The Chief Concern of Medicine: The Integration of the Medical Humanities and Narrative Knowledge into Medical Practices

1. The Functional Realism of Medicine

/ 35 / 1 the functional realism of medicine The Problem of “Narrative Medicine” While efficacy of training for and utilizing “narrative knowledge” within the practices of medicine—something that Rita Charon has aptly called “narrative medicine”—has grown and continues to grow in medical education and professional practice (see Charon 2006a for a thorough account), defending its method and aims to the medical establishment remains a difficult task. it seems that the burden of proof of its efficacy and scientific reliability still resides on the shoulders of the practitioners of narrative medicine. Those teaching physiology to first-year medical students seem relatively free of the similar onus of demonstrating in a decisive way that their course leads to better medical results, even though, it should be added, no such evidence exists to support that it does. Underlying the suspicion of the “softness” of narrative medicine is an often tacit metaphysical presupposition that the language of the positive sciences is a description of the nature of reality. Science advanced , in the work of galileo, Descartes, and newton, with an understanding of nature as mathematicizable and quantifiable. (in chapter 2, we examine this conception of science under the term mathematical physics to distinguish it from the more historically oriented science of evolutionary biology .) Biomedical science followed suit, and the benefits of this advance are not to be underestimated. nevertheless, this assumption of the primacy of “hard” quantifiable truth leads to three important responses. first, in the teaching and practices of medicine, it has led to the most notable and explicit expression of this assumption in the pursuit of “evidence-based medicine,” a 36 / the chief concern of medicine categorization, coined in the early 1990s and growing out of the work of the Scottish epidemiologist archie Cochran, that advocates that systematic, empirical , and quantifiable research—as opposed to “traditional,” more or less untested medical practices—form the basis of medical practice. needless to say, the pursuit of evidence-based medicine was and remains a salutary response to often unexamined assumptions about what is effective medical practice, but it also participates in the tacit metaphysical presupposition about what “counts” as knowledge, explored in this chapter. in a second response , more generally—and perhaps less self-reflectively than evidencebased medicine—the assumption of the primacy of quantifiable truth has led the medical establishment to seek evidence of the efficacy of narrative medicine in quantified results. if the effects of narrative medicine in medical education can only be justified in reflective (case-based) descriptions of its power and efficacy—or even in the schema-based understanding we present in this book—rather than in the evidence-based facts and formulas of systematic scientific testing and research, those holding this assumption will count such reflective descriptions against, not for, their use in the curriculum and practices of medicine.1 But there is a third response to this assumption, which we follow here (without discarding evidence-based medicine). one premise of our defense of narrative medicine is that while natural phenomena, including physiological ailments, can be described in mathematical and quantifiable vocabularies , that language can be said to correspond to a reality only insofar as the biomedical results of biomedical science are treated as just that—results, achievements, and outcomes of scientific inquiry. This reminder prevents two fallacies. The results of biomedical scientific inquiry should not be thought of as existing antecedent to the inquiry that produced them, and we should be prudent in our tendency to import those results to other clinical situations. Treating biomedical knowledge as the outcome of inquiry, whose reality inheres in the functional ability to resolve the problems that give rise to inquiry, infuses medical practice with both fallibilism—that is, the philosophical doctrine that all claims to knowledge can, in fact, be mistaken—and the possibility for growth and improvement. further, reminding the medical community of this insight prevents the clinical physician from failing to confront the individual patient as an individual (rather than a “case” of a disease)—with all her particularity, richness, affective experience, and what we describe as her concern—by viewing her narrative in the clinic as a shroud to the real biomedical knowledge sought after. as we suggested in the introduction , we believe that education in and mindfulness about narrative can The Functional Realism of Medicine / 37 avoid both of these mistakes.2 our hope and contention is that a medical community that treats biomedical knowledge...