"My Story Is Broken; Can You Help Me Fix It?": Medical Ethics and the Joint Construction of Narrative

Ä"My Story Is Broken; Can You Help Me Fix It? Medical Ethics and the Joint Construction of Narrative* Howard Brody // This essay explores some ethical implications of a narrative conception of the physician-patient relationship. I shall argue that the moral basis of the relationship is best preserved and enhanced when the physician and patient go about developing meaning within their encounter in a particular way. Ideally, the physician-patient relationship should be both ethically sound and therapeutically effective. Constructing certain sorts of narratives within that relationship attaches meaning to the patient's illness experience in a way that enhances the healing potential of the encounter. Moreover, when narratives are jointly constructed , power is shared between physician and patient, and the sharing of power constitutes an important ethical safeguard within the relationship. The Meaning of Illness and the Patient's Story Physicians have known, at least since the time of Hippocrates, that the mental, emotional, and symbolic aspects of the physician-patient encounter can ameliorate (or worsen) disease every bit as much as the specific medications and other treatments the physician employs. Modern research into the placebo response has amply documented the power of symbolic healing.1 * Two anonymous reviewers for this journal made several helpful recommendations for clarification and expansion. Literature and Medicine 13, no. 1 (Spring 1994) 79-92 © 1994 by The Johns Hopkins University Press 80 MEDICAL ETHICS AND THE JOINT CONSTRUCTION OF NARRATIVE Although the concept of symbolic healing is vague, a careful review of the literature allows a more precise identification of its operating components. These may be roughly subdivided as explanatory system, care and compassion, and mastery and control. As a general rule, patients will be more inclined to get better when they are provided with satisfactory explanations for what bothers them, sense care and concern among those around them, and are helped to achieve a sense of mastery or control over their illness and its symptoms.2 Patients will become worse when the illness remains mysterious and frightening, when they sense social isolation and lack of support, and when the illness is accompanied by a feeling of helplessness. These components can in turn be broken down into further subdivisions for more detailed empirical study.3 The physician who listens carefully to the patient's story of the illness lays the groundwork for all the important dimensions of symbolic healing. It is the patient's story of the illness—the way the patient has tried to organize, and hence to make sense of, the various manifestations of disease within the context of his own life—that displays the meaning the patient has attached to the illness experience before his contact with the physician. The physician can hardly offer a more satisfying explanation for the illness unless she has first heard out the patient, because the patient will not recognize the new explanation as being about his own illness unless he knows that he has been listened to initially. Being willing to listen to the patient's story—which oftentimes family and friends have dismissed with impatience—sets a tone of care and compassion for the physician-patient relationship. Finally, in Western culture people are used to the idea of gaining mastery or control over events by being able to tell a coherent story about them. Thus, listening carefully to the patient's story begins the process of healing at the symbolic level. It might be argued that healing at the symbolic level is a poor substitute for the scientific application of medical therapy to a properly diagnosed disease state. But symbolic healing as just described is totally congruent with a proper scientific approach to medical diagnosis and therapy, properly understood. George L. Engel, in a highly important paper on this subject, has noted that the beginning of all science is the careful, reproducible gathering of data.4 In the case of illness, the patient's history is the major source of data, since one cannot really perform an appropriate physical exam, or order the appropriate laboratory tests and x-rays, unless one has been guided by the patient's description of his own symptoms. But taking an accurate history is far Howard Brody 81...