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From method to hermeneutics: which epistemological framework for narrative medicine?

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Camille Abettan
Camille Abettan
Camille Abettan
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Abstract

The past 10 years have seen considerable developments in the use of narrative in medicine, primarily through the emergence of the so-called narrative medicine. In this article, I question narrative medicine's self-understanding and contend that one of the most prominent issues is its lack of a clear epistemological framework. Drawing from Gadamer's work on hermeneutics, I first show that narrative medicine is deeply linked with the hermeneutical field of knowledge. Then I try to identify which claims can be legitimately expected from narrative medicine, and which ones cannot be. I scrutinize in particular whether narrative medicine can legitimately grasp the patient's lived experience of his or her illness. In the last section of this article, I begin to explore the potential usefulness of this epistemological clarification. This analysis allows for a further understanding of what is really at stake with narrative medicine, and thus to identify when it may be convenient, and when it may not. Furthermore, this clarification opens up promising new possibilities of dialogue with critics of the field. I conclude that narrative medicine finds its proper place as a possible tool available to mediate dialogue, which is at the heart of the clinical encounter in medical practice.
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From method to hermeneutics: which epistemological
framework for narrative medicine?
Camille Abettan
1,2
Published online: 13 May 2017
Springer Science+Business Media Dordrecht 2017
Abstract The past 10 years have seen considerable developments in the use of
narrative in medicine, primarily through the emergence of the so-called narrative
medicine. In this article, I question narrative medicine’s self-understanding and
contend that one of the most prominent issues is its lack of a clear epistemological
framework. Drawing from Gadamer’s work on hermeneutics, I first show that
narrative medicine is deeply linked with the hermeneutical field of knowledge. Then
I try to identify which claims can be legitimately expected from narrative medicine,
and which ones cannot be. I scrutinize in particular whether narrative medicine can
legitimately grasp the patient’s lived experience of his or her illness. In the last
section of this article, I begin to explore the potential usefulness of this epistemo-
logical clarification. This analysis allows for a further understanding of what is
really at stake with narrative medicine, and thus to identify when it may be con-
venient, and when it may not. Furthermore, this clarification opens up promising
new possibilities of dialogue with critics of the field. I conclude that narrative
medicine finds its proper place as a possible tool available to mediate dialogue,
which is at the heart of the clinical encounter in medical practice.
Keywords Narrative medicine Hermeneutics Epistemology Gadamer
Personalized medicine
&Camille Abettan
camille.abettan@gmail.com
1
Center of Interdisciplinary Researches in Human and Social Sciences (CRISES, EA 4424),
Paul-Vale
´ry University, Rue du Professeur Henri Serre, 34090 Montpellier, France
2
Espace Re
´gional de Re
´flexion E
´thique du Languedoc-Roussillon, Ho
ˆpital La Colombie
`re, 39
Avenue Charles Flahault, 34295 Montpellier, France
123
Theor Med Bioeth (2017) 38:179–193
DOI 10.1007/s11017-017-9408-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... We believe that contemporary hermeneutics and dialectical perspectives can be used together to potentially answer these questions. We seek to analyze this viewpoint to support the comprehension of a worldwide phenomenon and its experience of truth (Abettan, 2017;Gadamer, 1999;Minayo, 2014). We believe that by encountering different perspectives from workers, we can respond to these questions and guide the construction of knowledge on methodological possibilities to fill this literature gaps. ...
... A female graduate student, the author of the present paper, interviewed the workers personally at health centers. We believe that a narrative is a hermeneutical and dialectical device to reach reality in terms of consensus and contradictions (Abettan, 2017;Gadamer, 1999;Ollman & Smith, 2008). The interviews, which were performed in private offices at the professionals' workplace, were previously scheduled by phone with each professional according to their availability. ...
... These questions had a hermeneutic and dialectic nature intended to seek consensual situations and possibilities of raising dissent. Reaching consensus, or dissensus in a discourse analysis, comprises hermeneutical and dialogical knowledge (Abettan, 2017;Gadamer, 1999;Minayo, 2014). The interviews' audios were transcribed according to Atkinson and Heritage (1999), transcription norms, and all transcripts were returned to participants for comment and agreement during the analysis process. ...
A Unique Way to Analyze the Realities of Health Workers Within A Hermeneutic-Dialectic Perspective
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We propose an original method of analysis within a hermeneutic-dialectic framework theoretically supported by the work of Hans-Georg Gadamer, Bertell Ollman, and Maria Cecilia Minayo. We draw a unique means of analysis to guide an understanding of the labor realities for health workers who care for older adults. This method of analysis proposes a way to create consensual opinions, question this consensus and then put these aspects in a dialogical encounter with the qualitative researcher and interpreter. We illustrate the application of this methodological process using dialogical conversations and narrative interviews with 12 health workers from the Brazilian Unified Health System (SUS). The hermeneutic-dialectic process of interpretation involves us in movements of comprehension, which allows us to understand realities including the actual sad situation of some territories, creating possibilities for home health care, the integrality of attention as a tool for providing home assistance in the primary care field, and the necessity of a set of services to provide an organizational routine for home visits to older people. This methodological analysis has the potentiality to help develop other research on similar topics. The results illustrate that good home care for older adults requires effective articulation between compassionate workers and public health agencies.
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... En 2015, Miriam Solomon écrivait de la médecine narrative qu'elle fut probablement l'approche la plus populaire ou importante des approches humanistes de la philosophie de la médecine (Solomon, 2015). De fait, l'approche est toujours présente dans les discussions, notamment à la frontière entre la philosophie de la médecine et les champs voisins que sont l'éthique médicale et les humanités médicales (Brody, 1997 ;Halpern, 2001 ;Charon, 2001Frank, 1997 ;Goupy et Jeune, 2016 ;Abettan, 2017). (Solomon, 2008(Solomon, , 2015. ...
... Les thèses philosophiques de la médecine narrative « Ce qui fut un temps considéré comme le vernis civilisé du médecin-gentlemans'occuper de littérature, étudier les humanités, écrire de façon poétique à propos de la pratique médicale -est maintenant reconnu comme une part centrale de l'éducation des médecins, pour l'empathie et la réflexion 71 . » (Charon, 2004, 863) La médecine narrative a récemment gagné en popularité et en visibilité dans le milieu médical, dans la discipline aux contours flous des « humanités médicales », ainsi que dans la philosophie de la médecine où elle est devenue un objet de discussion à part entière (Reiss, Solomon et Teira, 2011 ;Solomon, 2008Solomon, , 2015O'Mahony, 2013 ;Woods, 2011 ;Abettan, 2017 ;Ferry-Danini, 2018a ;Dzierzynski, Goupy et Perrot, 2018). La médecine narrative est un slogan utilisé pour défendre l'idée que la narration et les récits sont essentiels pour la médecine et sa pratique. ...
... Avant de se pencher plus en détail sur cet axe éthique et existentiel qui caractérise les thèses de NarraMéd, il faut souligner que certains auteurs ont proposé une défense de l'axe épistémologique de CN qui va au-delà de celle proposée par Rita Charon. Camille Abettan a récemment défendu l'idée que la pertinence de l'axe épistémologique de CN repose sur le caractère herméneutique de la médecine narrative(Abettan, 2017). Dans ce qui suit, j'étudie cette suggestion. ...
Une critique de l'humanisme en médecine La « médecine narrative » et la « phénoménologie de la médecine » en question
Thesis
  • Jun 2019
Ma thèse est consacrée à un examen critique des tentatives actuelles pour donner à l’appel à « plus d’humanisme » en médecine un fondement philosophique. En effet, comme je le montre, les deux approches « humanistes » aujourd’hui prédominantes — la médecine narrative et la phénoménologie de la médecine — échouent à donner un sens convaincant au concept même d’humanisme. Les deux approches ont d’abord en commun de se construire en opposition à ce qu’elles appellent le modèle biomédical, mais n’en donnent pas une caractérisation cohérente et n’en produisent pas de critique convaincante, qu’elles le considèrent comme un produit de la science (cas de la médecine narrative) ou comme avatar du naturalisme, (cas de la phénoménologie de la médecine). En deuxième lieu, les deux approches s’enlisent dans des problèmes qui leur sont propres. La médecine narrative s’appuie sur des thèses problématiques : thèse de l’unicité de l’expérience subjective, thèse de la narrativité. La phénoménologie de la médecine rencontre de son côté des problèmes méthodologiques quant à la définition de la phénoménologie elle-même, qu’elle tend à réduire à l’étude de l’expérience vécue ou psychologique. Enfin, je critique la stratégie qui leur est commune, consistant à mettre l’empathie au centre de leur conception de l’humanisme. J’esquisse pour conclure une voie possible pour reformuler le problème initial et déplacer la discussion vers des questions de justice et d’accès aux systèmes de santé.
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... According to Abettan [15], Narrative Medicine can play a key role in the reform of current medical practice, although to date, there has been little focus on how and why it can deliver results and be cost-effective. ...
... NM requires time and effort and cannot be considered the only important issue in medicine. According to Abettan [15], Narrative Medicine can make the treatment more personalised for each patient, but it is not the only way. ...
Narrative Medicine: theory, clinical practice and education - a scoping review
Article
Full-text available
  • Sep 2024
  • BMC HEALTH SERV RES
Background The origin of Narrative Medicine dates back to more than 20 years ago at an international level. Narrative Medicine is not an alternative to evidence-based medicine, however these two approaches are integrated. Narrative Medicine is a methodology based on specific communication skills where storytelling is a fundamental tool to acquire, understand and integrate several points of view related to persons involving in the disease and in the healthcare process. Narrative Medicine, henceforth NM, represents a union between disease and illness between the doctor’s clinical knowledge and the patient’s experience. According to Byron Good, “we cannot have direct access to the experience of others’ illness, not even through in-depth investigations: one of the ways in which we can learn more from the experience of others is to listen to the stories of what has happened to other people.” Several studies have been published on NM; however, to the best of our knowledge, no scoping review of the literature has been performed. Objective This paper aims to map and synthetize studies on NM according to theory, clinical practice and education/training. Method The scoping review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist. A search was conducted in PubMed, APA PsycNet and Jstor. Two authors independently assessed the eligibility and methodological quality of the studies and extracted the data. This review refers to the period from 1998 to 2022. Results A total of 843 abstracts were identified of which 274 papers were selected based on the title/abstract. A total of 152 papers in full text were evaluated and 76 were included in the review. Papers were classified according to three issues:✘ Nineteen studies focused on the definition and concept of NM (Theoretical). ✘ Thirty-eight papers focused on the collection of stories, projects and case reports (Clinical practice). ✘ Nineteen papers focused on the implementation of the Narrative Medicine approach in the education and training of medical doctors (Education and training). Conclusions This scoping review presents an overview of the state of the art of the Narrative Medicine. It collect studies performed mainly in Italy and in the United States as these are the countries developing the Narrative Medicine approach in three identified areas, theoretical, clinical practice and education and training. This scoping review will help to promote the power of Narrative Medicine in all three areas supporting the development of methods to evaluate and to measure the Narrative Medicine approach using key performance indicators.
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... Ways of knowing through narrative is an issue explored in theoretical medicine (Abettan 2017;Alderson 1998;Leder 1990) and medical humanities (Woods 2011), yet one that we would suggest is not adequately brought into focus in discussion of methodologies for training to support PCC and allied aims. Without an epistemic framework orienting learners to these forms of narrative knowing, healthcare training is at risk of implicitly fostering narrative as a method for accessing a fixed understanding of lived experience and/or setting up narrative understanding as in conflict with biomedical knowledge. ...
... Baron (1990) highlights this as a concern around the use of narratives in medicine, that is the conceptualising of patients as more static than they are and MacNaugton (2009) points to a danger in assuming we can directly access a patient's experience. Seeing narratives as a method for accessing lived experience is linked to cutting them off from their epistemological frameworks (Abettan 2017;Baron 1990). Hence we argue for the importance of narrative-based learning in this field that foregrounds epistemology explicitly, which includes pedagogically. ...
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  • May 2023
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... Шайдюк О. Ю. 1 , Кудинова М. А. 2 , Таратухин Е. О. 1 , Сапунов И. В. 1 , Замятин К. А. 1 В статье предлагаются причины промедления с обращением за медицинской помощью больных острым коронарным синдромом с точки зрения индивидуализации работы. Для анализа применён подход нарративной медицины, т. е. способа осмыслять медицинские ситуации методами гуманитарных наук, а точнее -понимать ситуацию заболевания как события жизни пациента, его биографического нарратива. ...
... Нарративная медицина -разновидность включения представлений и способов анализа, принятых в гуманитарных науках (культурологии, социологии, антропологии, психологии и др.), для понимания проблем небиологического (небиомедицинского) характера [2]. Нарратив -последовательное повествование (от англ. ...
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The article suggests the reasons for the delayed help-seeking in patients with acute coronary syndrome in terms of individualization of work. For analysis, the approach of narrative medicine was used, that is, a way to conceptualize medical situations using the methods of the humanities, or rather, to understand the disease as an event in the patient’s life — his biographical narrative. These categories are important both from the standpoint of ethics and patient orientation, and from the standpoint of health improving through education of the population. A number of attitudes are shown that lead to delay in help-seeking: rigidity of thinking, unwillingness to cause discomfort, atypical manifestations, distrust of medicine and the unknown medical process. In general, the inclusion of a disease in the biographical process occurs through denial of the disease, distrust of medicine and/or healthcare, procrastination. As a solution of these problems, an assessment of the general informational background of patients as society participants and education depending on the social category, is proposed.
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... According to Charon [95], this feeling is the price of more and more technologically sophisticated medicine, which focuses on the biological disease itself rather than on the particular patient suffering from a specific disease. J Gastrointestin Liver Dis, ePub ahead of printing Through the progress of the science in medicine, we gain a lot of knowledge that is considered verified and undoubted information about diseases, but we also need other kinds of knowledge, so-called hermeneutical knowledge allowing us to grasp something about the patient who is sitting in front of us that we cannot grasp otherwise [96]. This knowledge, however, can never be verified and always remains more or less subject of notion. ...
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Irritable bowel syndrome (IBS) lacks a clear understanding of the disease‘s pathogenesis and effective treatments thus producing frustration among providers and patients, leading to the stigmatization of the disease and the patients with the syndrome. A literature search was performed to make a hermeneutical review on empathic patient-provider communication and IBS. The relationship is defined by partners being dependent on one another in the pursuit of obtaining good outcomes. It is a unique interaction depending not only on the individual qualities of each partner but also on the specific patterns of the patient-physician synergy. Empathy is crucial for any relationship. It helps to recognize the other as the other of myself, a person like me. Meanwhile, stigmatization results from identifying and labelling human differences and stereotyping persons who are linked to undesirable characteristics. IBS is at high risk of stigmatization in various contexts and settings including health care, causing patients and physicians misconceptions and distress, which in turn leads to the worsening of the disease in patients and burnout in physicians. Narrative-based medicine helps create a holistic perspective of a patient’s problems and health, thus providing a tool for an empathic doctor-patient relationship that fosters mutual understanding and helps patients with IBS make sense of symptoms, increases their ability to manage their IBS in a psychologically flexible manner, subsequently helping them maintain their quality of life.
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Recognizing and Maximizing the Nexus of Perioperative Medicine and Narrative Medicine
Article
  • Mar 2023
  • ANESTH ANALG
Perioperative medicine remains an evolving, interdisciplinary subspecialty, which encompasses the unique perspectives and incorporates the respective vital expertise of numerous stakeholders. This integrated model of perioperative medicine and care has a wide-ranging set of clinical, strategic, and operational goals. Among these various programmatic goals, a subset of 4, specific, interdependent goals include (1) enhancing patient-centered care, (2) embracing shared decision-making, (3) optimizing health literacy, and (4) avoiding futile surgery. Achieving and sustaining this subset of 4 goals requires continued innovative approaches to perioperative care. The burgeoning field of narrative medicine represents 1 such innovative approach to perioperative care. Narrative medicine is considered the most prominent recent development in the medical humanities. Its central tenet is that attention to narrative-in the form of the patient's story, the clinician's story, or a story constructed together by the patient and clinician-is essential for optimal patient care. If we can view the health care experience through the patient's eyes, we will become more responsive to patients' needs and, thereby, better clinicians. There is a potential clinical nexus between the perioperative medicine practice and narrative medicine skills, which, if capitalized, can maximize perioperative patient care. There are a number of untapped educational and research opportunities in this fruitful nexus between perioperative medicine and narrative medicine.
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Tōjisha Research and Narrative Medicine: Contribution of a Japanese Experiment in the Investigation of Patients’ Personal Experience
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Tōjisha research is a methodology intended to help psychiatric patients through dialogue. It was introduced in the context of community care in Bethel House (Hokkaido, Japan) in the early 2000s and later spread to other parts of Japan as well as abroad because of its originality and apparent therapeutic success. It offers patients a framework to investigate their own problems, symptoms, and delusions and to build a discourse around them. In this paper, I present a short account of tōjisha research and I put it in the context of current debates over the benefits and drawbacks of narrative medicine. I argue that there is an original conception of the self and of empowerment of patients in tōjisha research compared to other models of narrative medicine. Finally, I mobilize these original aspects to address some rebuttals of narrative medicine.
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The Hermeneutics of Medicine
Chapter
  • Jul 2022
After a rather long journey through the philosophy of medical practice and the phenomenology of health we have now reached a crucial point of our investigation: the subject of hermeneutics. I have found it strategically, if not logically, necessary to proceed in the manner I have done in this work in order to make the questions considering the essence of modern medicine more relevant and understandable. The history of medical practice surveyed in Chap. 1 and the philosophy of health and illness surveyed in Chaps. 2 and 3 were needed in order to provide a framework for the contemporary activity in the clinic that I will explore in this chapter. Philosophical questions are indeed always raised at specific moments in history, and in answering them we must pay close attention to our own historical situation and to the past history out of which they have evolved. .
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DIALÉCTICA O ERÍSTICA. LA APROXIMACIÓN HERMENÉUTICA A LA ÉTICA BIOMÉDICA COMO PROBLEMA O COMO SOLUCIÓN* DIALECTICS OR ERISTICS. THE HERMENEUTIC APPROACH TO BIOMEDICAL ETHICS AS A PROBLEM OR AS A SOLUTION ASPECTOS METODOLÓGICOS EN BIOÉTICA
Article
Full-text available
  • Jan 2019
Telf. (34)981167000, ext. 1523 vergara@udc.es RESUMEN: El presente trabajo se dirige a poner de manifiesto las condiciones en que la aproximación hermenéutica puede efectuar una insustituible aportación a la ética biomédica. Esta aportación se entiende a la luz de una de las principales deficiencias que presentan las metodologías al uso (en este trabajo nos referiremos básicamente al principialismo y al casuismo), que, en el fondo, actúan como meras cadenas de transmisión de los prejuicios del agente moral. Si bien los prejuicios no se pueden evitar, esto no significa que no se puedan superar, si es que, con Gadamer, entendemos que la comprensión está de algún modo dirigida a la verdad de las cosas. Este postulado nos permite poner en conexión la hermenéutica gadameriana con la ética aristotélica-cosa que ya hace el propio Gadamer, pero sólo a los efectos de deslindar su noción de comprensión-, e intentar ofrecer una salida para la mencionada deficiencia de las metodologías al uso. ABSTRACT: This paper aims to highlight the conditions in which the hermeneutical approach can make an irreplaceable contribution to biomedical ethics. This contribution is understood in the light of one of the main shortcomings of current methodologies (in this work we will refer basically to Principlism and Casuistics), which ultimately operate as mere chains of transmission of the moral agent's prejudges. Although prejudices cannot be avoided, however, it does not mean that they cannot be overcome, if, with Gadamer, we realize that understanding is in some way directed towards the truth of things. This postulate allows us to connect Gadamerian Hermeneutics with Aristotelian Ethics-something which Gadamer himself does, but only to the effects of defining his notion of understanding-and to try to offer a way out for the afore-mentioned weakness of current methodologies.
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Narrative Medicine: Hearing the Stories of Illness
Book
  • Jan 2008
Narrative medicine has emerged in response to a commodified health care system that places corporate and bureaucratic concerns over the needs of the patient. Generated from a confluence of sources including humanities and medicine, primary care medicine, narratology, and the study of doctor-patient relationships, narrative medicine is medicine practiced with the competence to recognise, absorb, interpret and be moved by the stories of illness. By placing events in temporal order, with beginnings, middles and ends, and by establishing connections among things using metaphor and figural language, narrative medicine helps doctors to recognise patients and diseases, convey knowledge, accompany patients through the ordeals of illness – and according to Rita Charon, can ultimately lead to more humane, ethical and effective healthcare. Trained in medicine and in literary studies, Rita Charon is a pioneer of and authority on the emerging field of narrative medicine. In this important and long-awaited book she provides a comprehensive and systemic introduction to the conceptual principles underlying narrative medicine, as well as a practical guide for implementing narrative methods in health care. A true milestone in the field, it will interest general readers and experts in medicine, humanities and literary theory.
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Against Narrativity
Article
  • Dec 2004
Abstract I argue against two popular claims. The first is a descriptive, empirical thesis about the nature of ordinary human experience: ‘each of us constructs and lives a “narrative” . . . this narrative is us, our identities’ (Oliver Sacks); ‘self is a perpetually rewritten story . . . in the end, we become the autobiographical narratives by which we “tell about” our lives’ (Jerry Bruner); ‘we are all virtuoso novelists. . . . We try to make all of our material cohere into a single good story. And that story is our autobiography. The chief fictional character . . . of that autobiography is one’s self’ (Dan Dennett). The second is a normative, ethical claim: we ought to live our lives narratively, or as a story; a ‘basic condition of making sense of ourselves is that we grasp our lives in a narrative’ and have an understanding of our lives ‘as an unfolding story’ (Charles Taylor). A person ‘creates his identity [only] by forming an autobiographical narrative – a story of his life’, and must be in possession of a full and ‘explicit narrative [of his life] to develop fully as a person’ (Marya Schechtman).
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Against Narrative Medicine
Article
  • Sep 2013
  • PERSPECT BIOL MED
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.
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The patient as text: A model of clinical hermeneutics
Article
  • Jun 1986
  • THEOR MED BIOETH
The art of interpretation has traditionally been an integral part of medical practice, but little attention has been devoted to its theory. Hermeneutics or the study of interpretation has grown as a methodological interest primarily within the humanities. Borrowing from the medieval fourfold sense of scripture, which organizes interpretive activity both logically and comprehensively, I propose a hermeneutical model of clinical decision-making. According to the model, a patient is analogous to a literary text which may be interpreted on four levels: (1) the literal facts of the patient's body and the literal story told by the patient, (2) the diagnostic meaning of the literal data, (3) the praxis (prognosis and therapeutic decisions) emanating from the diagnosis, and (4) the change effected by the clinical encounter in both the patient's and clinician's life-worlds. The model is illustrated through application to a medical case.
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Clinical interpretation: The hermeneutics of medicine
Article
  • Mar 1990
  • THEOR MED BIOETH
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.
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