Mortal Exposureon the goodness of writing medical ethics
Narrative ethics has recently been advanced as an alternative to more "principled" and "theoretical" approaches to medical ethics. This turn prompts reflection on the distinctive activity of writing medical ethics. When writing medical ethics is recognized as a distinct activity, the forms of care it accomplishes can be distinguished from medical care. This distinction enables analysis of how caring for one's own needs as a writer of medical ethics is in productive tension with the ends of caring in medicine. One important good of writing medical ethics is that the act of writing forces one to reflect on the common mortal reality that is a condition of medical experience. Because it provides occasions for reflection on one's own mortality, medical ethics may no longer need immediate medical application in order to claim its contribution to caring.
Over the past several decades, narrative ethics has been increasingly celebrated as an alternative to theory-driven modes of ethical analysis (Hauerwas 1981; Hauerwas and Jones 1989; MacIntyre 1981). Characterization of narrative ethics as opposed to "theory" is not so straightforward, however, since narrative ethics is a theory. The critiques of modern philosophical ethics typically advanced by persons who invoke narrative as an alternative are most of all assertions about the deficiency of such theory, its inability to account for what [End Page 163] is happening in practice (Rorty 1989;Williams 1985). For just this reason the general turn to narrative has been taken up enthusiastically by many writers of medical ethics (Booth 2001; Chambers 1999; Charon 2006; Charon and Montello 2002; Hunter 1991; McKenny and Sande 1994; Nelson 1997). Energizing the application of narrative ethics to medical ethics most of all is the recognition that writings about encounters with medical care can actually shape how that care is experienced by all the persons involved. The concept of narrative ethics also can illuminate the multiple ends that writers are pursuing when they choose to write medical ethics. Writers of medical ethics are not just caring for others, but in the process are caring for themselves. Little in the literature on narrative and medicine so far has addressed the forms of self-care that draw many persons to write medical ethics in the first place. The present essay expands the current conceptualization of medical ethics to include ends that may only touch tangentially, if at all, questions of medical care or analysis of contemporary issues in bioethics.
The term narrative has a wide range of uses in contemporary medical education and medical ethics, including the specific clinical practice of "narrative medicine," analysis of medical pedagogy and epistemology, communitarian critique of the dominant principlist approach to policy and analysis of medical ethical issues, productions by physician-writers, and productions by persons living with illness or disability or caring for ill or disabled family members. Underlying all these uses of the concept of narrative, however, is a shared confidence that the activity of writing narrative is unqualifiedly good. A recent article, "The Craft of Writing," for example, posits that "writing can stimulate residents to listen to the patient's story, appreciate the joy and fascination in the doctor-patient relationship, and cultivate the attitude that a patient is more than his or her disease" (Reisman, Hansen, and Rastegar 2006, p. 1109). The claim—explicit in this article and typical more generally of the many contemporary appeals to narrative—is that the capacity of one person to write about another person's experience of medical care somehow can improve the quality of the care provided (Anderson 2000; Charon 2006; Morey 1994; Pennebaker 2000).
As appealing as positive claims on behalf of writing are, they typically are also self-authorizing. The authors of the "The Craft of Writing," for example, depend on the self-reported assessments of the resident participants in their workshop as proof that the writing makes a positive difference. To bolster this assumption, they cite published physician-writers who likewise assert the benefit of writing for medical practice. Elided from almost all assertions of the benefit of such writing is the possibility that positive differences are achieved only on paper. Missing from the current of optimistic appeals to narrative in medical ethics and education is the recognition that writing about caring for someone or receiving care is not the actual activity of caring for someone or receiving care. Writing is a distinct activity with its own purposes, uses, and abuses, none of which are necessarily continuous with compassionate caring. For the present argument, therefore, [End Page 164] "narrative" denotes any form of writing about encounters with medical care that exceeds the immediate context of the care provided. In other words, it is any form of writing that is about more than the immediate responsibilities of medical practitioners. Narrative in a general sense thus describes any turn to writing about experiences of medical care as a means to accomplish ends that concern more than the ends of medicine itself. The subject matter of medical ethics is thereby stipulated as much broader than medicine per se, in the sense that medical ethics happens whenever anyone reflects upon experiences of medical care by writing about them, whether the experiences are their own or someone else's.
When writing medical ethics is recognized as an activity distinct from medicine, the forms of care accomplished through such writing no longer may have much to do with medical care. The latter then becomes a pre-text, in a literal sense, for the former. Caring for one's own needs as a writer of medical ethics may further the ends of caring in medicine, but it may also exist in tension with them. Indeed, it is only through consideration of the ends attainable through medical ethics, as in tension with the ends of medicine, that it is possible to address the question posed by Tod Chambers (1999) in his analysis of how writers of medical ethics cases control the voices of the subjects they represent: "Unless patients become the authors of their own stories, as has been favored by Arthur Frank [1995, 1997], their language will always be mediated through the voices of others. Bioethics have tended to use forms of representation that require that they mediate the perspective of others. One wonders why so few of these ethicists have tried to write not simply about the problems of others but with others" (pp. 126-27).
In answer to Chambers's question, at least three forms of care for self are relevant for analysis of how writing about the problems of others in medical ethics becomes a means of addressing problems of oneself. First are the material constraints that are the context of almost all such writing. While inquiry into medical ethical issues may prompt the writing, it is also driven by needs for peer review, promotion, and salary that concern the writers. Second is the interest of writers of medical ethics to present a positive image of themselves. Maintenance of one's own self-image is necessary to maintain one's capacity to care for one's self and others, but the images caregivers and recipients of care each wish to project of themselves can sometimes contradict and undermine each other. Third is human vulnerability and helplessness in the face of mortality, and the needs of individuals to cope accordingly. Writing about other persons' suffering and dying can be an occasion to imagine the unimaginable for oneself, but always at the risk of discounting the reality of other persons' mortal experience.
Discussion of the self-concerned purposes of writing medical ethics may trouble advocates of the many applications of narrative, given some of the resistance to narrative inquiry as overly soft and unscientific, and also the tendency to evaluate writings in medical ethics in terms of their practical application (Chambers 1999). But writing medical ethics can't happen without manifesting the [End Page 165] troubles, needs, worries, fears, and also hopes, ambitions, and promises, of the writers themselves. Appreciation of the importance of writing consequently requires greater critical reflection on its moral complexity. Attention to the self-concerns evident in medical ethical texts may paradoxically enhance appreciation of a practical use of medical ethics that is basic and prior to all its others uses, in that medical ethics provides opportunities for persons to confront the mortal reality underlying the common human need for health care.
Publication for Publication's Sake
For anyone pursuing an academic career, publication is the single most important measure of success, a rule from which the field of medical ethics is not exempt. Forty years ago, professional education in medical ethics hardly existed. Today, undergraduate majors and minors, terminal masters, and Ph.D. programs are the norm at colleges and universities, which also continue to assemble ethics centers and convene innumerable conferences. Along the way, journals proliferate and books appear faster than one can keep track of them.
Ironically, the very success of medical ethics calls into question the ends of writing medical ethics, because the demands of an academic career may have little to do with writers' ostensible moral claims. Medical ethics draws continually on narratives of incurable disease, bodily disfiguration, denial of desperately needed services, premature or wrongful death, systematic injustice, and tragic loss. Without these narratives of embodied human suffering, medical ethics couldn't happen. But when these narratives are appropriated into the print culture of academia, they may serve purposes of their scholarly authors that have little relation to their origins in the experience of the sick individual.
Although the use of narratives of other persons' suffering to accomplish one's own ends may be especially likely to occur in medical ethics, it is part of a larger trend in the humanities and social sciences. Reflecting on her experience writing and teaching about South African activist Steven Biko, Patricia Yeager (2002) names this trend the habit of "Consuming Traumas: or, the Pleasures of Merely Circulating":
Differently positioned (not only not incarcerated, but at relative leisure to pursue polymorphous political passions), liberal academics also reproduce for themselves and their students stories of trauma, structural violence, systematic injustice, slaughter, inequality. These painful stories—about deterritorialization, decolonization, people pushed into the margins, bodies brutalized, populations dying, in exile—suggest a world of subsemantic history that demands the weight of political speech. At the same time (or, within the same heterodox space but under another name), we inhabit an academic world that is busy consuming trauma, creating professional connections—through its stories about the dead. We are obsessed with stories that must be passed on, that must not be passed over. But aren't we also drawn to these stories from within an elite culture driven by its [End Page 166] own economies: by the pains and pleasures of needing to publish, by salaries and promotions that are themselves driven by acts of publication, by the pleasures of merely circulating?(pp. 28-29)
Though Yeager directs her comments at "liberal academics" in general, her concluding question appeals with urgency to the medical ethicist—this writer and this very attempt at publication included—who trains to occupy a privileged position from which to comment on the meaningfulness of other people's illnesses and injuries and suffering and death. The main readership of most journals and edited volumes, after all, is almost certainly not the providers of primary care to persons suffering—or even teachers of providers of primary care—but "differently positioned" academic professionals, writing and reading at a second or third remove.
Just because writers of medical ethics are often "differently positioned" than the subjects about whom they write doesn't in itself entail that such writing is immoral or unjustifiable. But the real and often necessary distance of narratives of suffering from the sites of suffering suggests that the "pleasures of merely circulating" may become the predominant motive for writing. Publications in medical ethics are therefore always open to interpretation as attestations of the professional needs of their authors, and also of the philosophical and methodological commitments that make an academic career. The pursuit of a career in medical ethics may, ironically, undermine some of the claims of medical ethics to be an ethical discipline. Arguments typically take the form of claims about how to improve caring for the needy or how to humanize education for the caregivers, but the constraints propelling these attempts at publication also function as ends in themselves, as forms of caring for self that have their own place as medical ethics.
Recognizing that writing medical ethics is an activity in which writers realize their own needs and desires entails reconceptualizing the ends of medical ethics more generally. An interesting but neglected realm of inquiry is the ways in which the self-concerns of writers of medical ethics can conflict with the concerns of the persons whose narrated experience make such writing possible. This inquiry is especially significant because the person writing about the experience of receiving care is only rarely the person receiving care: those who suffer illness often depend on others to render their voices audible (Chambers 1999; Couser 2004, 2005; Irvine 2000). Writers of medical ethics should therefore strive to find ways to respectfully acknowledge that their own accomplishments in publication appropriate other persons' suffering experience.
Looking Good and Doing Good
Assuming the aim is publication, writing necessarily involves a concern about self-presentation. It is therefore necessary to consider how narratives that ostensibly address issues of caring for others also address the needs of writers to look [End Page 167] good, precisely by representing themselves as persons who are concerned with issues of caring. The needs of the writer and the needs of others may not be separable, and sometimes may even conflict.
In her essay "Writing Wrong," literary critic and poet Sandra Gilbert (2002) provides an example of how the concern to look good through writing can advance the possibilities of caring, but also can generate anxiety about self-presentation for both caregivers and persons receiving care. Gilbert reflects on the writing and publication of her book Wrongful Death (1995), which relates in detail—no names withheld or changed—the story of the death of her husband: how he died mysteriously after undergoing a surgical procedure that had been confidently described to the couple as "routine"; how it was only after insistent investigation on her part that she was able to determine that the cause of her husband's death was culpable negligence by the surgeon and hospital staff; and how she sued the hospital and negotiated a settlement.1
Writing this book, Gilbert explains, was her attempt to learn to live with the wrong she experienced, to craft an image of herself as someone who lives meaningfully with her loss. Reflecting upon that process, she emphasizes that the attempt is by definition a losing endeavor, because "it's a hopeless effort at a performative act that can never, in fact, be truly performed. You can't, in other words, right wrong by writing wrong, even though you are engaged in the writing because consciously or unconsciously you believe that your testimony will reverse, repair, or undo the wrong you're reporting" (Gilbert 2002, p. 261). As much as Gilbert feels compelled to tell her story, she worries about looking sentimental, or silly, or like someone who can't keep silent about bad news that no one wants to hear. All the more telling, then, that her own worries about how she looks through her writing are intensified when she reads an interview in local newspaper with the doctor whom she holds responsible for her loss. Gilbert recalls:
A few months after Wrongful Death appeared, my husband's surgeon was named director of a cancer research clinic at the medical center where he works, and I imagine that it was in connection with this promotion that he gave an extended interview to a local reporter, who produced an article that featured a prominent sidebar entitled, "When a patient dies," recounting the doctor's comments on what was clearly my husband's case.
Here's what the reporter recorded:
Dr X [that's right, at the moment I'm feeling too anxious to spell out the man's name] recently lost a patient for the first time in his career. "How do you deal with it?" reflects Dr. X. "You're there to look after people. You practice the best medicine that you possibly can. I don't think there's anything else that you can do. If you're talking in an abstract way about how you deal with the fact that [End Page 168] you may be sued, you thank God that most of the people you treat, and their families, are marvelous people." (emphasis added) There it is. "Marvelous people" don't sue. Marvelous people don't write wrong: they don't seek to rectify wrong nor do they record the wrong. Perhaps, indeed, because they are marvelous people wrong does not befall them! (Gilbert 2002, p. 266).
For Gilbert, reading this article is an experience of insult added to injury. One person—the reporter—presents an opportunity for a second person to look "marvelous" and a third person to look and feel crummy. Even though Gilbert doesn't hesitate to name the doctor in her book, it makes intuitive sense that she withholds the name as she recounts the anecdote, mirroring in her treatment of Dr. X the injury of erasure that she experiences in reading his comments. Her loss is reduced by his comments to the status of exception to the rule, and then consigned to the realm of abstraction.
In writing of her experience of reading Dr. X's comment, Gilbert demonstrates how the concern for self-presentation through publication can be a source of complicated conflict between caregiver and persons receiving care.2 Even as Gilbert recounts this anecdote, she notifies the reader that her concern for self-image is in tension with Dr. X's, since she lets her readers know that the interview she is citing occurred after the publication of her book and that she does in fact name Dr. X in the book. Gilbert thus gives the reader of her essay cause to question whether Dr. X too doesn't have good reason to feel concern for his self-presentation. The claim by Dr. X that he "recently lost a patient for the first time in his career" presumes a heroic infallibility upon even a generous interpretation: that he has never before "lost" a "patient" whose life his skill could have preserved, as if the fact of death determines whether the "patient" could have been saved or not. On the other hand, Gilbert can't avoid exposing herself to criticism as someone who has provoked Dr. X's pretension in response to her own public aspersions of him. A further complication is that in reducing him to anonymity, yet announcing the availability of his name to whomever is interested to know it, Gilbert facilitates my own consumption and recirculation of her trauma and the accusation against Dr. X. Treating Dr. X as a substitutable example of a troubled form of self-assertion makes it easier for me to assert my place in what Sedgwick (1990) calls the chain of "knowledge-relation" that originates with the death of Gilbert's husband and enfolds within itself the audience of this essay.
A final irony of the present reading of Gilbert's essay is that this citation—if successful—will facilitate my own self-representation, because my readers will accept my claim about the self-regarding purposes accomplished through writing medical ethics. Medical ethics is thus written out of the cross-purposes of [End Page 169] "consuming traumas": the narrative activities sustaining professional knowledge formation depend on the trauma of some persons, and the reduplication of that trauma through its narration and circulation by other persons. Medical-ethical knowledge is thus inescapably traumatic (see Spring-Summer 2003 volume of Journal of Clinical Ethics). Yet the "consuming traumas" that further the injuries of some, are also the basis and sometimes even the means of healing of others. Even Gilbert, after all, finds it worthwhile to write the wrong of reading Dr. X's comments by circulating them in an altered context.
Sublime Emotion and the Goodness of Writing Medical Ethics
The concern to "look good" is not opposed in any simple way to the accomplishment of good. The benefits of writing medical ethics should not be discounted simply because some of the persons who enable those benefits do so by indulging in the pleasures of merely circulating, or strive too much to make themselves look good in the process. Even when they seem to go wrong, the narratives circulated in medical ethics function as a medium for reflection on human limitation. Consequently, an important good of writing medical ethics may be the self-care it enables, in fostering the ability to reflect on the mortal reality that is a condition of medical experience.
To appreciate writings in medical ethics as forms of reflection on human mortality, it helps to consider the mutual relevance of moral and aesthetic experience. Writing specifically of goodness as an idea, the novelist and philosopher Iris Murdoch (1970) explains that the moral and the aesthetic are ultimately inseparable: "Goodness is connected with knowledge: not with impersonal quasi-scientific knowledge of the ordinary world, whatever that may be, but with a refined and honest perception of what is really the case, a patient and just discernment and exploration of what confronts one, which is the result not simply of opening one's eyes but of a certainly perfectly familiar kind of moral discipline" (p. 38). Following Murdoch's vision, writing medical ethics is inseparable from a perceptively searching openness to the complexity of experiences of medical care and the attendant art of observation. These qualities are developed through the activity of writing, but only as that activity hones and develops the writer's capacity to become the least important presence in the writing, to dissolve into a medium of expression of "what is really the case. "When Murdoch asserts that this "moral discipline" is "perfectly familiar," she is therefore cautioning against too quick or ready an estimation of the good one can accomplish through narrative, because one's own need to care for self is always in some tension with the "refined and honest perception" of the complex reality of which oneself is only ever a small part. Knowledge of the "perfectly familiar" is thus a goal of "perfection" to pursue with knowing acceptance that one's own needs [End Page 170] obstruct its attainment. To write better narratives requires self-awareness of the limits to one's own capacity for goodness.
The association of moral and aesthetic goodness suggested by Murdoch leads to consideration of how writing medical ethics functions as a means to experience the phenomenon termed "sublime" by Immanuel Kant and Friedrich Schiller. As a philosophical concept concerned specifically with the relation between ethics and aesthetics, the sublime describes how certain aesthetic experiences call to consciousness one's distinctly moral capacities, by also calling to consciousness one's utter helplessness against the fact of death. The concept of the sublime illuminates that much of the value of writings in medical is that they provide occasions for persons to reflect about their own mortality, so that writing medical ethics doesn't necessarily need to claim any obvious or immediate practical application in order to contribute to care for a most basic human need.3
In his 1801 essay "Concerning the Sublime," Friedrich Schiller explains how narrative depictions of human fragility can help human beings confront their own mortality and maintain their moral agency. Of the spectator of representations of human vulnerability to natural forces, Schiller writes:
Sublime emotions strengthen him toward this end as does a more frequent intercourse with the devastating character of nature, both where it displays its destructive might to him merely from afar and where it actually exerts this might against his fellow human beings. The pathetic is an artificial misfortune and, like the true misfortune, it puts us in immediate contact with the spiritual law that reigns in our bosoms. . . . The pathetic, one can thus say, is an inoculation against unavoidable fate, robbing fate of its perniciousness and diverting its attack to a human being's strength. (Schiller 1801b, pp. 82-83)
In this context, "pathetic" is not any form of judgment but a term of art deployed to enable a conceptual distinction between "genuine misfortune" and "artificial misfortune." One way to summarize the difference is that genuine misfortune concerns oneself, whereas artificial misfortune concerns other persons. The complexity of this distinction, however, is that one's capacity to withstand genuine misfortune, when it strikes, depends on prior exposure to artificial misfortunes. It is only through the training provided by exposure to artificial misfortune—in the form of narrative portrayals of other persons' suffering—that one is able to transform one's own misfortune into an occasion to reaffirm one's moral identity. What Schiller calls "the spiritual law that reigns in our bosoms" is the human capacity for morality. A distinctive moral accomplishment of human beings is to treat one's own genuine misfortune as artificial, as the misfortune of another. The concept of empathy is thereby turned on its head. Rather [End Page 171] than feel with another, as an extension of self, one feels for oneself as if one were another, enabling endurance of one's exposure to the fact of mortality that otherwise threatens to undo one's moral personality.
Although Schiller celebrates representations of artificial misfortune as necessary to development of an advanced survival skill—human awareness of finitude—the ideal of the pathetic he advances depends on an awareness of actual human illness. In a startling use of medical terminology, Schiller (1801a) exclaims that the triumph of spiritual human freedom—in other words, morality—"is an inoculation against unavoidable fate" (p. 37). Through this metaphor—drawing as it does on contemporaneous advances in understanding of immunology—the independence of human moral freedom from "sensuous" influence is prized as a medical accomplishment, where sensuous in this context refers to the inexorable laws of nature. Human freedom however, proven in the capacity for morality, can transcend the laws of nature. Fate is consequently figured as a disease, of nature and sublime emotion is the antigen that enables one to endure and transcend exposure to "what is really the case" regarding human embodiment. Sublime emotion thus enables oneself to persist as a morally capable creature despite one's natural finitude. (For a discussion of immunity as a legal and medical metaphor, see Cohen ).
Considered as an exhortation to understand sublime emotion, Murdoch's warning against familiarity can now be appreciated as a reminder that there is a limit to how much any person can think the truth of his or her own finitude. It follows that the condition Schiller calls "pathetic" can be generalized to all persons. "Inoculation" is only possible because one is vulnerable. No neat boundary exists between narrative representations of this condition as an artificial misfortune and its occurrence as a genuine misfortune. One of the most important goods of writing medical ethics is thus its display of "pathetic" characters, even as it is never fully possible to realize for oneself fully "what is really the case" in such display. The temptation along the way is to treat other persons as characters in a pathetic display, so that medical ethics is always at risk of slipping into a medical ethical voyeurism. The sublime emotion that enables persons to confront illness and death can then become a barrier to recognition of other persons' artificial misfortunes as their own genuine misfortunes. The ultimate difficulty is that empathetic relation itself wavers across this voyeuristic divide without ever fully settling on one side or the other.
Human beings need to find ways effectively to narrate and thereby incorporate into their own senses of self the fragility and vulnerability of their embodied existence. The attempt to write oneself as capable of mastering one's fate, by imaginatively writing oneself as invulnerable to fate through exposure to other persons' pathetic suffering, emboldens persons to exercise their moral freedom in caring for themselves and others. But the need to maintain one's moral agency also generates its own critique, since it always also threatens to descend into a form of voyeurism that can obviate compassion for and relationship with others. [End Page 172]
In its potential for distancing others as well as joining them, the cross-purposes of writing medical ethics are continuous with the limitations of medicine itself. In her explication of medical care as a process of narrative exchange from ailing individual, to caring medical team, back to individual, Kathryn Montgomery notes that the necessity of representation that makes caring relationships possible also isolates. Writing of the necessity of narrative representation to medical care, she notes: "Such metonymic imperialism is a hazard of the act of representing another person in a narrative of one's own construction, and it contributes to the professional shortsightedness that sees maladies rather than people as the objects of medical attention" (Hunter 1991, p. 61). Through the phrase "metonymic imperialism," Montgomery describes how medical caring involves the reductive identification of persons with their illnesses, and that such reduction is actually necessary to effective medical treatment even as it distances caregivers from the persons they attend. Writing medical ethics often also involves an "act of representing another person in a narrative of one's own construction," so that writing medical ethics also often risks "metonymic imperialism," whereby the construction and the person are wrongfully regarded as interchangeable. The ultimate hazard is that the familiarity of one's own narrative productions become over-valued, precisely because they are one's own, and thereby obstruct more "refined and honest perception" of one's own and other persons' experience (Brauner and Poirier 1988).
As Montgomery goes on to note, however, the breach between representation and reality, between narrative construction and suffering person, is ultimately incommensurable and even necessary to a lot of caring (Hunter 1991).4 With regard to medical ethics, the value of its writings are enriched when they manifest awareness that the narrative depictions of suffering they circulate are distinct from the genuine misfortunes that are an initiating source of the writing (Chambers 1999). Instead of assuming that writings in medical ethics can ever overcome the incommensurability of word and act, narrative and person, self and other, it is more responsible in the end to recognize that writing medical ethics weaves the writer into a metonymic chain of representation and relationship. Because there is no end to the flourishing chains of relationship that humans beings can forge with each other through narrative, there is no solution to the hazard of "metonymic imperialism," but the hazard can be as much an opportunity as a pitfall. It signifies the freedom, creativity, and openness of present relationships to the future [End Page 173] and to oneself. Unqualified claims for the goodness of narrative are therefore suspect. Oddly enough, they suggest a failure of imagination, as they fail to address the breach that writing medical ethics can only ever partially bridge.
The author wishes to thank Daniel Brauner, Farr Curlin, Kathryn Montgomery and the participants in the Narrative and Medicine Reading Group at Northwestern University Feinberg School of Medicine, and the anonymous readers for Perspectives in Biology and Medicine, whose reviews contributed substantially to the final draft.
1. Such at least is Gilbert's version of events. As with similar stories that end in financial settlement, the hospital side maintains official silence.
2. This story also raises questions of journalistic ethics and the importance of the distinction between a "reporter" and a "journalist," between one who transmits what was said, and one who seeks to establish the truth or falsehood of what was said.
3. Nuland (1994) is a notable—and rare—example of writing in medical ethics that seems explicitly intended to address this need.
4. Consider, for example, that much of the benefit of writing about one's own medical experience—the genre of "pathography"—is the accomplishment of a "metonymic imperialism" of one, whereby the writer constructively distances his writing-self from his illness-self (Hawkins 1993). Some amount of distancing from one's own troubles can be a sign of strength, not weakness. Successful writers, however, tend to get to have a definitive say about the experience of an illness that may obstruct attention to less able voices that report different experiences (Barbour 2000).