Sm. SC;. Med. Vol. 38, No. 6, pp.

855-862, 1994
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ONCOLOGY AND NARRATIVE TIME

MARY-JO DELVECCHIO GWD, TSEUNETSUGUMUNAKATA, YASUKI KOBAYASHI,
CHERYL MATTINGLYand BYRON J. GQOD
Department of Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115,
U.S.A.

Abstractancologists encounter the uncertainty of time horizons in their patients’ lives. Although
American oncologists are given a cultural mandate to instill hope in the therapeutic narratives they create
with patients, uncertainty leads them to expressions of time without horizons or of time with highly
foreshortened horizons as they seek to create for patients an experience of immediacy rather than of
chronology. The distinctiveness of the American pattern is highlighted through comparison with Japanese
exemplar cases and stories of therapeutic practices in oncology. Concepts drawn from narrative analysis
of temporality and the construction of the therapeutic plot are employed.

Key words+ncology, therapeutic emplotment, narrative time, biomedical cultures

Peter Brooks, the literary critic and essayist, in his
1984 work, Reading for the Plot, conceives of narra-
tive as “one of the large categories or systems of
understanding that we use in our negotations with
reality, specifically. with the problem of tempor-
ality,” with “time-boundedness and with the con-
sciousness of existence within the limits of mortality.”
Plot, as “the design and intention of narrative,” is
“what shapes a story and gives it a certain direction
of or intent of meaning,” a logic developed through
“temporal sequence and progression” [ 1, p. xi]. Tem-
poral unfolding and sequencing bring meaning to
narrative. And yet, Brooks proposes, there is a
“necessary retrospectivity” to narrative, a sense that
“only the end can finally determine the meaning.” He
contends that this “anticipation of retrospection” is
“our chief tool in making sense of narrative, the
master trope. of its strange logic.” And he draws on
Walter Benjamin’s claim “that what we seek in
narrative fiction is that knowledge of death which is
denied to us in our own lives; that death writes finis
to life and therefore confers on it its meaning”
[I, pp. 22-231.
When we introduce literary figures such as narra-
tive, plot, emplotment, temporality, and retrospec-
tion into our anthropological observations of
everyday clinical life, including interactions among
oncologists, patients and their kin, new aspects of
medical work and the therapeutic process become
apparent, providing openings to alternative modes of
analysis [2]. In this essay, we focus on two concepts
drawn from narrative analysis: therapeutic emplot-
ment and narrative time. Literary theorists, from
Aristotle to Ricoeur, have argued that plot provides
the underlying structure of narrative, constituting
stories and historical experience as unfolding through
time, constructing “meaningful totalities out of scat-
tered events” [3, p. 2781. Plot has both chronological
and non-chronological dimensions, Ricoeur argues,
succession and configuration, and both have been
central to the analysis of plot as the structure of
narrative [3, pp. 277-280,4]. Reader response theo-
rists such as Iser [S], on the other hand, have focused
attention on “emplotment” as an activity, the re-
sponse of a reader or hearer of a story who engages
imaginatively in making sense of a story, trying to
‘uncover the plot’, to determine what is really going
on and is likely to happen as the action of the story
progresses. The reader thus constructs a ‘virtual plot’
of remembered pasts and imagined futures that shifts
constantly as the action progresses, and which always
contrasts with the ‘actual plot’ of the written text [6].
But ‘emplotting’ is not limited to the teller or hearer
of stories; it is an activity central to (at least) Western
historical consciousness, a feature of the way we
make sense of life. And ‘emplotting’ is a crucial
imaginative response of those who face the sudden
threat of an illness such as cancer [7].
The conceptualization of therapeutic work as ‘em-
plotment’ was introduced by Mattingly in her analy-
sis of the work of occupational therapists with their
patients [8] and is elaborated in her essay in this issue
[9]. Therapeutic emplotment is the interpretive ac-
tivity, present in clinical encounters, through which
clinicians and patients create and negotiate “a plot
structure within clinical time, one which places par-
ticular therapeutic actions within a larger ‘therapeutic
story”’ [9]. Such ‘stories’ have relatively mundane
elements: which therapy will be undertaken first,
what side effects may be experienced, what the se-
quence of treatment is likely to be. In the treatment
of cancer, emplotting the illness and the development
of therapeutic stories also speak to much more
profound questions: what is likely to happen? will the
treatment be successful? What reaZfy will happen
next? Thus the emplotment of the illness and the
therapeutic course is a major task in the treatment of
cancer, one which we examine in this paper [lo].

855
856 MARY-JO DELVECCHIO GXD et al.

Narrative is deeply linked to temporality. Not only interpretations of their work; although our analysis is
do stories have a necessary temporal and sequential also influenced by clinical observations and discus-
dimension in their telling or reading, but they consti- sions with patients, the research reported here did not
tute reality and human action as sequential, histori- systematically compare oncologists’ and patients’ in-
cal, in time [4, 11, 121. Stories have beginnings and terpretations of particular encounters. A recently
endings. As Brooks notes in the passage quoted in the launched study is designed to do this, thus allowing
opening of this paper, narrative presumes directional- us to bring all three perspectives-that of patients,
ity and an ending, an outcome or conclusion toward oncologists, and social scientists-to the analysis of
which the story is directed and which bestows sense clinical and therapeutic narratives. The examples of
on what has occurred [13]. Concern about how the American practices and stories of therapeutic work
story will turn out, about how the present will be seen are contrasted with published stories and accounts by
retrospectively from the vantage of the ending, is Japanese physicians and social scientists who are
present as a structuring quality in all story-telling and venturing to transform contemporary Japanese medi-
emplotment, What Ricoeur [14] calls “narrative cal practice [17]. Our data include Japanese texts
time” is thus a crucial dimension of all plots and which have been developed as ‘lessons’ or exemplars
emplotting, and literature on time and narrative for clinical practice in recent Japanese medical jour-
provides a conceptual frame for analyzing the prob- nals and government publications. Even a brief exam-
lem of temporality and endings. Such analysis is ination of Japanese data, such as provided in this
especially relevant to narrative dimensions of clinical paper, brings aspects of American oncological prac-
work with the seriously ill. In this paper we examine tice into sharper relief and highlights the role of
how oncologists address the challenge of crafting culture and political economy in shaping therapeutic
therapeutic time, in particular how they deal with the practice.
problem of endings which is special to the treatment Three observations concerning the process of
of cancer, through an analysis of physicians’ reflec- therapeutic emplotment and the structuring of narra-
tions about their work and preliminary observations tive time in oncological practice emerge from our
of interactions between physicians and patients. work in progress. First, oncologists consciously and
The general approach we follow here draws on deliberately attempt to manage time horizons for
literary critical and philosophical studies of narrative, their patients, and therefore instill desire and hope,
and should be distinguished from conversation analy- through emplotment of therapeutic narrative and
sis or other forms of discourse analysis [ 151. Although action. Second, the emplotment of the therapeutic
these forms of analysis have contributed greatly to process and the structuring of narrative time differs
our understanding of power relationships between across biomedicine’s local worlds; these differences
professionals and patients and communication within are striking when we compare oncological practice
clinical encounters, here we draw on narrative theory and the culturally dominant therapeutic narratives
to examine how physicians use their professional produced by physicians in two medical systems-the
power to create therapeutic course, desire and hope American and the Japanese-with comparable levels
and to structure clinical time. of technological development. Third, physicians’
‘Endings’ are frequently part of oncologists’ stories have multiple and parallel therapeutic sub-
stories; yet, the fear that ‘endings’ will not only be plots, each tailored to specific audiences-pro-
undesirable but precipitous leads to resistance-by fessional colleagues, patients, or patients’ family,
both physicians and patients-to their explicit formu- friends and kin-and temporality or the management
lation during the course of therapeutic treatment and of narrative time is different in these alternative forms
interaction with patients. This resistance contributes of emplotting the illness.
to how oncologists seek to ‘emplot’ therapeutic ac-
tion, how they attempt to formulate experiences for
NARRATIVE TIME AND THERAPEUTIC EMPLOTMENT
patients designed to instill hope and lead them to
invest in often arduous and toxic treatments, how Oncologists encounter the uncertainty of time hor-
they structure time and horizons in attempts to avoid izons in their patients’ lives. Because American oncol-
creating a sense of false hope or despair, and how ogists are given a cultural mandate to instill hope in
they choose metaphors to engage patients in a the therapeutic narratives they create for and with”
struggle against disease and death, often largely patients, their knowledge and uncertainty about out-
shaped by the biotechnical context within which this comes of particular cancers and treatments and
occurs. patients’ uncertainty or anxiety about endings leads
We explore dimensions of therapeutic narratives to a number of narrative strategies of therapeutic
crafted by oncologists through examples drawn from emplotment. In particular, in our experience, it leads
our cross-cultural studies currently underway. Our oncologists to an expression of time without horizons
research texts are drawn from interviews with and or of highly foreshortened horizons, as they seek to
preliminary observations of American medical, surgi- create an experience of immediacy rather than of
cal and radiation oncologists [16]. Our methodologi- trivial chronology-of one meaningless treatment
cal focus for this essay is on oncologists’ after another. Time horizons, through therapeutic
 Oncology and narrative time 857

discourse and interaction, are distinctly foreshort- easy it is to jump in assuming a level of reception that isn’t
there.
ened, and experience is consciously composed ‘for the
moment’. Endings, though palpably present for par- Therapeutic emplotment may seem trivial in these
ticipants in the clinical encounters, are unspecified in early phases, but attention to the trivia of daily
the therapeutic narratives. Instilling hope ‘for the treatment and the focus on the technological require-
moment’ becomes a legitimate and realistic task in the ments set the ground for more significant encounters,
world of clinical oncology, a task placing the medical when difficulties of course and prognosis are ad-
oncologist in the role one characterized as ‘the dressed. These initial phases are captured in
patient’s cheerleader; I’ve got to be their cheerleader.’ metaphors of housekeeping, suggesting unremark-
The creation of an experience of hope through an able, possibly comforting and caring activity, without
emphasis on temporality and on experience ‘for the crisis or threat to daily existence: “There is a lot of
moment’ is often fraught with great anxiety for housework, the boring part of getting people into
patients, who seek knowledge of prognosis and cer- radiation therapy. All those little appointments and
tainty of illness course. Yet, in clinical observations time schedules and things. All of that occupies the
(and in interviews with patients in previous and trivial time when you circle around each other per-
current studies), we frequently find that patients, too, haps.” And, she continues, these issues provide the
evoke, participate, and at times collude in the shaping focus of attention while you wait to “talk turkey”, to
of narrative and clinical time in terms of open-ended be more explicit about the effects of treatment and
time horizons and immediacy. Given the inevitable course of disease.
‘blanks’ in any potential readings of the future they Metaphors that join images of struggle, progress
face, patients join with clinicians in constructing and hope stand in contrast to the housekeeping
stories which provide a commitment to treatment and metaphors, and may be employed subsequent to or in
hope for positive endings as well as a focus on the parallel with those which focus on the ‘trivia’ of daily
moment [5, Chap. 81. experience. One medical oncologist characterized his
‘For the moment’ is often defined in terms of each work with patients as follows:
carefully calibrated stage in the course of treatment
It’s like when you climb a mountain, and it looks so
and each step in disclosure of information about
enormous. The only way you can climb it is one step at (I
prognosis. A radiation oncologist noted that when time. And I tell [patients] that the only way we are going to
patients come to her, she is often uncertain about deal with this is one step at a time. The first step is going
what they understand about their diagnosis, much to be to control the pain, and then we are going to work into
less their prognosis. She characterizes her referred these various [therapeutic] options. Because then people put
their mental energies on to some thing, and they are not so
patients as being “only part way through the conver- overwhelmed.
sation.” Staging disclosure about treatment and
prognosis is part of this ongoing “conversation” and Although no ending is explicit in this reflection on
emerges as a major clinical task-the creation of clinical work, the image of mountain climbing does
therapeutic narratives-for medical and radiation give a metaphorical equivalent for therapeutic time
oncologists. which is marked not by degeneration but by progress
[18]. Climbing a mountain is arduous and one might
not succeed, but each step is important, heading the
METAPHORS IN THERAPEUTIC NARRATIVES patient closer to the top, to the desirable place, to the
end of the climb. Each step is organized in progressive
The metaphors which American oncologists em-
staging, each representing an advance over the last.
ploy in the creation of these therapeutic narratives are
Controlling pain is therefore a definite advance over
extraordinary in their contrasts: metaphors of house-
having pain, and lessening pain will help patients face
keeping and of the maintenance of daily life are
other therapeutic tasks ahead of them. The metaphor
mixed with metaphors of staging, struggle and pro-
of mountain climbing, used by many oncologists as
gress. Both types of images contribute to the experi-
they characterize treatment course, is often implicitly
ence of immediacy.
placed in opposition to the slow, downward spiral
Oncologists interviewed constantly referred to their
toward death. It is a metaphor of protest, an image
explicit and conscious efforts and the care with which
which suggests that the oncologist will pull the
they seek to frame the therapeutic process for patients
patient to safer, higher ground. It also is a metaphor
and mold the development of a dialogue. We later
which taps into American concepts that through
observed clinical interactions which largely matched
mobilizing personal will, the patient has resources to
these interview recollections. One radiation oncolo-
engage in the struggle for higher ground, for cure or
gist noted how she shapes the early phase of the
remission [ 161.
clinical dialogue and engages the patient:
As ‘immediacy’ is emphasized in the therapeutic
You are taught to approach people very cautiously and narrative, the horizon of the future is deliberately
develop the dialogue or the discussion over time. The first
blurred, even as patients may struggle to live into the
time you meet somebody, it is not necessarily the smartest
time to talk turkey. And we are taught to stage things, and future. Therapeutic time and life time (the patient’s
I think that has stayed with me, because I have seen how own sense of chronology not only of the therapeutic
858 MARY-JO DELVECCHIO GOOD et al.

process and of illness course but of life in toto) are everyday realities of living and of therapeutic house-
both addressed by oncologists. They are inevitably keeping, of treatment schedules, of dealing with
confounded. A chief of oncological surgery described immediate side effects, of assessing the current
how he tries to instill hope in patients by attempting efficacy of the latest therapy, of resuming a focus on
to lead them to an experience of immediacy while daily activities. As cancer patients come to learn to
concomitantly shaping a potential ending, but one live in the immediacy of treatment decisions and
which is deliberately ambiguous in terms of time and therapeutic activities set within the social context of
chronology: the clinic, they enter into a narrative form in which
endings are rarely made explicit and progression is
You have to love your patients. And I think that if you love
people and you truly love your patients-we all respond to measured in calibrated bits, even though disclosure is
love, and patients respond to it-you build a relationship considered to be the norm, a patient’s right in
that is mutually enjoyable. [It is through this relationship, American medicine, and frankness is valued.
he implies, that one instills hope and works out the course The narratives of immediacy often seem to co-exist
of life time.] It’s not a sense of hope that they are going to
with other, unspoken narratives. We found this par-
live for a long time or forever. It’s the sense, first of all, of
reminding them of the uncertainty with which we all live ticularly striking when working with several patients
everyday from the time of birth. And I often go with them who were close to death. Several radiation and
through Freud’s writing. [Here he discusses at length medical oncology patients, in their own private
Freud’s notion of fear of death as a primal drive.] Working worlds of family, friends and kin, had come to
through their own mortality is often a very beneficial and
resolution and had crafted endings to their lives (the
helpful thing. Realizing that someday they may die and if
may be soon and it may not be, gives a greater color and endings sometimes included a sensibility of living into
richness to every day that they’ll live thereafter. So I the future, beyond bodily presence). Yet, in their
encourage them to take the benefit of this disease, which is encounters with their oncologists, the conversation
to challenge them with their own mortality, and to evaluate continued to focus on treatment decisions, even when
their life in terms of enjoying their family and their friends
the oncologists were prepared to discard the thera-
and their job and the beauty of a Fall New England day in
a richer way than they would have otherwise.. peutic narrative and to take up the hospice role, to
speak with patients of endings and of dying. At this
The experience of immediacy is also contrasted point, the therapeutic narratives of immediacy and
with fear of ‘time running out.’ A medical oncologist hope, of struggle and progress, fragmented.
recounted how he intervenes to subvert the sense of
time running out, to shape therapeutic time and
NARRATIVE TIME AND BIOMEDICINE’S LOCAL WORLDS
narrative. In discussing how he attempts to instill
hope in patients, he related that patients The emplotment of the therapeutic process and of
have to have hope and they have to have structure. the sense of time differs across biomedicine’s local
Otherwise they have a clock ticking in their head. Doctors worlds. A society’s culture of hope, its conceptualiz-
who don’t provide hope, facilities that don’t provide hope, ations of individual will and psyche’s relationship to
or at least some positive outlook or support, the patients soma, as well as its culture of biomedicine, its utiliz-
don’t stay.. You have to give people something to wake
ation of biotechnology and its political economy of
up for in the morning, otherwise they might as well take
some cyanide. medical research-all contribute to frame the phys-
icians’ structuring of therapeutic time [16]. These
In our preliminary clinical observations, we found broader societal dimensions may justify action and
that oncologists quickly encourage patients to speak drive physicians to intervene, to shape ‘life time’ as
about immediate needs and desires. Patients we ob- well as clinical time [9].
served asked if they may take up golf again, exercise, The contrast between American and Japanese
return to work, take a trip. They asked about treat- physicians’ narratives of time and disclosure high-
ment side effects and what they should do in their lights cultural diversity in the conceptualization of
daily toiletry. Oncologists could enthusiastically re- therapeutic plot and progression, in the specification
spond yes and give sound advice. But patients also of time horizons in clinical narratives, and in cultural
asked if they should sell their boats, vacation cabins, ideals and struggles that emerge in the formulation of
to pay for the extra expenses incurred by being in endings. The dominant American narrative, new in
treatment [19]. In initial encounters, questions such as its magnitude to the latter 20th century, requires early
these appeared to the observer to be invitations to disclosure of diagnosis and a successive flow of
physicians to reveal the future, to open discussions information designed to engage patients in the thera-
about prognosis, and yet, physicians often deflected peutic endeavor and to instill hope [21]. In contrast,
such questions. (In an earlier study we conducted Japanese physicians have traditionally masked the
with patients undergoing anticancer therapies, diagnosis of cancer and are only beginning to struggle
patients’ concerns for information were foremost with what they refer to as ‘telling the truth’ [22].
about prognosis, second about disease process, and These differences in therapeutic plot and in the
third about treatment side effects and options [20].) structuring of time and endings, we propose, are
The clinicians whom we observed created narratives grounded in different conceptions of appropriate
of immediacy; they drew patients back into the medical interactions between patients and physicians,
 Oncology and narrative time
in different notions about how hope is maintained
and disease and death resisted, and in available
options for therapeutic interventions.
The Japanese practice of masking the diagnosis of
cancer has come under sharp public scrutiny in recent
years [ 16, 171, and there is evidence of increased
concern in the Japanese medical profession about
telling cancer patients ‘the truth’. In 1989, the
Japanese Medical Association and the Ministry of
Health and Welfare published a manual entitled
Manual of Terminal Care for Cancer Patients [23],
and devoted several chapters to lessons on ‘Telling
the Truth’ and ‘Psychological Care’ for cancer
patients. Telling the diagnosis of cancer rarely occurs,
but when it does, it becomes clear that the illness is
likely terminal. Thus the structure of the therapeutic
narrative in the treatment of cancer patients initially
proceeds without the patient having explicit knowl-
edge of the diagnosis. Whereas for American phys-
icians, discussing prognosis with patients constitutes
a major challenge, one often fraught with difficulty,
revealing the diagnosis of cancer to patients is often
a major hurdle for most Japanese physicians. In a
1987 survey of 1839 Japanese physicians conducted
by a medical pharmaceutical magazine published by
Upjohn, Scope [24], 75% of physicians of those who
had family members suffer from cancer had not told
their kin their diagnoses of cancer; 81% felt they did
the right thing by not revealing the diagnoses,
although most of these physicians would like to be
told the truth if they had cancer (69% directly, 22%
ambiguously). Eighty-one percent of the quarter who
did tell family members their diagnoses also felt they
had done the right thing. A more recent survey
conducted in 1991 indicates popular interest in
changing the shaping of disclosure and perhaps the
therapeutic narrative that has until recently been the
dominant mode in Japanese medical practice [25].
The following Japanese professional moral scen-
arios, drawn from the Manual of Terminal Care for
Cancer Patients [26], were developed as ‘lessons’ to
exemplify how Japanese oncologists should emplot
the clinical encounter, tell the truth, and give hope.
They provide an additional perspective on how ambi-
guity and metaphor are used in cosmopolitan and
local practices of biomedicine. In these Japanese
examples, the balance between ‘frankness’ and ambi-
guity are carefully considered.
Lesson 1. Physicians should consider methods and ex-
pressions for telling the truth. For example, an indirect
method for ‘telling the truth’, keeping a balance between
disclosure and non-disclosure (soretonuku), and giving a
‘hint’ will allow the process to be gradual and paced and
allow for ambiguity.
Lesson 2. Easy encouragement should be avoided. For
example physicians should avoid easy encouragement which
does not allow the patient to express their feelings. An
example of easy encouragement is:
Patient: Doctor, I can’t be treated any more.
Doctor: Don’t say such weak things, a weak attitude. Bear
up.
859
Patient: Uh, yea. (weakly)
In this situation, the patient expresses weakness and wants
the doctor to respond; thus the doctor has to be empathetic.
Lesson 3. How to communicate empathy.
Patient: I can’t be treated any more.
Doctor: You have a feeling you can’t be treated any more?
Patient: Yes, I am thinking about this, because I have been
hospitalized for almost 6 months.
Doctor: As you have said, months have passed.
Patient: I feel physically weakened.
Doctor: You have the feeling or sense of gradual weakening.
Patient: Yeh, I am scared to die-in these days. Scared.
Doctor: (replies with emotion) You are (yes) (sodesuka).
Lesson 4. How to inform the patient you are a co-fighter in
this process. In practical clinical situations, it is important
how we select expressions. For example a good term is
literally ‘a long term fight’. [This is a single word in
Japanese-chokisen.]
Doctor: Probably, we have a long term fight.
This will have three meanings to the patient. First using this
term will mean there will be no immediate results from
treatment, but also because the fight is ‘long term’ the
patient will also determine that you mean he will not soon
die. Second, a long fight implies an up and down process,
some days the patient will feel well, other days his condition
will be worse. This up and down process will give the patient
a sense of hope for good days. Third, the physician demon-
strates the positive attitude of being a co-fighter. Of being
with the patient through the process.
The Japanese physicians who constructed this lesson
believe that one can say many things through this one
word, leaving the rest to the partner in the conversa-
tion.
Lesson 5. Another example of demonstrating empathy and
being a ‘co-fighter’ is to touch the abdominal area, perhaps
thus indicating a visceral core, and ask ‘how is the common
enemy? ‘This is a very strong enemy’ or ‘We deal with the
enemy with deliberateness.’ These are good expressions, and
we can use ‘our enemy’ and ‘very strong opponent’ without
using the words such as ‘cancer’ or tumor’. Through these
expressions we can convey that we are co-fighters and with
the patients.
These Japanese lessons in how to construct new
therapeutic narratives, although offering a contrast to
the American mode, also seek to blur endings, time
and horizons, even as they convey the threat of the
disease. In fact, the interpretation given to the
metaphor of ‘a long term fight’ not only captures
uncertainty and maintains ambiguity about endings,
it also captures a common pattern of experience, of
‘ups and downs’ and uncertainty about outcomes, of
patients suffering life threatening or terminal cancer
1271.
MULTIPLE SUBPLOTS AND PROGRESSIONS
In any clinical encounter, multiple therapeutic nar-
ratives, each with its own plot structure and shaping
of narrative time, are present among participants.
Not only may there be explicit as well as unspoken
stories maintained by physicians, patients and kin-
possible courses and outcomes of the illness-but
different narratives are structured by oncologists in
conjunction with different actors or audiences [28].
 860 MARY-JO DELVECCHIO Goou et al

These parallel plots may be conceptualized as (1) and course but for a society’s choice of investment in
those which are professional and bounded, neither cancer research and in the production of anti-cancer
for lay nor patient consumption; (2) those which are therapies. The creation of hope and desire for par-
professional, designed for the patient; and (3) those ticular modes of anti-cancer therapies through
which are intended for family, kin and friends. metaphors central to emplotted clinical time can lead
Chronology, progression, the designation of an ‘end- to the cornmodification of ‘hope’ and to expectations
ing’ may not only be distinctive for each subplot but of material salvation through biomedical technol-
may be productive of tension in therapeutic inter- ogies. Additional research is necessary to explore the
action and in the experience of therapeutic work. consequences of varieties of therapeutic narratives in
Japanese physicians deliberately speak about the production, marketing, and employment of vari-
different stories constructed for kin and for patients. ous modalities of treatment [29].
In the manual discussed above, exemplar cases in
which only husbands were informed of a wife’s
terminal illness are contrasted with cases in which CONSTRUCTING ENDINGS
both the patient and spouse were informed of a
diagnosis of cancer with poor prognosis [23]. Conse- A critical dilemma for American oncologists arises
quences for family life are discussed through these when therapeutic action-urative or palliative-is
contrasting examples; in both case examples, how- no longer an option. At such times the therapeutic
ever, family members were told prior to the patient narrative may fragment. A shift in therapeutic em-
being told about the disease. plotment among patients, physicians and family
We also find distinctively American discrepancies members often occurs, and the physician’s pro-
among subplots elaborated in therapeutic narratives fessional and biomedical subplot, predictive of time
with kin and with patients. Although variation occurs and explicit about horizons, may suddenly become
by patient age and competency, and by severity of quite central to medical decisions and conversations
disease, American physicians create partnerships and with patients. Treatment is at an end. Patients are
therapeutic narratives primarily with their patients. moved from the care of oncologists to the care of
(Pediatric oncology poses special difficulties. The hospice physicians. At times, patients are physically
relationship may be primarily with parents, and moved from tertiary care hospitals to hospice sites or
alternative forms of therapeutic narratives are devel- home-based hospice care. The Japanese stories from
oped for parents and children.) Near the end of the the medical journals explain that it is at this moment,
patient’s life, the focus of the therapeutic narrative at the end of life, that ‘telling’ often occurs-that it
shifts to engage kin to a greater degree, and endings often occurs silently, conveyed through the tears of
may be made explicit for family members at this stage nurses, occasionally of physicians [30]. It is then when
even when ambiguity is maintained for the patient. immediacy, the ‘for the moment,’ becomes death.
This pattern contrasts with the accounts in the cur- It is also at such times that in the American case
rent Japanese oncology literature, which suggests that the technologies employed at the end of life may enter
patients are told of their diagnosis near the end of life the plotting of an ending to the therapeutic narrative.
and kin are informed of the disease more readily Decisions about whether to undertake treatments
during earlier consultations. which offer hope of remission often continue to be
Professional narratives, shared among physicians, made up to the very end, and ambivalence and
are more explicit about time and horizons, incorpor- indecision about the use of or removal from life
ate odds and statistics in assessment of certainty and supports often continue in a distinctively American
uncertainty, and are based on clinical experience, fashion, provoking images of the inconclusive and
evidence of clinical trials, and knowledge of specific unsatisfying endings of post-modern literature. Peter
types of cancers and treatments. Professional narra- Brooks, in Reading for the Plot [I, pp. 313-3141,
tives are revised continuously and are maintained reflects on difficult endings in a passage relevant not
among care providers as an alternative to those only to contemporary literature but to contemporary
developed with patients and their families. Although North American medical practice as well. He writes:
our research is incomplete at this time, it appears that Toward the end of Samuel Beckett’s Endgame. Clov speaks
the professional narrative may be shared with (‘imploringly’) to Hamm: ‘Let’s stop playing.’ Hamm
patients and families toward the end of life, when replies: ‘Never!’ Then, after a pause: ‘Put me in my coffin.’
And Clov answers: ‘There are no more coffiins.’
endings mean the conclusion of the struggle and when
the more hopeful therapeutic narratives fragment. Brook continues:
This is a time when American patients may fear Ends, it seems, have become difficult to achieve. In their
abandonment by their oncologists, and when oncolo- absence, or their permanent deferral, one is condemned to
gists talk about the ideal-not always realized-of playing: to concocting endgames, playing in anticipation of
being available to the end for their patients. a terminal structuring moment of revelations that never
comes, creating the space of an as-if, a fiction of finality.
Our research suggests that therapeutic narratives,
There is a wait for the end that never achieves satisfaction.
including the professional narrative, have conse- When ending comes, it is more in the nature of stalemate
quences not only for patients’ experience of treatment than victory.
 Oncology and narrative time 861

Such endings are also a part of therapeutic plots in emplotment” and “therapeutic narrative” in this paper
refers to how the unfolding stories of treatment are
American medicine.
created and shaped, rather than to a purported thera-
peutic, cathartic or healing dimension of the telling of
Acknowledgements-This paper is dedicated to the illness narratives.
Reverend Larry Hill who inspired our thoughts about 11. Good M. Oncology and narrative time. Paper presented
narrative time, endings, and crafting a meaningful life. The at the American Anthropology Association meetings,
authors wish to thank Rita Linggood, M.D. and Ena New Orleans, December 1990.
Chang, R.N., B.S. for their very thoughtful comments 12. Carr D. Time, Narrative, and History. Indiana Univer-
during this work; the patients, nurses and physicians who sity Press, Bloomington, 1986.
participated in various aspects of our studies and generously 13. See also Kermode F. The Sense of an Ending. Oxford
contributed their time; and Margaret Lock for earlier
University Press, London, 1966.
conversations on Japan and disclosure. The authors would
14. Ricoeur P. Narrative time. In On Narrative (Edited by
also like to thank the two anonymous reviewers for helpful
Mitchell W. J. T.), pp. 165-186. Chicago University
suggestions. The original version of this paper was authored
Press, Chicago, 198 1.
and presented by Mary-Jo Good at the American Anthro-
15. See, for example, Fisher S. and Todd A. D. (Eds) The
pological Association Meetings, 28 November-l December,
Social Organization of Doclor-Patient Communication.
1990, New Orleans, in Narrative Representation: Stories of
Center for Applied Linguistics, Washington DC, 1983;
Illness and Healing, invited session sponsored by the Society
Mishler E. The Discourse of Medicine: Dialectics of
for Cultural Anthropology and the Society for Psychologi-
Medical Interviews. ABLE%, Norwood, NJ, 1986;
cal Anthropology. Organizers and Chairs: Professor Linda
Waitzkin H. and Stoeckle J. D. Information control and
Garro and Professor Cheryl Mattingly.
the micropolitics of health care. Sot. Sci. Med. 10,
263-216, 1976; and Waitzkin H. The Politics of Medical
Encounters. Yale University Press, New Haven, 1991.
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1
_r._... 21. Oken D. What to tell cancer patients: A study of
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