Although science supplies medicine's “gold standard,” knowledge exercised in the care of patients is, like moral knowing, a matter of narrative, practical reason. Physicians draw on case narrative to store experience and to apply and qualify the general rules of medical science. Literature aids in this activity by stimulating moral imagination and by requiring its readers to engage in the retrospective construction of a situated, subjective account of events. Narrative truths are provisional, uncertain, derived from narrators whose standpoints are always (...) situated, particular, and uncertain, but open to comparison and reinterpretation. Reading is thus a model for knowing in both morality and clinical medicine. While principles remain essential to bioethics and science must always inform good clinical practice, the tendency to collapse morality into principles and medicine into science impoverishes both practices. Moral knowing is not separable from clinical judgment. While ethics must be open to discussion and interpretation by patients, families, and society, it is nevertheless substantively and epistemologically an inextricable part of a physician's clinical practice. (shrink)

The history of medical and professional ethics has largely been a history of attempts to identify, articulate, and defend principles that explain when and why certain actions, institutions, health care professionals, and particular decisions count as right or wrong, just or unjust, virtuous or vicious. Medical ethics has been dominated by principlism. However, so-called moral particularists have forcefully attacked the dominance of principle-based normative theories. The particularist critique of traditional moral theory derives from the rejection of the claim that the (...) normative content of ethics and medical... (shrink)

In this paper we introduce narrative and hermeneutical perspectives to clinical ethics support services (CESS). We propose a threefold consideration of ‘theory’ and show how it is interwoven with ‘practice’ as we go along. First, we look at theory in its foundational role: in our case ‘narrative ethics’ and ‘philosophical hermeneutics’ provide a theoretical base for clinical ethics by focusing on human identities entangled in stories and on moral understanding as a dialogical process. Second, we consider the role (...) of theoretical notions in helping practitioners to understand their situation in clinical ethics practice, by using notions like ‘story’, ‘responsibility’, or ‘vulnerability’ to make explicit and explain their practical experience. Such theoretical notions help us to interpret clinical situations from an ethical perspective and to foster moral awareness of practitioners. And, thirdly, we examine how new theoretical concepts are developed by interpreting practice, using practice to form and improve our ethical theory. In this paper, we discuss this threefold use of theory in clinical ethics support services by reflecting on our own theoretical assumptions, methodological steps and practical experiences as ethicists, and by providing examples from our daily work. In doing so, we illustrate that theory and practice are interwoven, as theoretical understanding is dependent upon practical experience, and vice-versa. (shrink)

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical (...) Reasoning Discussion Tool—a dialogical and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting. (shrink)

Alasdair MacIntyre's recent thinking both about the concept of a practice and the existence of narrative unity in human life raises important questions about how we should view clinical medicine today. Is it possible for clinical medicine to pursue patient well-being in a society (allegedly) afflicted with what he calls modernity? Here it is argued that MacIntyre's pessimistic view of the individual in contemporary society makes his call for patient autonomy in the clinical setting pointless. Finally, recent (...) work in gerontology is cited to make three points: first, MacIntyre's pessimism about us is too extreme; second, the concept of a fictionalized personal history is closer to reality than either MacIntyre's notion of narrative unity or the ideas of his imagined opponent (Sartre); and finally, we should not expect clinical medicine to produce patient well-being, when this is understood narratively. (shrink)

Eating disorders can be viewed as “embodied acts” that help to cope with internal and external demands that are perceived as overwhelming. The maintenance of EDs affects the entire identity of the person; the lack of a defined; or valid sense of self is expressed in terms of both physical body and personal identity. According to attachment theory, primary relationships characterized by insecurity, traumatic experiences, poor mirroring, and emotional attunement lead to the development of dysfunctional regulatory strategies. Although the literature (...) shows an association between attachment style or states of mind, trauma, behavioral strategies, and various EDs, the debate is still ongoing and the results are still conflicting. Therefore, we believe it is important to examine and treat EDs by understanding which narrative trajectory intercepts distress in relation to narrative and embodied self-concept. Drawing on clinical observation and a narrative review of the literature, we focus on the construction and organization of bodily and narrative identity. Because bodily representations are the primary tools for generating meaning, organizing experience, and shaping social identity from the earliest stages of life, we focus on the role that bodily interactions and sensorimotor and proprioceptive patterns have played in the development of EDs. We consider the role that lack of attunement, insecure attachment, and relational trauma play in mentalizing, affecting self-representation and emotion regulation strategies. The paper also considers a semantic mode of trauma in EDs that involves a top-down pathway through beliefs and narratives about oneself based on lack of amiability, on devaluation, and on humiliation memories. Finally, we would like to highlight the proposal of an integrated model with multiple access model to psychotherapy that takes into account the complexity of ED patients in whom aspects related to dysregulation, body image disintegration, and post-traumatic symptoms are associated with a suffering sense of self and a retraumatizing narrative. (shrink)

The increasing role played by medical ethicists in the clinical setting both as teachers and consultants has brought with it a demand for new methodologies that speak more precisely to the multiple problems encountered in actual attempts at case resolution. Some of these moves have to do with a revival of the truly classic case study approach to ethics, casuistry. This approach is anchored in the revelatory text of Jonsen and Toulmin, TheAbuseofCasuistry. A fine example of this methodology is (...) an article in TheJournalofClinicalEthics, Conjoined to this approach is a renewed interest in virtue ethics. The groundwork for this was laid by MacIntyre's masterful history of its demise in AfterVirtue. A clear and concise application of this ancient but always new approach is given in Pellegrino and Thomasma's book TheVirtuesinMedicalPractice. This way of doing ethics is particularly congenial to the practice of healthcare ethics in that it understands that virtue is just a rather fancy name for a good habit or skill. Since the practice of clinical medicine is quintessentially the learning and application of a range of often highly complex patterns of professional abilities and skills, a virtue ethics approach will allow for the concomitant development of a whole set of ethical skills. But both casuistry and virtue ethics may well be seen to be operative in a larger context now known as narrative ethics. (shrink)

Background Analysis of aphasic narratives can be a challenge for clinicians. Previous studies have mainly employed measures that categorized speech samples at the word level. They included quantification of the use and misuse of different word classes, presence and absence of narrative contents and errors, paraphasias, and perseverations, as well as morphological structures and errors within a narrative. In other words, a great amount of research has been conducted in the aphasiology literature focusing on micro-linguistic structures of oral (...) class='Hi'>narratives. Aspects of macro- linguistic structures, such as the analysis of content information by a speaker, consistency of using cohesive devices to present information within a narrative, and order of presenting information necessary to form a coherent discourse, have not been extensively investigated. The current investigation proposes a clinical analytic system to target three aspects of macro-linguistic structures in narratives among speakers with aphasia. Specifically, (1) the presence of search events (i.e., the mentioning of key events that allow the listener to understand; Capilouto, Wright, &Wagovich, 2006) within a narrative, (2) the sequence of the mentioned events, and (3) the informativeness (i.e., the fulfillment of lexical items that allow the user to understand what the event is detailing) of the event contents, were focused in the proposed framework. Method Ten controls transcripts from were selected from the AphasiaBank (MacWhinney, Fromm, Forbes, & Holland, 2011). Three narrative tasks, including sequential picture description of ‘Refused Umbrella’, procedural narrative of making a ‘Peanut Butter and Jelly Sandwich’, and telling of ‘Cinderella’ story, were used to establish normative data for the basis of analysis. Specifically, the Search Events (e) and Informative Words (i) used by at least 70% of the speakers were listed for each genre. The sequential order of mentioning the Search Events, i.e., common order of events in 90% of the speakers, (s.total) was determined. Twelve speakers with aphasia (nine fluent and three non-fluent) were recruited and administered the Western Aphasia Battery and Object and Action Naming Battery. Their performance in the above three discourse tasks were orthographically transcribed and analyzed using the following measures: e.total, e.matched with norm, e.missed, e.irrlevant, e.extra, s.total, i.pb&j, i.umbr, i.cind, and i.total. Three samples were randomly chosen to be re-analyzed for inter- and intra-rater reliability. Results Results of an independent t-test suggested significant differences between the fluent and non-fluent subjects in sequential order of Search Events for all genres (s.total) and i.total, suggesting sensitivity of this framework to differentiate between the two fluency groups. Results of Pearson product-moment correlations revealed significant relation between Informative Words and WAB spontaneous speech scores, AQ, as well as OAB scores, for both aphasic groups. The mean value of coefficients for intra-rater reliability (0.992), with significant correlations on e.match, e.miss, and e.extra, was higher than that of inter-rater reliability (0.897). Discussion Based on our preliminary results, this objective framework allowed clinical evaluation of impairment in macro-linguistic structures present in aphasic discourse. Further extension should involve more subjects encompassing a wider range of severity with different types of aphasia. (shrink)

Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included (...) “moral injury” and “moral distress,” identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs. (shrink)

Narrative theory is a dynamic and evolving field of inquiry that has made tremendous inroads in the medical humanities over the past 40 years. Numerous authors have popularized the idea that “thinking narratively” can produce important insights about the illness experience for physician and patient alike. This paper draws on aspects of narrative theory to emphasize the moral responsibilities that arise when we step into another person's life narrative, becoming a character in her or his story. This has especially significant (...) ethical implications for the physician–patient encounter in that each character in this shared story experiences time somewhat differently. This gives rise to the notion of “slow motion ethics” and a somewhat unique perspective on the moral responsibilities clinicians bear toward their patients. (shrink)

Gadow's understanding of nursing as a relational narrative anchored in a dialectic between the fundamental subjectivity of the individual client and the objectification of his illness poses some interesting questions for nursing ethics and care. For Gadow, nursing is an encounter with the immediate vulnerability of the client and also lends it responsibilities to the medical objectification of illness aiming at disease treatment and control. Hence, nursing agency is divided between its responsibilities induced by the personal vulnerability of the patient (...) and the more impersonal, but benevolent intention shaped by medical knowledge. Medical knowledge is impersonal in the sense that it is knowledge detached from the subjectivity of the patient. But how is nursing able to reconcile the interests derived from personal and experienced vulnerability with the more impersonal and often conflicting demands of medical knowledge? This question is even more intriguing because there seems to be an objective dimension within a patient's subjectivity itself: an autonomous person can critically evaluate his own subjectivity as a basis for informed self‐interest. The sick person is thus confronted with objectivity on two important levels: the objective facts of his disease and his detachment from his own experiential vulnerability when engaged in the critical evaluation of his self‐interest. This paper will discuss the normative dimensions of these complex and, frequently, conflicting perspectives from the theoretical perspectives of Thomas Nagel's normative responsibility and Sally Gadow's clinical epistemology and relational narratives. The empirical basis for the discussion will be an ongoing study of the ethical dimensions of pain relief and sedation in an intensive care unit. (shrink)

This paper argues that the newspaper Notre Journal enshrined the importance of narrative in the revolutionary psychiatry of its founder and editor, Frantz Fanon. Anchoring my analysis in the interdisciplinarity of the medical humanities, I demonstrate how care at Hôpital Blida-Joinville in colonial Algeria was mediated by the written word. I examine Fanon’s physician writing and editorial texts detailing the use of narrative approaches in the clinic. As an object of care, Notre Journal’s promotion of psychic healing, social actions, and (...) engaged professional practice shaped the interactions and experiences of patients and staff. Printed and distributed to the wider institution, the newspaper created community—during an oppressive French Occupation and at the outset of the War of Independence—in addition to nurturing creativity, curiosity, solidarity, and accountability. Still, Fanon would come to recognize the limits of narrative methods amidst cultural oral traditions, illiteracy, and divergent attitudes about narrating the self. (shrink)

The end of the 1990s witnessed the development of evidence-based medicine, which proposed to screen, organize, and classify knowledge production in the health sciences. In this period, an increasing number of scientific publications started to incorporate the digital format and became easily accessible through the Internet. Since then, we have become used to the idea that there is a hierarchy in medical evidence. Its upper stratum, the gold standard of evidence, contains systematic reviews and meta-analyses of randomized clinical trials. (...) The base of such hierarchy contains case studies, clinical cases, and personal opinions.This knowledge hierarchy is not harmless. It has practical influences on... (shrink)

This special issue aims to spotlight the individual, lived experiences of caregivers and those receiving care–areas often overshadowed by clinical and medicalized narratives within clinical ethics. Our aim is to enrich the discourse by incorporating stories and narratives of medical care and challenge existing clinical practices by emphasizing patient and practitioner experiences. Through a blend of clinical and academic insights, this issue provides phenomenological narratives, highlighting the importance of lived experiences in understanding and (...) improving clinical caregiving practices. The contributions, ranging from theoretical analyses to personal narratives, explore various aspects of caregiving. Each article contributes to a deeper understanding of the phenomenologies of care, advocating for a more inclusive, patient-centered approach in clinical ethics and practice. (shrink)

Este artigo aborda dois importantes conceitos freudianos que são mobilizados para a explicação do sintoma: o inquietante e o só-depois. Tais noções aparecem como complementares mediante a formação composta do sintoma que se dá entre elementos inconscientes e as vivências posteriores que permitem o retorno do recalcado. Essa composição nos permite tratar a teoria clínica freudiana a partir de um viés temporal, uma vez que a formação do sintoma se dá em etapas descontínuas na trajetória da vida subjetiva. Por isso, (...) nosso artigo discute a passagem dessa descontinuidade – quando o sintoma é sentido como uma repetição inquietante – para a constituição de uma narrativa de vida dotada de destinos pulsionais criativos, nos quais o que se mostrava estranho é assumido como próprio e familiar. Palavras-chave: sintoma; inquietante; estranhamento; só-depois; repetição.: This article discusses two important Freudian concepts that are mobilized for the explanation of the symptom: the uncanny and the afterwardsness. These notions appear together because of the composite formation of symptom that occurs between unconscious elements and aftermost experiences that allow the return of the repressed. This composition helps us in our goal to treat Freudian clinical theory in a temporal bias, since the formation of the symptom occurs in discontinuous steps along the path of subjective life. So our article discusses the passage of this discontinuity – when the symptom is felt as a uncanny repetition – for the establishment of a narrative of life based on creative instinctual destinations, in which what is showed strange is assumed as own and familiar. Keywords: symptom; uncanny; strangeness; afterwardsness; repetition. (shrink)

This review aimed to explore nursing literature and research on dignity in care of inpatients and to evaluate how the care patients received in the hospital setting was related to perceived feelings of being dignified or undignified. Studies conducted between 2000 and 2010 were considered, using Cumulative Index to Nursing and Allied Health Literature and MEDLINE, and the search terms ‘patient dignity’, ‘dignity in care’, ‘human dignity and nursing’ and ‘dignity and nursing ethics’. Findings revealed, from the perspectives of nurses (...) and patients, that dignity in care in the hospital setting is seen to be influenced by physical environment, staff attitude and behaviour, organisational culture and patient independence. This review can help nurses to better understand dignity in care, and for policy makers, there are implications about determining the physical environment, staff attitude and behaviour and organisational culture needed to promote patient dignity in nursing. By identifying the most important factors from patients’ and nurses’ perspectives that contribute to dignity in care, nursing interventions, such as campaigns and education in clinical practice, can be developed. (shrink)

Visual narratives like comics often are used as materials in clinical testing under a belief that they are transparent materials for individuals who may struggle with language, such as those with autism spectrum disorder (ASD), developmental language disorder (DLD), or aphasia. This review shows that this “Visual Ease Assumption” is largely unsupported, warranting reconsideration of the ways visual narratives are used with clinical populations.

Pediatric oncology has a strong research culture. Most pediatric oncologists are investigators, involved in clinical care as well as research. As a result, a remarkable proportion of children with cancer enrolls in a trial during treatment. This paper discusses the ethical consequences of the unprecedented integration of research and care in pediatric oncology from the perspective of parents and physicians. An empirical ethical approach, combining (1) a narrative review of (primarily) qualitative studies on parents' and physicians' experiences of the (...) pediatric oncology research practice, and (2) comparison of these experiences with existing theoretical ethical concepts about (pediatric) research. The use of empirical evidence enriches these concepts by taking into account the peculiarities that ethical challenges pose in practice. Analysis of the 22 studies reviewed revealed that the integration of research and care has consequences for the informed consent process, the promotion of the child's best interests, and the role of the physician (doctor vs. scientist). True consent to research is difficult to achieve due to the complexity of research protocols, emotional stress and parents' dependency on their child's physician. Parents' role is to promote their child's best interests, also when they are asked to consider enrolling their child in a trial. Parents are almost never in equipoise on trial participation, which leaves them with the agonizing situation of wanting to do what is best for their child, while being fearful of making the wrong decision. Furthermore, a therapeutic misconception endangers correct assessment of participation, making parents inaccurately attribute therapeutic intent to research procedures. Physicians prefer the perspective of a therapist over a researcher. Consequently they may truly believe that in the research setting they promote the child's best interests, which maintains the existence of a therapeutic misconception between them and parents. Due to the integration of research and care, their different ethical perspectives become intertwined in the daily practice of pediatric oncology. Increasing awareness of what this means for the communication between parents and physicians is essential. Future research should focus on efforts that overcome the problems that the synchronicity of research and care evokes. (shrink)

As a doctor and practitioner researcher, I use comics as a research method. This graphic article is an attempt to convince you, the academy and perhaps myself, that comics are research.

Narratives by survivors of abuse offer compelling entries into the experiences of abuse and its effects on health. Reading such stories can enlarge the clinician's understanding of the complexities of abuse. Furthermore, attention to narrative can enhance the therapeutic options for abuse victims not only in mental health arenas, but also in other medical contexts. In this article we define the genre of survivor narratives, examine one such narrative in particular (Push by Sapphire, 1996), and explore the (...) class='Hi'>clinical implications of narrative in abuse victims' clinical care. (shrink)

Introduction: Evidence supporting the use of music interventions to maximize arousal and awareness in adults presenting with a disorder of consciousness continues to grow. However, the brain of a child is not simply a small adult brain, and therefore adult theories are not directly translatable to the pediatric population. The present study aims to synthesize brain imaging data about the neural processing of music in children aged 0-18 years, to form a theoretical basis for music interventions with children presenting with (...) a disorder of consciousness following acquired brain injury.Methods: We conducted a systematic review with narrative synthesis utilizing an adaptation of the methodology developed by Popay and colleagues. Following the development of the narrative that answered the central question “what does brain imaging data reveal about the receptive processing of music in children?”, discussion was centered around the clinical implications of music therapy with children following acquired brain injury.Results: The narrative synthesis included 46 studies that utilized EEG, MEG, fMRI, and fNIRS scanning techniques in children aged 0-18 years. From birth, musical stimuli elicit distinct but immature electrical responses, with components of the auditory evoked response having longer latencies and variable amplitudes compared to their adult counterparts. Hemodynamic responses are observed throughout cortical and subcortical structures however cortical immaturity impacts musical processing and the localization of function in infants and young children. The processing of complex musical stimuli continues to mature into late adolescence.Conclusion: While the ability to process fundamental musical elements is present from birth, infants and children process music more slowly and utilize different cortical areas compared to adults. Brain injury in childhood occurs in a period of rapid development and the ability to process music following brain injury will likely depend on pre-morbid musical processing. Further, a significant brain injury may disrupt the developmental trajectory of complex music processing. However, complex music processing may emerge earlier than comparative language processing, and occur throughout a more global circuitry. (shrink)

In 2018-2019, at the Keck School of Medicine of the University of Southern California, we developed and piloted a narrative-based health systems science intervention for patients living with HIV and medical students in which medical students co-wrote patients’ life narratives for inclusion in the electronic health record. The pilot study aimed to assess the acceptability of the “life narrative protocol” from multiple stakeholder positions and characterize participants’ experiences of the clinical and pedagogical implications of the LNP. Students were (...) recruited from KSOM. Patients and staff were recruited from the Maternal, Child, and Adolescent/Adult Center for Infectious Disease and Virology at Los Angeles County+USC Medical Center. Ten patients, seventeen students, and ten MCA staff participated in the pilot study. Qualitative methods were used to gather data from students’, patients’, and staff’s perspectives. Three themes emerged from the thematic analysis: patients’ life narratives conveyed their unique life experiences and voices; the protocol could result in wide-ranging effects on HIV care; the LNP enabled students to contribute value to patients’ healthcare. Across groups, participants considered the LNP an acceptable intervention. The LNP, its limitations, and implications for HIV care, narrative medicine, and health information technology are presented. (shrink)

We propose extrapolating Conviction Narrative Theory (CNT) to clinical psychology and psychiatry. We demonstrate how CNT principles may benefit assessment, therapy, and possibly even modify public health views of neuropsychiatric disorders. Our commentary focuses on hoarding disorder as a model, elaborates on discrepancies in the scientific literature and suggests how the CNT may resolve them.

Epistemic injustice sits at the intersection of ethics, epistemology, and social justice. Generally, this philosophical term describes when a person is wrongfully discredited as a knower; and within the clinical space, epistemic injustice is the underlying reason that some patient testimonies are valued above others. The following essay seeks to connect patterns of social prejudice to the clinical realm in the United States: illustrating how factors such as race, gender identity, and socioeconomic status influence epistemic credence and associatively, (...) the quality of healthcare a person receives. After describing how epistemic injustice disproportionately harms already vulnerable patients, I propose a narrative therapy intervention. This intervention can help providers re-frame their relationships with patients, in such that they come to view patients as valuable sources of unique knowledge. Though I identify this intervention as a valuable step in addressing clinical epistemic injustice, I call upon medical educators and practitioners to further uplift the voices, perspectives, and stories of marginalized patients. (shrink)

This paper responds to a proposal for an intersectional approach to the clinical encounter between patient and medical provider. We agree that an intersectional framework offers new insights and information in the clinical encounter. Intersectionality involves awareness of the physician-patient dynamic, and understanding the various privileges and disadvantages of all parties involved, at a micro and macroscopic level. Yet, this analysis alone is insufficient to aid in the clinical encounter and risks harm. We worry about a clinician (...) making assumptions about her patient’s race, gender, economic status, and how these influence the patient’s own views of her life and health. We argue that a narrative supplement is a necessary element of intersectional clinical encounters. Prioritizing patient narrative curtails assumptions, builds trust, and improves care. (shrink)

There are more large-scale pregnancy trials that implement lifestyle interventions than ever before; yet, there is a dearth of information on pregnant peoples’ experiences in such trials. Contemporary lifestyle pregnancy trials draw on epigenetics and DOHaD research to design and justify prenatal interventions on the material environment to reduce health risks in future generations. This article draws on ethnographic data from a prenatal trial in the United Kingdom and focuses specifically on the experiences of pregnant participants during the intervention phase. (...) In this article, I develop the politics of postgenomic reproduction as a feminist and critical race framework to examine the complex and mercurial stakes of contemporary pregnancy trials. I argue that narratives of control and responsibility in epigenetic models are echoed and preceded by participants’ own embodied experience. The pregnant narratives show at once how their bodies are exposed to unpredictable and uncontrollable environmental exposures and that they are required to respond as if they have absolute control and responsibility. Attending to trial participants’ narratives from a feminist and critical race framework reveals how individualized lifestyle interventions are deeply political and racial, and carry implications for how pregnancy trials influence postgenomic reproduction. (shrink)

The character and extent of disabilities, especially cognitive disability, have posed significance problems for existing moral theories. Certain philosophers have even questioned the moral personhood of people with disabilities and have argued that people with profound cognitive impairments should not be granted the same moral status as those who are cognitively able-bodied. This paper proposes an alternative understanding of moral personhood as relational rather than individuated. This relational moral personhood finds its foundation in the clinical practice and psychoanalysis of (...) Julia Kristeva and the hermeneutic narrative identity of Paul Ricoeur. One consequence of this relational personhood is a new understanding of moral status through narrative co-authorship rather than intellectual or social capacity. Another consequence is a refiguration of narrative identity as narrative interdependence. (shrink)

In Rita Charon's account of narrative medicine, empathy seems to be an essential element of the clinical relationship. However, empathy has not received much attention, which I believe is problematic. First, I show that not only is there no clear definition of what empathy is, but that this conceptual gap creates ambiguity about its role in the practice of narrative medicine. Second, I argue that certain passages in Charon's work seem to implicitly characterize empathy as a combination of cognitive (...) empathy, affective empathy, and sympathy, and that its inclusion in the practice of narrative medicine can be problematic. Third, following Dan Zahavi, I argue that a phenomenological account of empathy not only seems most compatible with the practices, values, and theoretical framework of narrative medicine, but is also capable of resolving the problems posed by alternative definitions of empathy and the ambiguity about the role of empathy in narrative medicine. (shrink)

Contrasting traditional and common forms of ethics consultation with bioethics mediation, I describe the case of a “second opinion” consultation in the care of a patient with advanced cancer for whom treatment was futile. While the initial ethics consultation, performed by a colleague, led to a recommendation that some may deem ethical, the process failed to involve key stakeholders and failed to explore the underlying values and reasons for the opinions voiced by various stakeholders. The process of mediation ultimately led (...) to creative solutions in which all stakeholders could reach consensus on a plan of care. (shrink)

I argue that clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts. The literary critic reading a novel, the judge asked to apply a law, must arrive at a coherent reading of their respective texts. Similarly, the physician interprets the text of the ill person: clinical signs and symptoms are read to ferret out their meaning, the underlying disease. However, I suggest that (...) the hermeneutics of medicine is rendered uniquely complex by its wide variety of textual forms. I discuss four in turn: the experiential text of illness as lived out by the patient; the narrative text constituted during history-taking; the physical text of the patient's body as objectively examined; the instrumental text constructed by diagnostic technologies. I further suggest that certain flaws in modern medicine arise from its refusal of a hermeneutic self-understanding. In seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject — the living, experiencing patient. (shrink)

I have become curious about reciprocity within clinical practice. A vast topic that mobilizes considerations of money, knowledge, kinship, power, culture, and uses of the body, reciprocity is a strong means by which to achieve the egality required of just health care. Within health care, reciprocity might enable not only so‐called shared decision‐making and patient autonomy. It might open the door to mutual acknowledgement of the value of each participant's beliefs and habits. It might appear as a humble realization (...) that no one understands what health is and a concurrent welcoming curiosity about one another's conception of how the body and speech and mind work. From the intimate to the international levels of care, such forms of reciprocity may culminate in the radical and powerful state of reciprocal recognition.In this short essay, I will focus on one aspect of reciprocity in health care: the narrative and potentially reciprocal nature of attention in health care. A critical element in the development of therapeutic alliance, clinical accuracy, and effective practice, attention requires a donation of the self as a vessel into which can enter that which is perceived or, from the other side, a penetrating of that which is perceived so that one sees it from within its own vessel. (shrink)

The aim of this literature review was to compose a narrative review supported by a systematic approach to critically identify and examine concerns about accountability and the allocation of responsibility and legal liability as applied to the clinician and the technologist as applied the use of opaque AI-powered systems in clinical decision making. This review questions if it is permissible for a clinician to use an opaque AI system in clinical decision making and if a patient was harmed (...) as a result of using a clinician using an AIS’s suggestion, how would responsibility and legal liability be allocated? Literature was systematically searched, retrieved, and reviewed from nine databases, which also included items from three clinical professional regulators, as well as relevant grey literature from governmental and non-governmental organisations. This literature was subjected to inclusion/exclusion criteria; those items found relevant to this review underwent data extraction. This review found that there are multiple concerns about opacity, accountability, responsibility and liability when considering the stakeholders of technologists and clinicians in the creation and use of AIS in clinical decision making. Accountability is challenged when the AIS used is opaque, and allocation of responsibility is somewhat unclear. Legal analysis would help stakeholders to understand their obligations and prepare should an undesirable scenario of patient harm eventuate when AIS were used. (shrink)

During the last three decades there has been a wave of interest in narrative and narrativity in the humanistic and the social sciences. This “narrative turn” has spilled over to medicine, where narrative medicine has gained a considerable influence.However, there have also appeared second thoughts on the role of narratives in our lives, as well as on what narratives may mean in relation to clinical medicine.This article presents some influential voices in this debate and scrutinizes the assumptions (...) of narrative medicine in the light of these. It is concluded that there are sound reasons to tread this path with some caution and avoid the too far reaching ambitions on behalf of narrativity in relation to clinical medicine. However, narrative medicine should still be seen as a promising attempt within the broader scope of medical humanities to emphasize the importance of human subjectivity in clinical medicine. (shrink)

During the last three decades there has been a wave of interest in narrative and narrativity in the humanistic and the social sciences. This “narrative turn” has spilled over to medicine, where narrative medicine has gained a considerable influence. However, there have also appeared second thoughts on the role of narratives in our lives, as well as on what narratives may mean in relation to clinical medicine. This article presents some influential voices in this debate and scrutinizes (...) the assumptions of narrative medicine in the light of these. It is concluded that there are sound reasons to tread this path with some caution and avoid the too far reaching ambitions on behalf of narrativity in relation to clinical medicine. However, narrative medicine should still be seen as a promising attempt within the broader scope of medical humanities to emphasize the importance of human subjectivity in clinical medicine. (shrink)

Religions often operate as comprehensive worldviews, attempting to answer the deepest existential questions that human beings can ask: Who am I? Where do I come from? Where am I going after I die? How should I live? Often ethical systems are embedded and justified within these broader narratives. Inevitably, the clinical ethics consultant will encounter and engage with religiously based ethical systems. In this issue, the authors reflect seriously and deeply on the implications of such engagement.

This article is an introduction to a special issue of Theoretical Medicine and Bioethics on clinical reasoning. Clinical reasoning encompasses the gamut of thinking about clinical medical practice—the evaluation and management of patients’ medical problems. Theories of clinical reasoning may be normative or descriptive; that is, they may offer recommendations on how clinicians ought to think or they may simply attempt to describe how clinicians actually do think. This article briefly surveys these approaches in order to (...) show the complexity of clinical reasoning and the inadequacy of any one theory for capturing the full richness of clinical reasoning. The authors of this issue offer both normative and descriptive elements in their accounts. Topics discussed include the importance for clinical reasoning of tacit knowing, risk assessment, narrative and hermeneutics, wisdom, and virtue epistemology. (shrink)

The aim of the study was to explore the experiences of night nurses. An interpretative phenomenological study was undertaken, and 35 nurses working in Italian medical, surgical and intensive care units were purposely recruited. Data were gathered in 2010 by semi‐structured interviews, collecting nurses' narratives, memorable cases and metaphors, aimed at summarising the essence of work as a nurse during the night. The experience of night nursing is based on four interconnected themes: (i) working in a state of alert, (...) (ii) growing by expanding autonomy and responsibility, (iii) assuring sensitive surveillance and (iv) experiencing deep intimacy. Memorable episodes were polarised along (i) expected/unexpected events; (ii) positive/negative epilogues; and (iii) life/death issues. Many of the emergent metaphors described working during the night as being in the middle of a space where an apparent calm scene takes place, but unpredictable factors may suddenly change the order of events and the outcomes, creating chaos. Working during the night alerts nurses, who increase autonomy, expanding their role and assuming more responsibility with respect to that assumed during daily shifts. The nurses' clinical reasoning is based on data they carefully listen to, and on the meaning that nurses give time by time to different noises and silence. While in the past a sense of companionships was reported, a loneliness or a ‘neutral’ experience concerning the relationships with colleagues seems to prevail during night nursing. Working night shifts is a complex task, and specific training must be assured to students/novices. (shrink)

Much has been written about the importance of narrative in teaching ethics and humanities to medical students and residents, as well as the value of narratives in clinical care. Relatively little has been said about the essential role of narrative in bioethics consultations. For most consults, the interpretation of narratives is the central moral feature, and the ethics consultant is inevitably one of the narrators. In a recent consult in which I participated, at least three narratives (...) were in play. The medical record itself was a narrative, or really, a variety of narratives. A second distinct narrative was the story of why this case had come to be categorized as an ethical concern for the medical team. A third narrative was the tentative sketch running through my mind as a consultant‐partly factual, partly anticipatory and conjectural, inevitably personal‐about what was going on here. (shrink)

Method in ethics consultation has at least three distinguishable components: a canon – that is, the rules that guide actions, cognitions, judgments, and perceptions involved in performing an ethics consultation; a discipline – that is, a mastery, or at least possession, of the specific types of actions and intentions of ethics consultation which are guided by the rules that are embodied in the actions of competent ethics consultants; and a history – that is, the narrative of, and critical reflection on, (...) the actions, including the analyses, assessments, and communications undertaken in the course of the consultation, including the reasoning about the practical issues and the steps toward resolving the ethical question or issues that arose. As a doing, then, ethics consultation consists in actions and intentions that constitute a distinctive set of meanings in the clinical space of patient care in which the meanings brought to patient care through the actions and communications of the ethics consultation help shape, to some extent, the way that the case develops and is understood, which is further reflected in how the case is represented. In this sense, statements about ethics consultation methodology, and theories of ethics consultation, are secondary to the actual practice itself. The analysis and interpretation of actions and communications of those involved in the clinical care of the patient represents a complex process that blends the meaning of ethical concepts, principles, and theories with the constructed and uncovered clinical and value meanings of the case. (shrink)

Russo suggests that the personal narratives of those who have experienced mental and emotional distress now constitute a diverse and dispersed, nonetheless considerable, body of knowledge that is of interest to non–user/survivor researchers. The issues she raises about the potential use of that knowledge pose practical and ethical challenges to both user/survivor researchers and those from other research traditions. On reading this paper, I became conscious of my own work, where I have explored my personal experiences in the context (...) of clinical research and the history of psychiatry. In one such piece, I describe myself as “a voice crying out from the data”, and use my... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative Formulation RevisitedOn Seeing the Person in Mental Health RecoveryAnna Bergqvist (bio)The use of narrative in mental health contexts models consciousness as something necessarily embodied, as already part of the world, in an inherently value-laden and perspectival way. As such narrative presents a powerful tool for critical reassessment and reevaluation of preconceived ideas in relating to difficult concepts in clinical interactions.Narrative structures can reveal psychological differences between persons (...) in a way that matters for the provision of effective treatment and management. As emphasized by Solomon (2015), narrative reasoning is also motivated by distinctly first-personal concerns that are operative in the practitioner–client relationship. I maintain that the dynamics of that interpersonal relationship are part and parcel of what it means to address the patient's needs to be seen as a person in humanistic empathetic care—without thereby reducing truth to an individual person's perspective to encourage positive transformation.1The notion of empowering narratives to encourage positive change is a core concept behind the emphasis on the critical role of empathy in explaining human development and psychoanalytic change within the self-psychology tradition but is also key to recovery-based models of the significance of person-centered quality of life in medicine more generally. This is defined in mental health as recovering a good quality of life as determined by the values of (by what matters or is important to) the individual concerned (Allott, Loganathan, & Fulford, 2002; Fulford, 1989, 2004; Fulford, Peile, & Carroll, 2012). The importance of strengths in this regard was reflected for example in the UK government program on values-based mental health assessment. The 3 Keys program, as it was called (National Institute for Mental Health in England, NIMHE, and the Care Services Improvement Partnership, 20082) identified three shared 'keys' to good practice in mental health assessment: three things that were identified in a wide-ranging consultation as being important alike by health professionals of all kinds and by 'service users' thus understood as patients and carers (Fulford, Duhig, Hankin, Hicks, & Keeble, 2015a; Fulford, Dewey, & King, 2015b). The third of these keys was defined in [End Page 7] the subsequently published Good Practice Guidance, as "a person-centred focus that builds on the strengths, resiliencies and aspirations of the individual service user as well as identifying his or her needs and challenges" (NIMHE, 2008: 6); and the guidance included a number of real-life case examples of best recovery practice reflecting this aspect of mental health care (Slade et al., 2014).What my (Bergqvist, 2018, 2020, 2022, forthcoming) account adds to this claim is that while such choices are revelatory or expressive of a distinctly first-personal stance, they do not constitute or determine selfhood and self-interpretation in a fixed way. Moreover, the reason is that one can also adopt a second-personal stance on one's own experience and address oneself, where the relationship between the first- and the second-personal narrative perspective on experience and self-understanding is itself a dynamic and open-ended evaluative process.Anna Bergqvist Anna Bergqvist is Reader in Philosophy at Manchester Metropolitan University since 2021, and has been Postgraduate Research Coordinator and AHRC North West Doctoral Pathway Consortium Lead for Philosophy since 2020. I was elected to a Visiting Fellowship at St Catherine's College University of Oxford for Michaelmas Term 2021. Her service to the profession out with the University includes acting as Secretary of the World Psychiatric Association (WPA) Section for Philosophy & Humanities in Psychiatry (October 2020 – present), Executive Committee Member of the Royal College of Psychiatry (RCPsych) SIG in Philosophy (February 2020 – present) and External Examiner, University of Liverpool (November 2019 – present, 4-year tenure). She is also Director of the Values-based Theory Network at St Catherine's Collaborating Centre for Values-based Practice at the University of Oxford, and Member of its Whiteness and Race Equality Network. Her approach to philosophy bridges the disciplines of moral philosophy, moral psychology and philosophy of psychiatry to improve lives through her reputable expertise in moral perception and co-production as a mechanism for change.Notes1. Here I side with Goldie (2012) and Solomon (2015), who... (shrink)