Perspectives in Biology and Medicine

Perspectives in Biology and Medicine

Volume 56, Number 4, Autumn 2013
Johns Hopkins University Press
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Against Narrative Medicine

Abstract

This essay aims to provoke debate on how and what the medical
humanities should teach. It argues that the field has been dominated
(to its detriment) by two misguided movements, postmodernism and
narrative medicine, and that it should be redirected from utilitarian
aims towards the goal of exposing medical students to a climate of
thought and reflection.

C. P. SNOW’S FAMOUS 1959 REDE LECTURE at Cambridge, The Two Cultures and
the Scientific Revolution, is still widely cited for its description of the
“mutual incomprehension” between literary intellectuals and scientists.
The description struck a chord, and the phrase “the two cultures” entered
the language. It is still used today as a sort of shorthand to describe the
disconnect between science and the humanities. Some would argue that
Snow’s argument is even more relevant today than it was in 1959, when

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 postmodernism had yet to become the dominant force within the
humanities. Today, the clash of the two cultures is at its starkest in the new
discipline of medical humanities.

The Problem with Medical Humanities

The purpose of medical humanities is currently unclear, and the lack of any
substantial research base has given it a low status within medical schools.
The confusion about medical humanities is largely due to two
developments: first, obscurity and overspecialization on the part of
postmodernist humanities academics; and second, the narrative medicine
movement, which has achieved preeminence within the discipline almost
to the exclusion of all else. [End Page 611]

Postmodernism and Medical Humanities

Medical humanities began in the 1960s with modest aims. Initially, it

covered such ground as ethics and the history of medicine. Then it began to
examine great works of literature, or not-so-great works of literature written
by authors who were medically trained, to examine whether these works
could teach about the experience of illness or the business of doctoring. In
the early years, courses in medical humanities were generally taught by
doctors who happened to have an interest in literature, history, and ethics,
but career humanities academics from a variety of disciplines, such as
English literature, history, philosophy, sociology, and anthropology,
gradually began to take a keen interest. Medical schools, however, failed to
spot the seismic changes in the humanities that began in the late 1960s:
deconstruction, structuralism, post-structuralism, and relativism, all of
which might be placed under the broad umbrella of postmodernism.
Doctors and trainees were mystified by postmodernist claims that there
was no objective truth, that all written documents—even scientific papers—
were “narratives” informed by the cultural and economic milieu of the
authors, and they failed to recognize the anti-scientism of postmodernism’s
high priests, such as Foucault and Derrida.

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 Modern scientific medicine is essentially a product of the Enlightenment,
and its astounding success in the 20th century was proof enough for most
doctors of the truth of Enlightenment ideals. Yet like all astounding
successes, a degree of arrogance crept in, and modern medicine began to
be seen in some quarters as inhumane, mechanistic, arrogant, and self-
serving. Medicine, for all its success, has become unsure of itself,
particularly in the area of doctor-patient relationships.

And into this void has stepped the medical humanities. The
contemporary study of medical humanities has grand ambitions: the
promotion of social justice; the teaching of empathy; the encouragement of
sensitivity to ethnic, gender, and cultural issues; and an end to the old
patriarchalism. Medical humanities has its own journals, conferences, and
academic departments, and it has enthusiastically adopted the language of
academic postmodernism. Here is a sentence from a recent article in the
journal Medical Humanities entitled “Medical Humanities as Expressive of
Western Culture”: “The act of asserting disciplinarity, even
interdisciplinarity, derives momentum from a certain teleological impetus
to self-narrate, producing a coherent or centralising version of self-hood in
relation to one’s envisaged audience” (Hooker and Noonan 2011, p. 80).
This passage is reminiscent of the infamous 1996 Sokal hoax, when the
eminent physicist Alan Sokal submitted a paper to the American journal
Social Text entitled Transgressing the Boundaries: Towards A Transformative
Hermeneutics of Quantum Gravity. The paper, a parody of postmodernist
jargon, was accepted and published.

Complementary/alternative medicine, according to this worldview, is

simply a different narrative. The leading article in the New England Journal
of Medicine is understood to be no different from a poem: it is simply
another narrative, and no single narrative should be “privileged.” A recent
article in the Journal of Evidence [End Page 612] Based Healthcare, for
example, labels evidence-based medicine as a “good example of
microfascism at play in the contemporary scientific community” (Holmes
et al. 2006, p. 180). This mode of thought has achieved a remarkable
dominance, particularly in elite U.S. universities.

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 Narratology
The medical humanities journals are aimed at a small audience of
specialists. Certain words and phrases occur regularly: “otherness,”
“postcolonialism,” “advocacy.” But the word that has dominated discourse
in the medical humanities is narrative. A quick review of original articles
published over the last 10 years in the journal Medical Humanities reveals
that just over 10% contained the word narrative in the title.

“Narratology” has its origins in literary critical theory. The distinguished

literary critic John Sutherland (2010) has called it “The Higher Mumbo
Jumbo”: “The art of literature, Henry James tells us, lies in the telling, the
narrating, not in what is told—the raw materials of fiction are, in
themselves, just that: raw. Concentration on narrative has created a critical
climate; an orthodoxy and a whole new set of players in the great game of
fiction—implied readers, implied authors, unreliable narrators” (p. 30).
Narratology has spawned a pseudo-scientific terminology (“narrativity,”
“narreme,” “narrate”), as well as banal statements of the obvious, such as
the definition of narrative discourse as “someone telling someone else that
something happened” (Charon 2001, p. 1898). One of the ironies of
postmodernism is that for all its anti-scientism, it is very keen on coining
scientific-sounding words and phrases.

Narrative Medicine
Inevitably, the obscure academic theory of narratology colonized the
developing discipline of medical humanities. The term “narrative
medicine” has been promulgated by Rita Charon (2001), a Professor of
Medicine at Columbia University. In the space of little over a decade,
narrative medicine has become the dominant and unchallenged orthodoxy
in medical humanities. Like the postmodernists, the narrative medicine
lobby believe that patients are ill-served by a medical establishment that is
relentlessly mechanistic and dehumanizing. “Inevitably,” writes Raymond
Tallis in (2004), “many commentators trained in the
humanities, and remote from the responsibility for making and acting on

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 correct diagnoses, see the tussle or tension between stories as a
hermeneutic power struggle, with the omnipotent doctor crushing the
powerless patient with his version of events” (p. 48).

Charon has written extensively on the subject and runs the Program in
Narrative Medicine at Columbia. The program’s mission statement declares
that “Narrative Medicine fortifies clinical practice with the narrative
competence to [End Page 613] recognize, absorb, metabolize, interpret
and be moved by the stories of illness.” As an example of narrative
medicine in practice, Charon cites an encounter with a woman with
Charcot-Marie-Tooth disease, a hereditary disorder. She learns that the
patient’s seven-year-old son has started to show signs of the disease, and
she is “engulfed by sadness as she listens to her patient. . . . the physician
grieves along with the patient, aware anew of how disease changes
everything, what it means, what it claims, how random is its unfairness,
and how much courage it takes to look it full in the face” (p. 1897). We learn
that in a subsequent visit, Charon gives the patient a piece she has written
about their previous encounter and reports that the patient “felt relieved
that her physician seemed to understand her pain.” (I suspect that many, if
not most, of my patients would regard such an intervention as
inappropriate.)

“She can listen at a different level,” says an admirer: “For instance, your
doctor might ask: ‘How long have you had shortness of breath?’ You say,
‘Since I divorced my husband.’ The next question might be ‘How long ago
was that?’ In contrast, a Rita Charon would then say, ‘Tell me about that
relationship.’ She teaches them how to listen and what to listen for”
(Holloway 2005, p. 38). We are not told whether “a Rita Charon” would
pursue a more conventional line of enquiry (duration of symptoms, etc.)
before exploring the dynamics of the patient’s failed marriage, or how this
imaginary patient might have been tempted to reply, “None of your
business.”

Practitioners and students of narrative medicine are thus encouraged to

see the clinical consultation as a story, set against a complex backdrop of
personal history, culture, ethnicity, gender, and economic status. Students

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 are taught the skills of “narrative competency.” Literature is mined for
examples of the experience of illness. Reading and writing groups
encourage students and doctors to write their own narratives about their
patients and their jobs, and they may even—à la Rita Charon—encourage
patients to read what they have written about them.

Discourse in narrative medicine is clouded in impenetrable jargon,

strongly influenced by postmodernist literary theory. And much of the
language employed has a religious flavor: “witnessing,” “professing,”
“honoring.”

Narrative Medicine and Sentimentality

Although it is easy and amusing to poke fun at narrative medicine for its
smugness, its pretention, and its risible jargon, there is a more serious issue
at stake. Narrative medicine is spiritually arrogant and potentially harmful.
It encourages doctors to stray from their core professional duties into
uncharted waters, to take on roles such as spiritual adviser, social worker,
life-coach, friend. Vulnerable patients may develop unrealistic expectations
of doctors, hopes that will inevitably be disappointed. And it is not only
patients who lose out. Impressionable medical students may feel
themselves to be failures if they fail to match the superhuman [End Page
614] empathy of a Rita Charon. Doctors who are not “engulfed with
sadness,” or who fail to “grieve” with their patients might be seen to have
fallen short in some way and might be encouraged to undergo training in
“narrative competency.” Diffident students may understandably shy away
from writing “narratives,” particularly if English is not their first language
and indulgent personal reverie is not a part of their culture. Narrative
medicine thus encourages sentimentality— that is, the expression of
emotions that one does not truly feel. But as Bruce Charlton observes in an
essay in (1998):
“When sentimentality intrudes into medicine, we can be confident that
charlatanry is seldom far behind” (p. 38).

Narrative Medicine and Consumerism

Medicine is, and always has been, messy, imprecise, and uncertain. Doctors

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 are commonly criticized for being impersonal and hurried in their dealings
with patients. In our consumerist age, this dissatisfaction will inevitably
worsen. Tallis (2004) has warned of the customer-friendly doctor: “the
doctors of the future will be easy-going and friendly conformists,
relentlessly reasonable and entirely clubbable. . . . able without thinking to
assume the relaxed user-friendly mode of automated openness and the
postures of ‘caringness’” (p. 243). Tallis argues that the customer-friendly
doctor, although superficially more empathetic, is motivated mainly by the
desire for a quiet life and is unlikely to take time for those difficult decisions
that may ultimately prove to be in the patient’s best interest.

Doctors should—and generally do—treat their patients with courtesy,

dignity, and kindness. It is inevitable that they sometimes fall short in this
regard and fail to show grace under the intense pressure of modern
practice. The narrative medicine imperative to express an empathy which
the doctor may or may not feel cheapens, undermines, and coarsens the
relationship between patient and doctor. Older, more stoically inclined
patients in particular may find this form of engagement with their doctor
vulgar, embarrassing, and intrusive.

Can Narrative Medicine Teach Empathy?

We also need to be on our guard against ideas such as that the study of
medical humanities can teach “empathy.” Jane Macnaughton (2009), from
the Centre for Medical Humanities in Durham, has argued that “it is
potentially dangerous and certainly unrealistic to suggest that we can really
feel what someone else is feeling. It is dangerous because, outside the
literary context, where we are allowed direct experience of what a fictional
patient is feeling, we cannot gain direct access to what is going on in our
patient’s head” (p. 1941). She concludes: “a doctor who responds to a
patient’s distress with ‘I understand how you feel’ is likely, therefore, to be
both resented by the patient and self-deceiving” (p. 1941). Sherwin Nuland,
author of (2010), is also sceptical about teaching empathy:
[End Page 615]

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 there have been many attempts to teach empathetic care of the
dying but too often they have proven to be scattered, superficial,
and, in the end, ineffectual. . . . There often exists a quality of
studied pedagogy in such academic attempts and even self-
congratulation on the part of students as well as faculty, which
belies the realities that must be dealt with at the actual bedsides of
the sick. . . . The lessons of the classroom transfer far less well than
many teachers have presumed, to the emergency rooms, intensive
care units, acute medical and surgical wards, and other in-patients
divisions of our hospitals.

(p. 272)

Limits to Narrative
After many years of unquestioning acceptance of narratology within the
academy, pockets of resistance are emerging. Philosopher Galen
Strawson’s influential 2004 article “Against Narrativity” has been widely
cited and keenly debated. In the article, Strawson attacks both the
“psychological narrativity thesis,” which holds that “human beings see or
experience their lives as a narrative or story of some sort,” and the “ethical
narrativity thesis,” which states that “experiencing or conceiving one’s life
as a narrative is a good thing; a richly Narrative outlook is essential to a
well-lived life, to true or full personhood” (p. 428). Strawson divides
humanity into narrative and non-narrative (or episodic) people: “The
aspiration to explicit Narrative self-articulation is natural for some—for
some, perhaps, it may even be helpful—but in others it is highly unnatural
and ruinous. My guess is that it almost always does more harm than good”
(p. 447).

Strawson’s polemic predated the arrival of social media: while the

Facebook generation has enthusiastically embraced the public narrative
afforded by the new media, their parents’ generation has looked on in
horror. Although Strawson’s article was mainly aimed at academic
philosophers, the narrative medicine lobby has grudgingly acknowledged
that his thesis may have some validity and “should stimulate robust debate

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 within the medical humanities regarding the limits of narrative” (Woods
2011, p. 73). In his meditation on death,
(2008), novelist Julian Barnes is also sceptical about the notion of life as a
narrative: “Perhaps because my professional days are spent considering
what is narrative and what isn’t, I resist this line of thought. Lessing
described history as putting accidents in order, and a human life strikes me
as a reduced version of this: a span of consciousness during which certain
things happen, some predictable, others not. . . . But this does not in my
book constitute a narrative” (p. 188).

Why Study Medical Humanities?

Is the study of art and literature a waste of time in an already crowded
medical school curriculum? It is surely no bad thing for medical students to
be exposed to art and literature, regardless of its utility, but there is scant
evidence that familiarity with canonical literature and great paintings
makes for a better doctor. So what [End Page 616] is the point of medial
humanities? Howard Brody (2011) addressed this question and pointed
out that some medical humanities academics viewed the discipline as
“additive”—“sprinkling a bit of humanities over the top of an essentially
unchanged biomedical enterprise,” while others took an “integrated
view”—that is, that medical humanities could play “a more fundamental
and critical role” (p. 2). A proponent of the latter view is Paul Ulhas
Macneill, a lawyer who teaches ethics at the Yong Loo Lin School of
Medicine in Singapore. Macneill (2011) argues that medical humanities
should “take a more active role within medical education by challenging
the assumptions and myths of the predominant biomedical model and by
engaging more critically with the myths of medicine and the overstatement
of medical competency” (p. 85). He refers to “the fictions of the biomedical
model and its concomitant fiction of clinical practice as science,” and
suggests that the role of medical humanities should be to challenge such
“fictions” (p. 89).

I would argue that the study of medical humanities should provide

hinterland and perspective. These are unquantifiable attributes. By
hinterland, I mean a connection with broader culture, a connection with the

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 world beyond the medical school and the hospital. By perspective, I mean
an understanding of the place of medicine in society, the historical forces
that have shaped it, and the challenges it will face in the future.

How Should We Teach Medical Humanities?

Brody (2011) proposes three conceptions, or “narratives” for medical
humanities: (1) as a list of disciplines; (2) as a program of moral
development; and (3) as “a supportive friend.” The first narrative, that of
Western culture as “a sort of grand conversation,” seems now almost
redundant with the rise of specialization and “narrow conversations
intelligible only to specialists within certain disciplines.” Even the term
“liberal arts education” appears to be a relic of a bygone age. As a model of
the second concept—a program of moral development—Brody cites the
example of the Italian poet Petrarch, who “took a special interest in
educating the youth, and he assumed that the university ought to prepare
students with the wisdom needed to live successfully and to provide civic
leadership in changing and challenging times” (p. 4). Petrarch believed that
the lives of the heroes of classical antiquity could serve as a model and
inspiration for his students in 14th-century Italy, and he was particularly
inspired by Cicero and the Stoic philosophers. He labelled the new
discipline studia humanitatis, or humanism. Brody uses the life of William
Osler to explore the third concept, of medical humanities as a supportive
friend. Osler, the fons et origo of modern medical education was a devoted
(if somewhat pompous) classicist, who peppered his writings and lectures
with quotations from the great authors of Greek and Roman antiquity. He
loved books for their own sake, regardless of their utility, and found solace
in reading. The Oslerian ideal, writes Brody, “recaptures the pure joy and
love we feel for our [End Page 617] favourite books” (p. 6, original
emphasis). Brody argues that we need a mix of all three
conceptions/narratives, and warns against obscurity and specialization.

Nuland (2010) poses the question: “Is medical school a trade school or
part of the cultural and humanistic tradition of a university, which is
fundamentally a house of learning?” (p. 284) Cardinal Newman’s 1858 The
Idea of a University (like Snow’s Two Cultures, originally a public lecture at a

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 university) makes an eloquent case for the generalist approach. He argues
against narrow specialization, and his thesis is defiantly anti-utilitarian: he
believes that “Knowledge is capable of being its own end.” The university,
he writes, should be a place “in which the intellect may safely range and
speculate, sure to find its equal in some antagonistic activity and its judge
in the tribunal of truth” (p. 99). Students should be free to “think uselessly”
and should absorb generic skills of reason, thought, and scholarship, skills
that can be applied later to vocational training or research.

The study of medical humanities should expose medical students to a

climate of thought and reflection—they may never have such an
opportunity again. Medical schools should be free to be creative and
visionary in the design of their medical humanities courses: over time, the
best model (or models) will emerge. We should abandon any notions of
utility. In the end, as Oscar Wilde remarked, “All Art is quite useless.”

Consultant Gastroenterologist, Division of Medicine, Cork University Hospital, Wilton, Cork, Ireland.
Email: seamus.omahony@hse.ie.

Acknowledgment
The author is grateful to Kenneth Boyd, Iain Macintyre, Sandy Raeburn, and Fergus Shanahan for their
comments and suggestions during the preparation of this essay.

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