Locating Narrative In Medicine’s Moral Domain: Notes (Musical And Otherwise) From A Recent Presentation

June 15, 2009 at 4:19 pm

A Group of Musicians

Commentary by Martin Kohn, Cofounder and Senior Associate for Program Development, Center for Literature, Medicine and Biomedical Humanities at Hiram College, and retired faculty, Northeastern Ohio Universities College of Medicine

My wife is a nephrologist. She loves kidneys (and how they function) almost as much as she loves me. We recently celebrated our 23rd anniversary. She's a deductive thinker par excellence. I'm a lateral thinker to the nth degree. When we argue she'll often exclaim, "I can't follow your train of thought." "What train?" I reply earnestly. Recently, she asked me (again), "can you define narrative for me?" "Not yet," I replied, buying a little more time.

In spite of working in the medical humanities for nearly 30 years I continue to struggle with explaining just what narrative is and how it permeates medicine's moral domain. So I recently agreed to a request to present grand rounds to the Bioethics Department at the Cleveland Clinic, forcing myself to ransack old notes and articles and catch up with at least a few developments in the field. I offer below a sampling of my presentation. The through line was:

WORDS/STORIES——————-PERSONS———————-COMMUNITY

WORDS/STORIES

I began this portion of the presentation with numerous claims about the centrality of words and stories in our lives: that they are as constitutive of the self as are our genes; that they preserve "the teller from oblivion." (1); that they are the foot soldiers of meaning; that they "do not simply describe the self, they are the self's medium of being. " (2); that narrative is a conveyance in which and through which we (and our words and stories) confront time, and that ultimately, meaning and sense filled words and stories, into which we are born and which are temporally borne by us, become our constructed truths about the world (noting that the root of the word narrative, "narr/gno," is after all, knowledge.).

Finally, I claimed that words and stories also make community possible. Community being formed by which bits of experience we choose to string together (to re-member, both individually and communally) and which we re-present as plotted events, connecting us to the unfolding drama of our shared lived experience.

Further exploration of the centrality of story in the work of physician-writers Robert Coles, Rachel Naomi Remen and Rita Charon was followed by a synopsis of creative writer, Scott Russell Sanders' essay, "The Power of Stories" (3).

PERSONS

After a brief exploration of Cassell's notion of "topology of person," (4), I focused on a more poetic treatment of the aspects of the person that appears in a poem by Billy Collins, "The Night House." The poem reveals the body's role-as "the house of voices"- in the experience of the person who lives in the moral lifeworld as that body, and who "Sometimes puts down its metal tongs, its needle, or its pen/To stare into the distance,/To listen to all its names being called/Before bending again to its labor" (5).

These voices (heart, mind, soul, conscience) in the body's house are arrayed below (with attributes I provisionally assigned them) where they serve as elements of the first of three tributaries flowing into moral personhood.

First tributary: THE HOUSE OF VOICES /IN THE EMBODIED PERSON/ IN THE MORAL LIFEWORLD

•The open (feeling) "heart"
•The curious (improvisational) "mind"
•The seeking (animating) "soul"
•The silvery (calculating) "conscience"

Second tributary: EXPRESSIONS OF MORAL REFLEXIVENESS/OUR MORAL BEING IN THE WORLD

I shared with my audience a most delicious description of "character" which is, I believe, the primary vehicle through which moral reflexivity operates. The excerpt below comes from the novel, Mrs. Ted Bliss, by Stanley Elkin:

the constant, minute-to-minute routine of putting together a character, assembling out of little notes and pieces of the past-significant betrayals, deaths, yearnings, successes, meaningful disappointments, and sudden gushers of grace and bounty- some strange, fearful archaeology of the present, the Self to Now, as it were, like a synopsis, some queer, running quiddity of you-ness like a flavor bonded into the bones, skin, and flesh of an animal.

Third tributary: REFLECTIVE PRACTICE/DOING MEDICAL ETHICS OR BIOETHICS THROUGH PARTICULAR FRAMEWORKS

A (partial) list of the reflective frameworks appears below:

•Juridical: Study of the rational application of principles as action guides. Morality is seen as a body of knowledge. (7)
•Narrative: Study of voice and authority, point of view, coherence of story, co-construction of story, narrative frameworks of illness stories, etc. Morality is seen as a continual interpersonal task done by all in the community. (7)
•Care: Study of what empathy calls forth from us
•Feminist: Study of systemic/historic power imbalances and calls to challenge those imbalances
•Communicative: Study of the distortion of free communication /attempts to remediate those imbalances
• Naturalized: "Minimally, naturalism in ethics is committed to understanding moral judgment and moral agency in terms of natural facts about ourselves and our world." (8).

Combining these tributaries into EMBODIED BEING AND DOING produces movement, a kind of flowing moral lifestream that conveys a style or action that contains a certain musicality to it. So I searched for two musical examples to visually and aurally illustrate what I meant by musicality. The first example is a rendition of Johnny One Note (The ads will disappear after about 30 seconds, if you try to remove them the video starts over). The second example features the song Libertango by Astor Piazzolla (originator of the Nuevo Tango style, who plays the bandoneon, a folk instrument related to the accordion, with an ensemble including Yo-Yo Ma).

Johnny One Note is a show tune from the 1937 Rodgers and Hart musical Babes in Arms. Title, lyrics and in this instance, performing style, all align (for me) as a critique of the hegemonic "principlist" approach to moral analysis of medical issues. Featured in this rendition of Johnny One Note is Johnny Mathis (as an alpha male!) surrounded by the adoring Lennon Sisters, backing him to the hilt as he gives his all for ONE NOTE (autonomy?). In contradistinction, Libertango is polyrhythmic, featuring layered and shifting voices and is multi-genre, a mix of classical and jazz and folk music. It represents well the "multiple tributaries" approach that revels in the complexity (and beauty) of the moral lifeworld that I advocate.

COMMUNITY

To finish my presentation, I turned to two works, "The Narrative Quality of Experience, by Stephen Crites (9); and Gerald Gruman's A History of Ideas about the Prolongation of Life (10). Stephen Crites was a philosopher and a scholar of religion with special interests in the connection between narrative and experience. His work emanates from and illuminates the point at which experience and action interpenetrate, where narrative becomes the vehicle through which consciousness temporally expresses experience; and where simultaneously our actions take on a particular musicality in response to the expressed stories we live our experience out of. (How do we label the iconoclast/the oddball, one who doesn't live by the conventional expectations or stories of our culture? We do so by saying that they "march to the beat of a different drummer.")

Most pertinent to the focus on community are Crites' contentions about sacred and mundane stories. He explains: "people live in [sacred stories which] are anonymous and communal… [that] orient the life of people through time, their life-time, their individual and corporate experience and their sense of style, to the great powers that establish the reality of their world…[ this makes, he claims] every sacred story a creation story…the story itself creat[ing] a world of consciousness and the self that is oriented to it" (pp. 295-6). He further explains that these sacred stories are always present in some way in the mundane stories [and that] "people are able to feel this resonance; because the unutterable stories are those they know best of all" (pp.296-7). He believes that "the stories people hear and tell, the dramas they see performed, not to speak of the sacred stories that are absorbed without being directly heard or seen, shape in the most profound way the inner story of experience"(p. 304).

Crites anticipated (he was writing during the late 1960's) a conversion of consciousness that reflected a cultural shift into post-modernity. Evidence for the shift would be found, he explained, in "a traumatic change in man's story" (p. 307), wherein the stories to which he has "awakened to consciousness must be undermined… [and] through a new story both the drama of his experience and his style of action must be reoriented… he must dance to a new rhythm… [for] the very cosmos in which he lives is strung in a new way" (p. 307).

I took Crites' notion of sacred stories and shift of consciousness and set them within the work of another philosopher, Gerald Gruman- challenging us to consider that the shift in consciousness that Crites was sensing about 40 years ago, has now reached a critical point.

In his classic work, A History of Ideas about the Prolongation of Life (published five years prior to Crites' article), Gruman provides ample evidence of the human yearning for immortality, citing numerous examples across time and cultures; however, he also describes an alternative historical-cultural phenomenon: acceptance of our body's limitations. He presents his evidence of these two urges through two conceptual domains: the Meliorist camp, i.e. the 'we can continuously improve the human condition' folks, and the Apologist camp, i.e. the 'we need to accept ourselves the way we are' people.

These camps, and both of these human urges, are in tension- and I would argue are competing sacred stories about immortality. The meliorist camp promotes solipsistic immortality; the apologist camp supports species immortality. H. R. Moody, philosopher and humanistic gerontologist, has offered two similar framing concepts: one, aligned with a sacred story of progress and human control over nature, he labels 'techno-utopian mastery'. (11) Aligned with the sacred story from the apologist standpoint of mystery or acceptance of our place in the natural order of the world is his 'ecological vision of aging'a"where youth and age are…. accepted as part of the natural life cycle" (p. 33).

AIA offered to my audience a neologism to describe a synthesis of the two sacred stories -the one grounded in mystery and reverence, the other grounded in mastery and control. The word I coined is eco-meliorism. It grew out of a new sacred story, the one to which I believe our consciousness is awakening- sustainability- and which I define as the careful (even slow) movement toward human betterment in light of human presence in ongoing, interrelated natural systems.

Sustainable Health

There is evidence that we in medicine (and our larger community) are beginning to live within the sacred story of sustainability, developing interesting syntheses that emanate from an eco-meliorist approach. I would include in this list hospice and palliative care, the Eden Alternative in nursing homes, and the Planetree organization. There's also movement toward the sustainability story in science- Bioneers (whose motto is "revolution from the heart of nature") , green chemistry, and the adoption by some of the "precautionary principle." In our larger society there are other examples of eco-meliorism including the slow food movement and even a call for slow money, such as that advocated by Woody Tasch. (See his book, Inquiries into the Nature of Slow Money. Investing as if Food, Farms, and Fertility Mattered).A All of these endeavors point toward a new sacred story of sustainability, toward stringing our cosmos in a new way, toward waking up into a new consciousness, toward marching to the beat of a different drummer.

Wallace Stevens wrote the poem "Six Significant Landscapes" nearly 100 years ago (12). I ended my presentation (and now this blog entry) with its final verse and with a question: How might we live and practice and think differently if we lived in different "rooms", if we changed not only our physical habitat, but also our narrative habitat? (And now, I think I'll grab a glass of wine, put on my sombrero, and read the poem to my wife….)

Rationalists, wearing square hats, / Think, in square rooms, / Looking at the floor, / Looking at the ceiling. / They confine themselves / To right-angled triangles. / If they tried rhomboids, / Cones, waving lines, ellipses — / As, for example, the ellipse of the half-moon — / Rationalists would wear sombreros.

References

1. Portelli, Alessandro. The Death of Luigi Trastulli, and Other Stories: Form and Meaning in Oral History. (Albany, N.Y. : State University of New York Press) 1991, p. 59

2. Frank, Arthur W. The Wounded Storyteller: Body, Illness, and Ethics. (Chicago: University of Chicago Press) 1995, p. 53

3. Sanders, Scott Russell. The power of stories. Georgia Review, 1997; 51:113-26.

4.Cassell, Eric J. The Nature of Suffering and the Goals of Medicine. (New York: Oxford University Press) 1991, p. 47

5. Collins, Billy. Picnic, Lightning. (Pittsburgh, Pa.: University of Pittsburgh Press) 1998, p.80

6. Elkin, Stanley. Mrs. Ted Bliss. (New York: Hyperion) 1995, p. 55

7. Lindemann Nelson, Hilde. Context: backward, sideways, and forward. In Charon, R., Montello, M., eds. Stories Matter: The Role of Narrative in Medical Ethics. (New York: Routledge) 2002

8. Walker, Margaret Urban. Introduction: Groningen naturalism in bioethics. In Lindemann, H., Verkerk, M., Walker, M.U., eds. Naturalized Bioethics: Toward Responsible Knowing and Practice. (Cambridge and New York: Cambridge University Press) 2009, p. 1

9. Crites, Stephen. The narrative quality of experience.A Journal of the American Academy of Religion, 1971: 39:291-311

10. Gruman, Gerald J. A History of Ideas about the Prolongation of Life: The Evolution of Prolongevity Hypotheses to 1800. (Philadelphia: American Philosophical Society) 1966

11. Moody, H.R. Who's afraid of life extension? Generations, 2001-02; xxv: 33-37

12. Stevens, Wallace. Harmonium (New York: A. A. Knopf), 1993, p. 100