
analysis of schema of narrative roles in
works of, 276
use of comedy by, 272
use of heroic narrative in Henry V, 270
See also Hamlet; Henry V; King Lear;
Merchant of Venice; Much Ado about
Nothing; The Taming of the Shrew
Shklovsky, Viktor
on “defamiliarization,” 334, 350, 351
on techniques to provide vicarious experi-
ence, 353
sickness
definition of as part of unhealth, 4, 6,
11, 13
Simon, Neil, 272
Slingerland, Edward
on cognitive modalities, 76
description of narrative by as neural sys-
tems, 100
on theory of mind, 61–­62
See also What Science Offers the Human-
ities
Smith, Barbara Herrstein
on action of narrative, 101
definition of narrative by, 86, 91
and understanding of narrative, 92
social background
as context for patient’s story, 194
Sontag, Susan
analysis of metaphors used in illness by,
239–­41
See also Illness and Metaphor
Sophocles
and role of individual values in ethics,
301–­3
See also Oedipus; Philoctetes
speculation
definition of, 15
as method of systemic understanding, 20
See also abduction
Spiegel, Maura
on nonchronological sequencing of narra-
tive, 233
The Spirit Catches You and You Fall Down,
by Anne Fadiman
examples of transcultural medicine in,
201–­2, 307
index  /  453
role of characters in, 265
use of as teaching tool, 235
Stafford, Jean
absence of rapport in story of, 149
attention to realistic details in narrative
of, 349
on ethical failure of trustworthiness in
story of, 308
roles of characters of, 267
stories of as dramatic narrative, 263
story of on failure of judgment of narra-
tive roles, 311
story of on power and paternalism, 145–­
46, 337
See also “The Interior Castle”
Steen, Francis
on details of narrative, 40
on narrative in cognitive terms, 92, 100
on narrative preparing for action, 90,
298
on predation theme in narratives, 102
on theory of mind, 62
on use of improvisation in narrative struc-
tures, 101
view of narrative knowledge by, 61, 77–­
78, 368–­69
stereotypes
use of art narrative to overcome, 231
Stevens, Wallace
on reality of death, 339
See also “Sunday Morning”
Stone, Dr. John, 371
comedy in poem of, 272–­73
definition of health by, 63, 274
definition of illness by, 6
on meaningful whole of story of poem of,
176, 178–­79
on patient-­physician relationship in poem
of, 145, 149
as physician/writer, 141, 277
poem of as example of use of narrative in
medicine, 181
poem of as image of shared pain and suf-
fering, 195
roles of character in narrative of, 148,
266, 267
salient feature of narrative in poems of,
170
use of communication elements in poetry
of, 218
use of religious imagery by to create em-
pathy, 166, 231
Stone, Dr. John (continued)
use of stories to teach empathy, 166
See also “Gaudeamus Igitur”; “He Makes
a House Call”; On Doctoring
story filters. See narrative filters
storytelling
cognitive science explanation of, 78
providing by of situations, 150
Stroud, Scott
on ethical successes, 313
on using narrative to develop narrative
skills, 313
on vicarious experience from narrative,
298–­99, 334, 348
on virtue ethics, 363
subject knowledge
definition of, 298
and ambiguity of ethical meaning, 312
art narrative provoking of, 299
“Sunday Morning,” by Wallace Stevens, 339
Swenson, Sarah, 398n2
symbolic logic, 43
systematic ambiguity
definition of, 274–­75
irony as, 273
and understanding surprise endings in
narrative, 275–­76
systematic knowledges
technē as, 60
systematic science. See epistēmē
systemic reasoning skills
Aristotle’s comparison of with practical
reason, 59
The Taming of the Shrew, by William Shake-
speare, 272
technē (skill)
definition of, 49, 72
Aristotle’s view of in practical reason, 70
for communication of bad news, 325–26
creation of on structure of narrative, 101
definition of by Martha Nussbaum, 71–­
72, 98
of deliberation in narrative, 104–­5
to determine narrative genre, 269
to determine roles of characters, 266
of experience, 76, 90
to gain understanding of meaningful
whole, 275
of humanistic knowledge, 326
hypothesis formation as, 56
of listening to patients, 211, 232
454  /  index
medicine as, 70
modalities of understanding under, 59
and phronesis, 290, 314, 368
practical reason as systematic skill of,
84
as seen in Tolstoy’s The Death of Ivan Il-
ych, 335
as skills to apprehend meaningful whole
in narrative, 174
as a systematic knowledge, 60
as teachable technique for practical rea-
son, 82, 93, 124
use of in diagnosis, 111, 113, 129
use of in History and Physical Exam, 85
use of in narrative skills, 53, 78, 85, 95,
249, 275, 308, 326
use of in schema-­based medicine, 100
use of in scientific reason, 65
use of to discern chief concern, 251–­52
See also methodical skill
Tender Is the Night, by F. Scott Fitzgerald
ambiguity over genre of, 271
analyzed, 273
failure in judgment in, 310
use of schemas of roles to analyze narra-
tive of, 275
The Tennis Partner, by Abraham Verghese
as example of denial as failure, 228–­29
as a memoir, 280–­81
theoretical physics, 43
theoretical reasoning. See scientific reason
theory of mind
definition of, 60–­61
educated guess of from narrative, 298
and empathetic understanding, 159
Thomas, Lewis, 277
“Three Ways of Spilling Ink,” by J. L. Aus-
tin, 371
Time and Narrative, by Paul Ricoeur, 249
“Tintern Abbey,” by William Wordsworth,
290
Tolstoy, Leo
chief concern of in The Death of Ivan Il-
ych, 334
connection of emotions by in The Death
of Ivan Ilych, 343–­44
defamiliarization of experience by, 29,
350–­51
focus of on indifference of doctors, 334–­
35
on listening in The Death of Ivan Ilych,
340–­41
 on professional arrogance in The Death of
Ivan Ilych, 336–­37
provoking of vicarious experience by,
353–­54
quote from work of, 329
realistic description of Ivan’s life by, 348–­
50, 365
satirical realism of in The Death of Ivan
Ilych, 333–­34
two narrative frames of in The Death of
Ivan Ilych, 337–­38
use of irony by to present values, 346–­47
use of meaningful whole by in The Death
of Ivan Ilych, 339
use of narrative by in describing reality of
death, 339, 343
use of narrative of to achieve empathy,
161
use of novella to relate narrative to medi-
cal practice, 331
use of realistic details by, 350–­53
use of six elements of speech in, 337
work of as demonstration of nexus of liter-
ature and medicine, 364
tragedy
definition of, 104, 119
Aristotle’s study of, 259, 260, 303
and Aristotle’s use of katharsis, 259
character roles in, 271
cognitive experience from, 172
emotions of pity and terror in, 344
focus on human suffering by, 258
as genre of drama narrative in medical
practice, 274
as seen in Paley’s story, 108
Tolstoy’s The Death of Ivan Ilych as, 342–­
45
and way attended to, 268–­69
See also narrative genres
“Treatise of Man,” by René Descartes, 176
Ulysses, by James Joyce, 94
unhealth, modes of
definition of, 4–­5
“The Use of Force,” by William Carlos Wil-
liams
as example of abuse of power in patient-­
physician relationship, 143
as example of failure to listen, 223
example of patient’s silence as form of
communication, 243
role of characters in, 265, 268
index  /  455
use of communication elements in, 218
use of violence in, 337
utilitarian ethics, 65–­66
Valéry, Paul, 257
Vannatta, Dr. Jerry B., 69–­70
and art of storytelling, 352
on use of narrative knowledge, 9–­12, 153–­
54
on vicarious experience of art narrative,
362
Vannatta, Seth, 367
verbal schemas, 27
Verghese, Dr. Abraham
as case historian, 141
as physician/writer, 277
quote of, 211
story of as example of denial as failure,
228–­30
story of as example of stereotype, 230,
231
use of observations of patient by, 186
on writing memoirs of, 280–­81
See also My Own Country; The Tennis
Partner
vicarious experience
ethics acquired from, 296, 348
through examples of physician’s failure to
listen, 224
as provided by art narrative, 150–­51, 166,
201, 226, 297–­99, 300, 311, 362
as provided in The Death of Ivan Ilych,
334, 353–­55
use of mirror neurons in, 398n2
vicarious identification, 312
Vienna Circle, 43
The View in Winter, by Ronald Blyth
on sense of aging, 209
virtue ethics
definition of by Aristotle, 29, 99–­100,
294, 358
checklist for, 379, 380
decency as, 314
as domain of competence, 307
drama narrative portrayal of, 323–­25
in face of death and dying, 316, 326
and failure to achieve, 308–­9
and medical mistakes, 306
as portrayed in The Death of Ivan Ilych,
330, 346–­49, 364
realization of, 313
schemas of, 386–­89
virtue ethics (continued)
as used in everyday medicine, 29–­30, 322
use of narrative skills in, 308, 363
use of speculation in, 66
vocabularies
of biomedical knowledge, 48–­49
difference of between sciences and narra-
tive, 39–­40
in humanities, 38, 56
importance of, 47
of narrative knowledge, 48
quantitative science domination of, 44
as scientific, 36–­37, 56
Von Wright, Georg Henrik, 117
Watson, Dr. John (character), 128–­32, 212,
234, 250, 270
Welch, Joseph Linden, 314
“What I Would Give,” by Rafael Campo,
164–­65
What Science Offers the Humanities, by Ed-
ward Slingerland
on cognitive modalities, 76
theory of mind described in, 61
“When Good Doctors Go Bad,” by Atul Ga-
wande
as example of physician’s failures, 224,
226
“Whither Thou Goest,” by Richard Selzer,
316
Wiggins, David
on nontechnical deliberations, 72–­73, 81,
95
study of Aristotle’s concept of practical
reasoning by, 60
on use of perception in morality, 68
Williams, Raymond, 236
Williams, Dr. William Carlos
on art narrative addressing stereotypes,
231
attention to realistic detail in narrative of,
349
on effect of physician’s view of life, 289
on listening to narrative, 220
on the meaningful whole, 176
narrative plots of, 263
on patient’s silence as form of communi-
cation, 243
as physician/writer, 141, 277, 281–­82
456  /  index
quote of, 168
roles of characters by, 268
salient feature of narrative in poems of,
170
on structure of feeling, 239
story of as example of abuse of power in
patient-­physician relationship, 143–­
45, 149
story of as example failure to listen, 223
use of communication elements in stories
of, 218
use of poetry of in training physicians,
181–­84
use of schemas of roles in narrative to an-
alyze works of, 275
on use of stereotypes, 254–­55
use of stories of to teach empathy, 166
See also Autobiography; The Doctor Sto-
ries; “Old Doc Rivers”; “The Red
Wheelbarrow”; “The Use of Force”
Wit, by Margaret Edson, 104
example of negotiating care in, 322–­25
Wittgenstein, Ludwig, 67
See also Philosophical Investigation
The Woman Who Walked into Doors, by
Roddy Doyle
characters in, 264–­65
ethical medical behavior acquired from,
296–­97
as example of marital trouble experience,
237
example of narrative knowledge on cul-
tural differences, 204
as example of physician’s failure to listen,
226–­27
example of physician’s mistakes, 304
moral element in, 300, 301
narrative form of, 315
role of paternalism in novel of, 142–­43
use of communication elements in,
218
Wordsworth, William, 290
World Health Organization, 374
description of health by, 179
“The Yellow Wallpaper,” by Charlotte Per-
kins Gilman, 234
as example of marital trouble, 237
roles of characters in, 267