Narrative Knowledge, Phronesis, and Paradigm-Based Medicine

Literature is hardly of interest to medicine only because great books have been written about illness and death. More fundamental by far than the content of Bleak House or King Lear is the modeling, by literary acts, of deeply transformative intersubjective connections among relative strangers fused and nourished by words. Recognizing that my responsibility toward my patient includes my being a dutiful and skillful reader helps me to understand what skills to develop within my doctorly self.

—Rita Charon, Narrative Medicine (54)

In this essay, I examine the concept and function of “narrative knowledge” both in general and in the practice of medicine. I focus on narrative knowledge not only in terms of the knowledge that a physician-listener can glean from narrative—knowledge that Rita Charon richly describes in her presentation of part of medical practice she calls narrative medicine—but also the knowledge of narrative itself and how a working understanding of the shape and features of narrative can contribute to successful medical practices (which she also describes). There is great controversy concerning the nature of narrative, its “salient” features, its cognitive functioning, its role in cognition and, indeed, in human neurological organizations, its place in interpersonal relationships and larger social formations. In her response to David Rudrum’s pragmatist analysis of narrative, Marie-Laure Ryan nicely summarizes “a tentative formulation of … nested conditions” by which narrativity could be progressively defined or circumscribed (193–94). She lists nine criteria by which people might decide if a particular text is a narrative, beginning most generally with the contention that “(1) narrative must be about a world populated by individuated existents” and ending with “(9) The story must have a point” (194). When people are asked if a particular text is a narrative, she writes, some will be satisfied it is if the text is about individuated existents in a world that undergoes historical change cause by external events, “while others … will insist that narrative must be about human experience.” Still others, she writes, will insist a narrative demonstrates a “sequence of [non-habitual] events [that] must form a unified causal chain and lead to closure”; and finally there are some who see that “the story must have a point,” even “while others … think that a pointless utterance can still be a narrative” (194).

While such controversy inhabits scholarly debates about the nature of narrative and the qualities that allow us to recognize a text as a narrative, no such controversy inhabits the situation when a patient tells her doctor the narrative of her illness. These stories, like Ryan’s final criterion, must have a point, an overriding “concern”: the stories patients bring to physicians are necessarily goal-oriented even when—or perhaps particularly when—they present themselves in the form of a not-yet-completed narrative. In fact, it is engagement with just such not-yet-completed narratives that led Aristotle to develop his ethical notion of phronesis, his sense of “practical reason,” one of whose chief examples, in his discussion, is the work of medicine. (Aristotle’s father was a physician.) For Aristotle, phronesis is focused on action rather than knowledge, actions that make its agents achieve goodness in particular behavior and in life more generally (see II, 2; 1104a). Such an understanding, as Aristotle suggests, is closely connected to practices of medicine, whose aims, after all, are not so much the achievement of knowledge as action that realizes a certain result, namely an imprecise or unfixed sense of “health” that can only be grasped (as Aristotle notes of “practical reason”) in “outline and not precisely” simply because there can be no “fixity” in understanding what good health always and only is. But even if there is no fixity in understanding health, there is a range of agreed-upon understandings of what we might mean by health, whether it be the restoration of an earlier state of affairs before affliction or illness, the achievement of an ideal of human physical and psychological potential, or simply the accomplishment of functioning in day-to-day living in the face of affliction or illness.² This range...