Primum Non Nocere: On Accountability in Narrative-Based Medicine

Narrative-based medicine, a term coined in the United Kingdom, has offered creative approaches to understanding and improving the doctor-patient relationship.¹ These include eliciting, reading, and discussing patient narratives and turning to literature for fully embodied stories of illness and recovery. In North America, John Engel and colleagues have identified six narrative skills or competencies (listed in Rita Charon’s Foreword to Narrative Medicine) relevant to clinical work and which inform a philosophy of care and a clinical discipline called narrative medicine. These include: the exercise of the moral imagination, the practice of empathic presence and mindful listening, reading and interpreting complex texts, writing reflectively and telling complex clinical stories, reasoning with stories, and engaging in narrative ethics. ² The field is indeed an exciting one and has allowed physicians worldwide to discover new meaning in their work.

Nonetheless, it is essential that these newer uses and techniques of medical storytelling inspired by clinical encounters continue to reflect enduring ethical standards related to patient confidentiality, to ensure non-exploitation of patients for personal gain by physicians, and to foster public trust in the profession. As Edmund Pellegrino and his colleagues have so eloquently put it, “By its traditions and very nature, medicine is a special kind of human activity—one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest.”³

Doctors have always shared narratives about patients, but as we’ll see, telling stories about patients has had built-in standards of accountability. Newer narrative explorations in healthcare can have their positive impact maximized by being “read” through a more modern lens of accountability, thereby reducing unforeseen harm to the patient, to colleagues, or to the reputation of medicine as a profession based on public confidence and trust. As we’ll see, what I call “narrative accountability” in medicine has always meant serving the patient first and enhancing learning within the profession second.

When assessing the merits of more modern narrative-based practices (such as asking doctors to write, read, and share texts about clinical encounters), it is also necessary to acknowledge that no innovation or intervention in the history of medicine, however promising or well-intentioned, has been without iatrogenic risk. The rediscovery of narrative within medicine is no exception.⁴

Some History

Medicine has always been a storied enterprise, so when examining the ascent of specific narrative-based practices in the twentieth and twenty-first centuries, it is useful to track the rise, fall, and apparent resurrection of medical storytelling. Mike Bury reminds us that prior to the advent of the biomedical model of illness in the nineteenth century, the doctor’s primary (and sometimes only) role was to take a careful history: “This involved information about the patient’s lifestyle, his/her moral stance and the wider environment in which the patient lived. Eschewing all but the most rudimentary physical examination of the patient, the aristocratic doctor . . . was expected to attend to patients’ narratives and develop treatment regimens accordingly, usually through procedures that restored the body’s equilibrium.”⁵

As the science of medicine preoccupied itself with departures from statistical norms and reproducible definitions of disease, the experience of individual patients became less important, and one could argue that the ritualized task of diagnosis became an anti-narrative act. Bury suggests that narrative has returned to medicine in the last twenty years due to a relative decline of the importance of infections (when compared to the nineteenth and twentieth centuries) and to a growing emphasis on degenerative and chronic illnesses for which there are no ready cures.⁶ Other narrative-building trends include an erosion of medical authority alongside the patient’s growing insistence on finding meaning in the illness experience—and an apparent cultural trend toward self-revelation, in print and online. As Lars-Christer Hydén, quoting Jean-François Lyotard, suggests: “‘A number of authors have pointed out that the old grand narratives—the...