An Introductory Philosophy of Medicine

Chapter 9. Diagnostic Knowledge

"There are two modes of cognitive functioning, two modes of thought," according to Jerome Bruner, "each providing distinctive ways of ordering experience, of constructing reality" (1986, p. 11). The two modes of cognitive functioning are paradigmatic or objective and narrative or subjective.' They represent distinct kinds of knowing and are not only irreducible to each other but are also complementary to one another. The first mode of knowing, paradigmatic-Bruner's preferred term-"attempts to fulfill the ideal of the formal, mathematical system of description and explanation. It employs," he continues, "categorization or conceptualization and the operations by which categories are established, instantiated, idealized, and related one to the other to form a system" (1986, p. 12). Paradigmatic knowing depends upon empirical verification and rational skills to develop a sound argument.

Narrative knowing, however, "deals in human or human-like intention and action and the vicissitudes and consequences that mark their course. It strives," Bruner claims, "to put its timeless miracles into the particulars of experience, and to locate the experience in time and place" (1986, p. 13). It is concerned with a good story that reveals the human condition. Sarah Worth (2008) substitutes the term "discursive" for Bruner's term paradigmatic or logico-scientific, because discursive depicts best the immediateness or directness of reasoning and knowing. In this chapter, her terminology is adopted.

According to the Oxford English Dictionary, diagnosis is derived from two Greek words: din, which means through or by, and gnosis, which means to know or learn. Diagnostic procedures, then, are epistemic means through or by which the physician gains knowledge or learns of the patient's disease state. Following the consensus that knowing is of two modes or types, diagnostic knowledge is divided into discursive (objective) and narrative (subjective). Discursive diagnostic knowledge is obtained through biomedical diagnostic procedures of the medical interview, physical examination, and laboratory tests and procedures, as discussed in Chapter 5. Narrative diagnostic knowledge is obtained through the patient's story of the disease symptoms or the illness experience. Both types of diagnostic knowledge are important for determining the patient's disease state.

However, the epistemological question arises as to how certain can a clinician be concerning the information obtained from these diagnostic attempts to understand the patient's disease state or illness experience. In this chapter, the epistemological issues associated with the traditional means of obtaining clinical information through the medical interview and physical examination and through humanistic modifications particularly in terms of the patient's story or narrative are explored. Finally, discursive diagnosis obviously exacerbates the quality-of-care crisis while nattative diagnosis attempts to mollify or even to resolve it.

9.1 Discursive Diagnostic Knowledge

Traditional forms of knowledge are based on discursive reasoning, which asks questions over knowing the "how" or the "that" (Worth, 2008). Such reasoning is logical (inductive or deductive, but not abductive) in nature. It depends upon rational argumentation, in which the connections between the premises and conclusion are formal. Biomedical practitioners obtain diagnostic knowledge through the medical interview and the physical examination, as well as laboratory tests.

William Oster (1849-1919), the Regius Professor of Medicine at Oxford University, laid the foundation for modern clinical diagnosis in the early twentieth century, by emphasizing the pathological analysis of the patient's symptoms. His predecessor, Archibald Garrod (1857-1936), known for his work on inborn error of metabolism, advanced Osler's diagnostic approach to include the patient's biochemical constitution. Today, the patient's genetic make-up is also an important component of the diagnostic procedure. In this section, the epistemological issues associated with the biomedical model of diagnostic procedures for the medical interview and physical examination are discussed, especially in terms of the generation and justification of diagnostic hypotheses and of medical errors.

9.1.1 Generation of Discursive Diagnostic Knowledge

Murphy (1997) provides a comprehensive analysis of the diagnostic process, especially for the biomedical model, in terms of strategy, actual tactics, and logic behind it. The strategy of the diagnostic process consists of two main objectives: classification and measurement. Classification refers to the categorization of disease states, regardless of variation in the expression of the disease's manifestation within a patient, while measurement pertains to the quantification of a patient's symptoms. The goal of biomedicine is to provide adequate measurement of a patient to secure diagnostic accuracy and certainty. The tactics of the diagnostic process entails the means utilized to obtain the facts of the disease state. Finally, the logic of diagnosis involves the process of how facts are utilized or interpreted to determine a patient's disease state or to make a diagnosis. Importantly, the diagnostic process comes to a conclusion, "when any further data the diagnostician might seek are either redundant or irrelevant" (Murphy, 1997, p. 311).

The knowledge of a patient's disease state is initially obtained from the symptoms expressed by a patient. These articulated symptoms provide a physician with information necessary to formulate questions about the patient's disease state. Many of these questions are answered by observing the clinical signs of the disease. The signs observed by a physician form the basis for hypotheses formation in terms of diagnosing a patient's disease state. Moreover, clinical signs are particularly important for evaluating diagnostic hypotheses. "The signs serve," according to Coulehan and Block, "to confirm or disconfirm the hypotheses that we are beginning to develop from the history, or perhaps the results of the examination will suggest entirely different hypotheses" (1992, p. 126). Signs, and to a lesser extent symptoms, play a vital epistemological role not only in generating but also in establishing diagnostic knowledge.

Once the medical history and the physical examination are complete, the physician may formulate a list of possible diagnoses. Based on this list, additional medical tests are conducted to gather more data concerning a patient's disease state. "A valid, relevant, and appropriate set of hypotheses is critical for the next sequential steps in the process," claim Kassirer and Kopelman, "namely gathering and interpreting further information and selecting the appropriate diagnostic tests" (1989, p. 34). The results of these tests allow a physician to make a differential diagnosis, the process by which the physician entertains the possible diseases to account for the clinical data. The generation of a differential diagnosis is equivalent to the scientific method by which a scientist makes a tentative hypothesis and then tests it experimentally. The experimental results are used to determine validity of or to justify a particular hypothesis? In like manner, physicians gather initial clinical data and form tentative diagnoses and then proceed with clinical tests to determine which diagnosis is correct or justified.

The generation of clinical hypotheses is a process that is not well understood.' Kassirer and Kopelman (1989) narrate a case study in which a physician was given sequential clinical data on a fifty-two year-old male, who smoked one pack of cigarettes a day for thirty years and drank 1 pint of alcohol a day for twenty years. The patient's presenting symptom was a progressive weakening over the past three months of his right arm and leg. The physician generated 28 hypotheses to account for the symptoms based on cigarette smoking and alcohol consumption, with the 21st hypothesis, a cerebellar mass, being confirmed after brain surgery.

Kassirer and Kopelman make several important observations concerning factors involved in hypothesis generation for clinical diagnosis. The most influential factor is the heuristic cue, which in this case was the patient's alcohol and cigarette use. Another important factor is a physician's own training. As Kassirer and Kopelman report, "studies show that when physicians generate diagnostic hypotheses, they do so by recalling those disease processes most prevalent in their own institutions" (1989, pp. 33-34). Certainly what a physician learns previously about a heuristic clue, especially a clue like cigarette smoking, predisposes formulation of hypotheses focused on a specific class of diseases like cancer.

Coulehan and Block (1992, 2001) propose a feedback loop mechanism for understanding the medical interview, as well as the generation and justification of medical hypotheses. The process begins with a patient articulating the chief complaint, followed by a clinician's questions concerning the history of the present illness. As an exchange takes place, the physician begins to generate hypotheses based on the information. Generally the number of possible hypotheses is rather enormous at the early stages of the process. As the physician learns more about the patient through the medical interview, including the family and social histories, the feedback of information begins to restrict the field of hypotheses to a select few. As more information is obtained through the feedback loops of "technique" and "content," a short list of hypotheses is arrived at that is then compared to results obtained from physical examinations and laboratory tests. Coulehan and Block cite with approval Alvan Feinstein's comparison of medical diagnosis to scientific experimentation, except they recognize that physicians cannot change one variable at a time as scientists can do.

Relying on Platt and McMath, Coulehan and Block (1992, 2001) identify four different types of medical hypotheses. The first type of hypothesis, the disease hypothesis, which the physician formulates, is about the diagnosis vis-a-vis the disease. As noted earlier, the physician's task is to generate a differential diagnosis that ultimately leads to the identification of the patient's disease state. Related to the disease hypothesis is the narrative hypothesis that the physician formulates about the patient's story. Does the story cohere in a rational sense? In other words, do the various parts of the medical interview fit together in terms of what the physician knows about various diseases? Can a causal relationship emerge from the symptoms the patient relates about the history of the present illness and other parts of the medical interview? Central to the hypothesis the physician formulates about the patient's story is the hypothesis the physician formulates about the patient's character. Can the patient be trusted to give an accurate account of the illness experience? Will the patient be compliant? Finally, the physician formulates a hypothesis about the medical interview itself in terms of possible errors and problems inherent to it. These hypotheses are critical for developing accurate clinical knowledge about the patient.

9.1.2 Justification of Discursive Diagnostic Knowledge

A critical epistemological issue with clinical knowledge obtained from medical interviews and physical examinations, as well as from laboratory tests, is its accuracy. Kassirer and Kopelman define accuracy as "the correspondence between a finding and the true state of the entity or phenomenon it is describing" (1991a, p. 29). For medicine, problems arise with the accuracy of clinical information, since such information is obtained from clinical interviews and examinations which depend on the patient's accuracy. Unfortunately, the patient's accuracy can be distorted by bias and faulty memory.

Kassirer and Kopelman propose that accuracy should be appraised in terms of the information's validity, which depends on several contexts. The first is "face" validity, in which the physician's intuitions support the information's accuracy. The next two are "construct" and "criterion" validity, in which the information represents a functionally consistent value and can be compared to some known standard, respectively. The final is "content" validity, in which "the datum is representative of the item being assessed and adequately embodies all the dimensions of the item being measured" (1991a, p. 29).

The validity of clinical knowledge obtained from diagnostic procedures also raises the issue of criteria for justifying such knowledge. Kassirer and Kopelman (1991a) provide nine criteria or guidelines to address this issue. These guidelines include the exercise of caution when relying on past medical information, especially previous diagnoses that may be based on insufficient clinical data. Another important guideline is to ask detailed questions concerning the patient's personal habits, especially those involved in illicit drug and promiscuous sexual behavior. Physicians must also be wary of a patient's bias and distorted memory.

Social factors are also important. For example, Kassirer and Kopelman (1991a) report a case history in which a female patient lied about her identity in order to obtain medical care by using a cousin's Medicaid card. Because the patient lied about her identity an accurate diagnosis was delayed. Moreover, a patient should properly understand the questions, especially with the physician avoiding unnecessary jargon. Finally, questions must not lead a patient to give misleading answers; rather, physicians should "allow patients to present the story of their illness in a free narrative fashion" (Kassirer and Kopelman, 1991a, p. 29).

Clinical judgment vis-a-vis diagnosis of a patient's disease is dependent not on a complete collection of the patient's symptoms and signs but on an adequate collection. "Clinicians never have," according to Coulehan and Block, "all the data that may be relevant to a given illness or disease situation or a given patient. There is always something left out," they insist, "and all diagnostic and therapeutic decisions are made in the context of some uncertainty" (1992, p. 283). Uncertainty is simply part of medical practice, given the variability of the underlying biology.

The joining of medicine to the biological sciences and the other natural sciences, however, represents an effort to minimize the uncertainty of medical practice (Botkin, 1992). But the issue is how to join the universals that make up science with a particular patient to provide a sure diagnostic or therapeutic analysis. "Despite an enormous number of reliable, well worn diagnostic and therapeutic paths," observes Hunter, "there is never enough certitude" (1991, p. 30). However, the physician is obliged to act even in the face of such uncertainty.'

Besides the incompleteness of medical information gathered by a physician concerning a patient's disease condition, errors are also committed during a medical interview. These errors can have drastic consequences in terms of diagnostic accuracy and, of course, with respect to patient care. For example, medical error is the eighth leading cause of death in the US (Zhang et al., 2004).1 Diagnostic errors have been categorized according to several different taxonomies.' For example, Jiajie Zhang and colleagues utilize an action-based cognitive taxonomy to categorize medical errors at the level of the individual physician and of the physician's interaction with medical technology.'According to them, "medical error is a cognitive phenomenon because it is an error in human action which is a cognitive activity" (Zhang et al., 2004, p. 194). In other words, an error is the failure to obtain a planned outcome not due simply to chance.

Zhang and colleagues divide medical errors into two broad categories: slips and mistakes. Slips "result from the incorrect execution of a correct action sequence," while mistakes "result from the correct execution of an incorrect action sequence" (Zhang et al., 2004, p. 195). For example, a mistake occurs because of incomplete knowledge whereas a slip occurs because of a failure to perform correctly even with adequate knowledge. Both slips and mistakes are divided into execution and evaluation subcategories. Evaluation slips and mistakes are further divided according to goals, intentions, and action specification and execution. Execution slips and mistakes are also further divided according to perception, interpretation, and action evaluation.

Jerome Groupman (2007) provides a list of medical errors, based on biases and prejudices, which often keep a physician from making the proper diagnosis. These errors include representativeness errors, attribution errors, and affective errors. The first type of error results from thinking in terms of a "prototype" For example, a patient's fit and trim physique may keep a physician from considering chest pains as indicative of a heart attack. The next error is based on a "negative stereotype," in which a physician notices a possible deleterious lifestyle behavior and then attributes diseases to the patient common to this lifestyle. For example, abdominal pains in a patient with alcohol on the breadth may be attributed to liver cirrhosis. The final error is based on the physician's desire to avoid diagnoses of fatal diseases for well liked patients.

9.2 Biomedical Technology

Contemporary medical knowledge, with respect to its generation and justification, is also technology dependent. It is generated and justified by the technical devices employed to examine and investigate the patient's disease state and therapies to relieve that state. According to Le Fanu (2002), three groups of technical advances, including life sustaining, diagnostic, and surgical, are critical for the rise and development of modern medical knowledge. Of these three, diagnostic technology provides the most spectacular clinical knowledge of patient's body and disease state. For example, imaging technology makes the body almost transparent to the clinical gaze. What was once shrouded in darkness and mystery is now made bright and commonplace. "The brain, thanks to the CT and MRI scanners," exclaims Le Fanu, "can now be seen with a haunting clarity, while the fetus that previously grew hidden from view within the womb can, thanks to ultrasound, be observed virtually from the moment of conception" (2002, pp. 187-188). These technologies are nonpareil in terms of the knowledge they provide of both the patient and the disease process.

Although medical imaging technologies apparently make the body transparent, "their ubiquitous use renders the interior body more technologically complex" (van Dijck, 2005, pp. 3-4). The complexity associated with the notion of transparency is not unproblematic, however, for the interior of the body is mediated by these imaging technologies. Transparency is a "layered" notion, in which the ground layer is certainly the ability to take a look. But, the other layers include additional information and the ethical issues it raises. This information makes the interior of the body simply more than a transparent object but rather a cultural object. "The transparent body," according Jose to van Dijck, "is a complex product of our culture-a culture that capitalizes on perfectibility and malleability" (2005, p. 5).

Medical technology is also influential in terms of enhancing diagnostic accuracy. It provides the means for collecting objective evidence and observations concerning the patient's disease so as to make a precise and accurate diagnosis, especially in terms of the machines used to conduct tests on the patient's vital fluids. These machines are employed to produce the objective data that is considered free of human biases. "From the beginning of their introduction in the mid-nineteenth century," claims Reiser, "automated machines that generated results in objective formats such as graphs and numbers were thought capable of purging from health care the distortions of subjective human opinion" (1984, p. 18).

According to humanistic or humane practitioners, however, medicine is still a very human affair, regardless of its technical development and sophistication. Although technology can help to increase diagnostic accuracy during a physical exam, it cannot guarantee it. For example, a physician's presuppositions as to the diagnosis can often interfere with making a correct diagnosis (Voytovich et al., 1985).

Kassirer and Kopelman (1991b) discuss the troubles associated with a clinical case, in which the attending physicians presumed a patient's disease was caused by liver malfunction. The patient was a thirty-seven year-old female with a history of ascites and anasarca. Her presenting symptom was leg edema. The initial differential diagnosis included kidney, liver, and heart diseases. The focus of the attending physicians was on the liver, but laboratory tests on urine and blood were inconclusive and a liver biopsy revealed no grossly abnormal, anatomical structure. Finally, echocardiography revealed the patient was suffering from mitral valve stenosis.

In their comments on this case, Kassirer and Kopelman disclose that the patient not only complained of edema as the presenting symptom but also of breathlessness. Moreover, distended neck veins and cardiac murmurs were obvious clinical signs. Why did the attending physicians fail to recognize the importance of these symptoms and signs? Kassirer and Kopelman claim that the attending physicians presumed liver disease based on the patient's history.'Their recommendation is that physical examinations "must be carefully tailored to the disorders in the patient's differential diagnosis" (1991b, p. 25).

With the development of medical technology, clinical knowledge, in terms of concepts like disease and health, life and death, has become better defined. For example, prior to the introduction of Laennec's stethoscope debate raged over the clinical determination of death. After the stethoscope, cessation of the heart beat became the standard for defining death (Jennett, 1986). But this definition was inadequate for an increasing number of patients who were comatose and were sustained by a respirator and intravenous nutrition.9 By mid twentieth century, with the rise of another technology-organ transplantation-death was redefined again using another technology. In 1968, an ad hoc Harvard committee redefined death in terms of the cessation of brain activity, known as "brain death," as measured by electroencephlography (Giacomini, 1997). The committee's concern was to provide a definition of death so that organs could be harvested for transplantation, from comatose patients.

Later, in the early 1980s, a President's commission on medical ethics defined death in terms of the whole brain: "irreversible cessation of all functions of the entire brain, including the brain stem" (President's Commission, 1981, p. 2). However, the notion of "whole brain death" was also problematic. For example, patients declared whole-brain dead still exhibit physiological activity such as evoked potentials and neurohumoral activity. To resolve these problems, some researchers proposed a definition of death based on higher functions of brain activity. Youngner and Bartlett (1983), for instance, argued that a general notion of brain death is inadequate and should be replaced by a more precise definition that focuses on the loss of cognitive functions." Finally, Thompson and Cozart (1981) resisted the technical definitions of death such as brain death and argued for a humanistic notion of death that transcends the technical to include the moral.

Finally, Cassell (1997) argues that technology produces several insidious problems for modern medicine." Specifically, these problems center around the inappropriate use of technology therapeutically, especially life support technology, as well as unwarranted use diagnostically, especially ordering laboratory tests not germane to the patient's symptoms. These problems reflect around a half-dozen features of human nature, such as our fascination with gadgets, our inability to tolerate any ambiguity or uncertainty, and our desire for power and control. The underlying issue is that we become enslaved to our technology. "Technologies come into being to serve the purposes of their users," observes Cassell, "but ultimately their users redefine their own goals in terms of the technology" (1997, p. 63). For medicine, technology often redefines its goals from a patient's suffering from an illness to a patient's pain associated with a diseased body part.

9.3 Narrative Diagnostic Knowledge

Narrative, as noted earlier, is a powerful means for explaining and organizing the world and its events.' The Latin word for narrative, gnarus, is derived from the Sanskrit root, gna, which is also the root for the word gnosis or knowledge. In a sense, narrative structures the world. "We live in a world," according to Gary Morson, "in which narrative is essential" (2003, p. 59). Without narrative the world lacks a cohesive wholeness or unity, in terms of its ethnographic complexity (van Maanen, 1988). The structuring that narrative provides the story's plot serves as the focal point around which the temporal sequence of events coalesces and is organized. The plot, rather than logic or causation, functions to connect the events. It structures not only the temporal dimension of events but also their non-temporal dimension (Worth, 2008). It also provides a way of understanding and explaining the world and our relationship to it and to each other. In other words, the plot provides meaning for and understanding of those events. In this section the generation and justification of general narrative knowledge is discussed, followed by a discussion of medical narrative diagnostic knowledge.

9.3.1 Generation of Narrative Knowledge

Narrative knowledge depends on the tacit dimensions of a story (Polanyi, 1962). It involves the implicit or unspoken clues essential for understanding the story's comprehensiveness. In other words, the narrator has a particular perspective from which the story is told. Without the essential, tacit dimension, the listener may fail to understand the overall meaning of the story and focus only on limited facts of it, which may represent a distortion of the story's true meaning.

Richard Weinberg (1995), for example, narrates the story of a young woman who came to him because of chronic abdominal pain. Although she was seen by several gastroenterologists, who performed the requisite laboratory tests, Weinberg was able to diagnose the "illness" by connecting with the patient through their common interest in the pastry, Napoleons. Through that connection the patient made a return visit and he noticed rings under her eyes and inquired about her sleeping habits. From this tacit clue, Weinberg was able to gain her trust and discovered that she had been sexually abused by her sister's boyfriend almost a decade earlier. By connecting with the patient, the physician was able to enter the patient's narrative world. Without connecting to and understanding that world, the physician may be helpless to assist the patient.

According to Worth (2008), the generation of narrative knowledge involves knowing what something is "like" in terms of a story. She illustrates such knowledge with the story of Socrates' death: Socrates was a person who challenged the Athenians in their traditional ways of knowing in such a way that he unsettled some his contemporaries who claimed he offended the gods so that Socrates was tried as a heretic and condemned to drink hemlock. Worth contrasts this narrative account with the standard logical, discursive account, as exemplified by the syllogism:

Socrates is a man, All men are mortal, Therefore, Socrates is mortal.

As evident from the narrative account there is no logical conclusion per se, but knowledge is transmitted in the account in terms of the events that transpired surrounding Socrates' death. The second account also transmits knowledge but knowledge that is simply contained in the premises. It is analytic rather than synthetic in nature (Ayer, 1952).

Stories like the first account of Socrates death exhibit "narrativeness" or the unfolding of the events in the account, while the second account exhibits little, if any, narrativeness (Morson, 2003). "The sense of process, the activity of tracing possible futures from a given past," according to Morson, "is essential to narrativeness" (2003, p. 61). Besides process, narrativeness also exhibits "presentness" or the condition that an event is not simply a logical derivative of prior events but one that is open to an array of possibilities. In other words, a future event although contingent upon past events is also independent of them and cannot be predicted. "Events themselves seem capable of working out in one way or the other," claims Morson, "so that if a sequence were repeated, the outcome might be different" (2003, p. 63). In the death of Socrates, for example, the first account provides ample room for the events to be otherwise. Socrates could have stopped challenging the Athenians, for instance, or the Athenians could have accepted Socrates' challenge. The second account makes Socrates' death inevitable. The narrative account captures so much more of what life is about: "We live in a world of everlasting and perpetual process, and to embrace process is to embrace life itself' (Morson, 2003, p. 73).

Narrative reasoning and, hence, the generation of narrative knowledge depend upon the imagination; for the ability to imagine is tied intimately to narrative reasoning (Worth, 2008). Psychological studies show that when learning we form mental images of the learned material, so that recall is based not on memorizing sentences but on the constructed mental images. Skills of imagination then aid in knowing and learning. Well constructed narratives that utilize just the relevant data and have well developed plots are easy to follow, especially in terms of implicit causal connections, while badly constructed stories with poorly developed plots are hard to follow and implode under the strain of irrelevant detail and facts.

Just as discursive reasoning is facilitated by engaging in logical and formal drills, so narrative reasoning is enhanced by engaging in exposure to well constructed stories (Worth, 2008). For the way we construct and generate narratives is connected to the way we know and understand. Although narrative reasoning skills do not lead to propositional knowledge as does discursive reasoning, it does lead to knowledge that involves an affective meaning, in that the narrated world is much richer and more meaningful than the abstracted world.

9.3.2 Justification of Narrative Knowledge

Although narrative provides a fuller account of the process of life, an important epistemological issue concerning narrative knowledge, as broached earlier for narrative explanation, is its validity or truth content. "For philosophers and logicians," claims Lubomir Dolezel, "the distinction between reality and fiction, between truth and falsity, between reference and lack of reference, is a fundamental theoretical problem" (1980, p. 7). Specifically, proponents of discursive knowledge charge that proponents of narrative knowledge cannot distinguish fact from fiction or fable. In other words, the allegation is that the traditional means of justifying knowledge, especially discursive knowledge, are not applicable to narrative knowledge. There is no empirical or logical means by which to verify it.

In comments on the debate among historians over narrative, Hayden White acknowledges that the critical method of the natural sciences provides scientists with explanations of natural phenomena. "To many of those who would transform historical studies into a science," writes White, "the continued use by historians of a narrative mode of representation is an index of a failure at once methodological and theoretical" (1987, p. 26). Moreover, Andrew Norman (1991) argues that narrativists impose a story structure onto a pre-narrative phenomenon in order to obtain storied or narrative knowledge. The problem is, as Keiswirth acknowledges, "that a true story, one that claims to represent actual happenings... works as a communicative act exactly the same way as a fictional story, one that doesn't make such claims" (2000, p. 313). Narrativists have taken different approaches to resolve this problem.

Narrative naturalists argue that the narrative is a valid form of generating knowledge because it is a product of mental activity, at a fundamental level. As Keiswirth explains, "narrative naturalists want to see the relationship between the narrative way of knowing and the known as virtually transparent: story does not discursively impose order on an inchoate flow of mental materials, as some others contend; rather, it displays the narrative means by which the mind functions. In this way," he continues, "story is not merely invented but develops naturally as part of our conceptual and cognitive machinery, either alongside or underlying our logical and linguistic equipment" (2000, p. 305).

Along similar lines, Mark Turner (1996) posits a "literary mind" in which story, projection, and parable function to justify narrative knowledge. He holds that narrative reasoning operates at a level prior to conception or cognition; for it is the primary mental means by which perceptions are strung together to generate thought and knowledge. Turner posits "small spatial stories" that serve as the substrate for organizing the often chaotic flow of perceptions. From the story, we then project to other stories, in terms of parables, which help to determine meaning and to establish understanding.

For narrative constructivists, however, "story does not mirror paradigmatic, mental operations but is forged from a more active give-and-take between experience and meaning, particularly the experience of temporality in consciousness and how this is reciprocally apprehended and expressed whether posited in phenomenological or existential terms" (Kreiswirth, 2000, p. 308). For example, Paul Ricoeur presupposes a reciprocal relationship between narrativity and temporality: "I take temporality to be that structure of existence that reaches language in narrativity and narrativity to be the language structure that has temporality as its ultimate referent" (1980, p. 169). Temporality represents the "deepest level" of temporal organization compared to "within-time-ness" and "historicality:" Finally, Ricoeur locates narrativity's role within the plot: "A story is made out of events to the extent that plot makes events into a story. The plot, therefore, places us at the crossing point of temporality and narrativity" (1980, p. 171). Plot, then, is the means by which story is made an "intelligible whole" and meaning emerges from the narrativity's portrayal of temporal experience (Ricoeur, 1984).

For other narrative constructivists, narrative is justified in terms of personal identity and its construction: "we must inescapably understand our lives in narrative form, as a `quest"' (Taylor, 1989, p. 52). Identity has both an ethical and a sociopolitical context (Kreiswirth, 2000). For the ethical context, for example, the moral self represents an unfolding narrative of what our social role is and how that role is discharged (Maclntyre, 1984). What is to be done and how it is to be done unfold in terms of the interlocking narratives of individuals within a society. The self is a "narrated quest," in which it strives for the "good" (Maclntyre, 1984, pp. 218-219). Only in terms of a person's story does the self, especially the moral or ethical self, emerge: "stories capture our sense of ourselves and others as developing moral agents, with pasts, presents, and futures" (Kreiswirth, 2000, p. 309).

For the sociopolitical context, individuating narratives and their ethical and moral dimensions are influenced by and judged according to cultural standards. "Narratives that explore certain individuals and groups self-identified by gender, race, sexuality, class, or ethnicity," claims Kreiswirth, "tend to validate the tellings not only in terms of their specificity, credibility, dynamism, and the cultural or political work they perform but also in terms of how they can be seen to respond to the dominant tales of social identity and power within and against which they are produced" (2000, p. 310).

Personal narratives and the individuals they construct are "shaped by the prevailing norms of discourse in which they operate" (Rosenwald and Ochberg, 1992, p. 3). George Rosenwald and Richard Ochberg (1992) reject the weaker notion that a "good" story is one that "works" for the individual. Rather, they posit a dialectic in which the individual is constructed in terms of conflict with the social context. Rosenwald and Ochberg admit that "desire (and the life stories in which it is represented) is inevitably shaped by the forms each culture provides. At the same time," they contend, "desire strains against these forms. The silences, truncations, and confusions in stories as well as the occasional outbreaks of action contradicting an individual's `official' narrative, point out to us-and to the narrator, if only his or her recognition can be enlisted-what else might be said and thought" (1992, p. 7).

Narrativists want to distinguish fundamentally between discursive and narrative knowledge, especially in terms of justifying truth claims. For both types of reasoning operate with different principles and criteria (Worth, 2008). Hence, proponents of narrative knowledge have developed non-traditional, alternative means for justifying storied knowledge. For example, instead of focusing on traditional notions of truth narrativists focus on the story's lifelikeness or believability (Bruner, 1986). The goal then of narrative knowing is not empirical proof but verisimilitude. For narrative knowledge provides a plausible rather than a true account of the world (Hannabuss, 2000). The criterion of plausibility posits the significance of plot for determining a story's validity, by structuring the temporal events of the story that leads to a conclusion (Polkinghorne, 1995).

D.C. Phillips, however, claims that the criteria of "plausibility, evocativeness, presence of an engaging plot, and the ability to generate playful exploration... are inadequate" (1994, p. 13). For example, Philips criticizes the reliance on plot for determining a story's validity or truth accordingly: "The conditions which the need for a clear plot imposes upon a story are epistemically irrelevant; the plain fact of the matter is that unification of the narrative, having a clear conclusion to which the narrative coherently leads, and so forth, can be achieved without the story being true" (1997, p. 105).13 Moreover, plausibility is too weak a criterion, since there are true stories that initially seem implausible. The best that can be accomplished with narrative is a regulatory truth: "Often our goal is to find the truth, and we do the best that we can, using the strongest epistemic warrants that are available" (Philips, 1997, p. 108).

Kreiswirth also addresses the questions concerning narrative validity or truth: "what kinds of tales and tellers should we approve, and for what purposes? And what should count as criteria for approval?" (2000, p. 295). The answers the naturalists and constructivist provide to these questions are problematic, especially in terms of narrative bivalency: "the `what' of the story told and the `how' of its telling" (Kreiswirth, 2000, p. 302). Kreiswirth appeals for a disciplined narrative in which epistemological issues are not ignored but rather narrativists attempt "to know what's happening in the telling, where it's happening, what it claims, and what it does" (2000, p. 316).

Rosenwald (1992) also addresses this problem and suggests an epistemological foundation for a disciplined narrative by delineating several features of a better or good story. The first feature is that a better story has narrative generalizations substantiated by specific instances within the narrative. "Better stories," as Rosenwald points out for the second feature, "tend to be structurally more complex, more varied and contrastive in the events and accompanying feelings portrayed, more interesting and three-dimensional" (1992, p. 284). However, a better story must also be more coherent besides being more inclusive and detailed: "A good story must not only be horizontally coherent-episodes hanging together to warrant generalizations-but also vertically-episodes warranted by acts, feelings, and so on" (Rosenwald, 1992, p. 285). The last feature of a good story is that it leads to novel acts as the narrative is further articulated. "The truth of a narrative is therefore not representational and not pragmatic," concludes Rosenwald, "but dialectical: the narrative is true in that it enshrines the toil of undoing representational and social perplexity-both forms of routinized suffering; it is true as the laborious negation of the prior self-consciousness" (1992, p. 286).

9.3.3 Medical Narrative Diagnostic Knowledge

"Medicine is fundamentally narrative," according to Kathryn Hunter, "...and its daily practice is filled with stories" (1991, p. 5). For humanistic practitioners, then, medical knowledge and practice are fundamentally narrative in nature. "Doctors may try, in the usual fashion of history taking, to restrict their patients to simple yes-or-no answers to questions designed to reveal some diagnostic pattern," observes Cassell, "but patients almost always respond in telling stories" (1991, p. 167). In other words, the objective data obtained during the diagnostic procedures of the biomedical model are important; however, for the humane practitioner a fuller account of the disease involves allowing the patient to recount or narrate more fully the illness experience. How a patient narrates the symptoms shapes the content of medical knowledge, especially in terms of diagnosis, and influences therapeutic outcomes. For example, if the patient fails to mention important symptoms of the disease during the medical interview then the chance of the physician making an accurate diagnosis is quickly diminished and the proposed therapeutic modality may be ineffectual.

For the humane practitioner, the patient is a text that needs to be interpreted. "The practice of medicine," according to Hunter, "is an interpretative activity. It is," she argues, "the art of adjusting scientific abstractions to the individual case" (1991, p. xvii). Biomedical research and technology provide objective knowledge, in terms of data and observations, concerning diagnosis and therapeutics but at the expense of bracketing the patient's existential concerns and personal life. For example, in the case study narrated by Kassirer and Kopelman (1989), the only relevant clinical data are the patient's alcohol drinking and cigarette smoking behavior. And at no time were questions asked about the patient's life style choices that led to these abusive and destructive behavioral patterns.

Bracketing of a patient's personal life is a major contributor to modern medicine's quality-of-care crisis. Humane practitioners incorporate a patient's story in order to address the existential concerns and the crisis itself. "The metaphor of the patient as text and the physician as a well educated, attentive close reader of that text," notes Hunter, "goes a long way toward capturing the complexities of the emotional and epistemological relation between the physician and patient" (1991, p. 12). And, it also goes a long way in addressing the quality-of-care crisis.

Part of the problem with the biomedical model is that symptoms and signs are thought to provide direct access to the disease, such that a report by the patient of pain must be directly correlated with a sign observed by the physician. If the sign cannot be observed, then the physician questions whether the patient is truly experiencing pain. Important for the physician to understand is how the presenting symptom became a symptom for the patient in the first place. The problem is that medical science considers symptoms as generalities, when in fact they are specific expressions and characteristics of this patient. Patients become aware of illness when they assign meaning to a particular bodily dysfunction. "Disturbances in bodily function, when they become severe enough," according to Cassell, "are assigned significance in terms of disease" (1991, p. 102). The role of the physician is to uncover this world of meaning for each patient through the medical interview.

The symptoms for a patient are embedded in a story, as the patient lives out the illness. That story cannot be reduced to physiological and pathological signs alone, in terms of the meaning associated with the illness. If physicians are to help in terms of either a cure or healing, then they must access the illness narrative in order to enter into a patient's illness experience. For example, during the present illness history part of the medical interview the humane clinician often seeks the patient's input as to what is wrong or what is causing the illness.

"The physician," according to Billings and Stoeckle, "must appreciate what illness means to the patient. This meaning," they observe, "is often embedded in what the patient thinks has caused the illness-the illness attributions" (1999, p. 113). These attributions can be a process that explains either the disease's cause or the direct cause itself. The source for patient attributions can be lay medical knowledge, cultural beliefs about disease, or personal meaning obtained from the patient's personal experience or the experience of family members or friends. "By appreciating attributions," conclude Billings and Stoeckle, "the doctor learns about the basis of the patient's behavior; by responding to them, the doctor facilitates, personalizes, and enhances care of the patient" (1999, pp. 117-118).

A patient's narrative is important for gaining knowledge of the individual patient as a person and not just as a body (Cassell, 1991). Using the example of an underfed, elderly man who succumbed to pneumonia after his wife died, Cassell claims that scientific "medicine might hold that the story is only concerned with what happened to his body, but we know that stance to be insufficient because what happened to his body would have been different if some nonbody features of the narrative were changed" (1991, p. 112). In other words, illness is unique to an individual in terms of its origins and impact on that individual. The illness experience is made intelligible by a patient's history. "To know that illness," Cassell insists, "one must know something of the person. To know the person," he continues, "one must know something of the narrative" (1991, p. 167). Thus, knowledge of both the illness and the person are intimately connected and knowledge of the illness, at least knowledge of this patient is not possible without the patient's narration of the illness experience. Patient narratives structure medical knowledge.

Story telling, however, is not simply one-way, from patient to physician. Physicians also frequently tell stories to their patients (Cassell, 1991, p. 167). Since the patient is a text the physician is like a literary critic, who also produces a text derived from the patient's text, concerning the patient's disease. Whereas the patient's text is of the illness experience, the physician's biomedical text is an interpretation of that experience into medico-scientific language-often with a flat affect. Consequently, the physician's "medical narrative is all but unrecognizable as a version of the patient's experience" (Hunter, 1991, p. 13). The biomedical narrative, although technical in nature, is critical for communicating not with the patient but with other healthcare professionals involved in the patient's care.14 However, the physician's text is the predominant one for the medical community and often eclipses the patient's text. The problem is how to connect the two texts so that the patient's existential concerns are addressed. The quality-of-care crisis is located at the disjunction of these two texts.

Finally, as for narratives in general, medical narratives, particularly the physician's narrative, also require verification in terms of their facts. Hunter (1991) adopts the criteria of Barney Glaser and Anselm Strauss for validating the narrative's medical facts. The first criterion is the narrative's fitness and ability to account of the relevant evidence and observations of a patient's illness. For example, the diagnosis should explain a patient's presenting symptom and signs obtained by a physician from the physical examination and laboratory tests. The next criterion is the acceptability of the diagnostic account to healthcare colleagues and especially to the patient. The third criterion is that the medical narrative qua diagnosis must be generalizable to other patients with similar symptoms and signs. The final criterion is that the diagnosis should guide a physician to effective therapy for treating the patient. Based on these criteria, Hunter concludes that "the method of reasoning embodied in the differential diagnosis... operates as a check on both the adequacy of the hypotheses and the reliability of the technology" (1991, p. 17).

9.4 Summary

Biomedical practitioners base diagnostic knowledge on a discursive framework that often objectifies the patient, leaving him or her reduced to an objectified organ or tissue. Of course, this diagnostic process has contributed to the quality-of-care crisis. In response to that crisis, humanistic or humane practitioners attempt to infuse the human dimension of the patient, through the patient's narration of his or her illness story, into the diagnostic procedure and the resultant knowledge. Moreover, the patient's story is not complete simply with the objective epistemological details of the narrated illness experience but must also include the ethical and moral details of that experience. Medicine is not simply gathering data or even information about the patient's disease or illness, but must also include the patient's values. Narrative diagnostic knowledge, then, is required for comprehensive diagnostic knowledge that makes possible a patient's return to wholeness.

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