At the intersection of medicine, ethics, and literature exists a practice known as narrative medicine—an approach which stresses the humanization of patients and the subsequent care that follows attentively tuning into the stories of those grappling with illness and death. Dr. Rita Charon, an internist and literary scholar at Columbia University, has been a great proponent of narrative medicine in recent decades despite acknowledging that she was not the first to invent it (Charon 3:45). Narrative medicine allows patients to express to their provider not only the physical symptoms and side effects of their illnesses, but to explicate the intrinsic and deeply personal ramifications through storytelling via their identity, experiences, and choices. This practice requires diligent observation and empathy on the part of the medical professional to glean a deeper understanding of patients’ needs. According to Dr. Charon, narrative medicine aims “to donate the expertise, to enact a fidelity, to give someone company, and to form staunch, study affiliation… so that no one has to be in… the glare of death alone,” (Charon 17:21). This method operates under the universal principle of death as an intrinsic evil which instills fear in everyone, especially the vulnerable. According to centuries-old philosophical writings, however, this was not always a sure-fire assumption. Epicurus asserts that people should not fear the inevitability of death as it does not exist while people are alive. While this may not be a prevalent belief in modern society where survivorship is the necessary condition for a fulfilled life, Epicurus also writes that an absence of pain should be the primary life goal which requires prudence to maintain. Thus, prudence presents itself as the fundamental ethical base in medical practice. Because narrative medicine is a holistic consideration of a person, Hume’s idea of the self or identity becomes critical in determining the value of the various parts of the stories told by patients to recognize that people are constantly changing and evolving, physically and mentally, to acclimate to their respective afflictions. Ultimately, this ties into Immanuel Kant’s idea of rational beings having agency instead of simply existing as a means to an end or becoming reactive to their environments, which is how doctors should conduct individual interactions with clients.

In Epicurus’ “Letter to Menoeceus”, his perception of death takes on a rather stoic outlook. However, Charon refutes this idea by claiming that our collective understanding of death, or lack thereof, empowers us to share, as Kant suggests, a sense of discomfort in light of its threat. Epicurus writes that because a living person does not coexist with their own death, it is futile to feel fearful. In other words, worrying about death exclusively hurts in the present as death simply “pains in the prospect”. Though in theory Epicurus makes a logically airtight case, he does not acknowledge the aspect that makes humans sentient, and more importantly, rationally moral creatures: emotions. Charon substantiates this emotional viewpoint by writing that our perceptions of death are “deluded” by our experiences with grief as “depending on one’s own contact with death—in the military, as a hospitalized patient, with family losses . . . a patient might feel death a personal enemy or a distant abstraction,” (Charon 24). Because people experience sorrow and hopelessness after losing a loved one, they know the ramifications that death will have on the people they know, not to mention their own loss of sensation and experience. Furthermore, someone’s death can be viewed as the death of everyone they know at once—mourning the loss of countless people in a single moment. Based on Charon’s argument, the doctor-patient relationship within the context of death essentially determines empathy embedded in consultations as “perhaps doctors could share some of their realism about death with patients,” (Charon 25). The connection they form over the tacitly understood depth of death is what makes the relationship intimate and comfortable as opposed to sterile and academic. This empathy facilitates a shared attack against fear and “provides company to combat the isolation and with it an animating belief in the patient’s ability to endure whatever will come,” (17). Rather than being apathetic towards the perils of solitude and fear, the doctor must act intentionally and ensure quality care to the patient throughout recovery from listening carefully to replying thoughtfully. In Fundamental Principles of the Metaphysics of Morals, Kant corroborates this belief as he stresses that people, different from objects, are an end in themselves rather than a means to an end and should be treated as such. This extends beyond the self and acting in self-interest to make choices that ensure our survival and instead making decisions that provide for others too. Our lives are enriched and amplified positively on a human level in the process of doing so. Kant writes, “the ends of any subject which is an end in himself ought as far as possible to be my ends also, if that conception is to have its full effect with me,” (27). This applies to medical practice not only in the explicit wording of the Hippocratic oath, but also when synthesizing two human experiences to further the ends of either one. Thus, medical practitioners should depend on a shared vision of death, in the face of it, to gain a deeper, more humanistic insight into their patients while simultaneously acting within the capacities of a confidant and a caretaker.

Hume breaks down the storytelling elements of narrative medicine in A Treatise of Human Nature. He emphasizes the fragmented nature of the self as a culmination of various impressions and ideas. Piecing together these impressions and ideas could help medical professionals consider treatments for patients as illness takes a physical toll, but also applies pressure on mental health in the intrinsic sense of strained identity and self-esteem. Furthermore, prudence is required when making such value judgements. When interpreting the narration of patients, doctors must listen to the words, but also closely examine the unspoken bits as minute as tone, body language, and facial expressions (Hutto). Such signals, along with any stories told in conjunction, become puzzle pieces into obtaining a holistic view of the patient—essentially humanizing them. Within her own patient interactions, Charon recounts, “I had to follow the patient’s narrative thread, identify the metaphors or images used in the telling, tolerate ambiguity and uncertainty as the story unfolded, identify the unspoken subtexts, and hear one story in light of others told by this teller,” (Charon 4). Often, many things are left unsaid in storytelling and the impressions of someone and the attributed character we lend them can shift with every passing moment. More importantly, diligence in listening is critical in determining who the patient was, who they are now, and who they are becoming. In this vein, the more narration the patient engages in, the better understanding their provider has of their background and needs. Hume writes that we consist of “nothing but a bundle or collection of different perceptions, which succeed each other with an inconceivable rapidity and are in perpetual flux and movement,” (Hume). This suggests that we will never have a stable version of our self-identity, as it will seldom be unilaterally aligned throughout our lives, which is further complicated by bodily diseases. In her book, Charon uses the play entitled Wit as an example which encapsulates the knowledge disparity between ordinary people and professionals and the distrust that it produces as a result. Specifically, the concluding scene in which the wife clutches recklessly to her husband’s wrist and struggles to seek out better solutions is deeply moving in that it shows a sharp contrast between the academic thought process of the doctor and the emotional response of the family. Bridging this gap, by preparing medical professionals to deal with such plight and feel empathetic towards the situation, can have the potential to close the language gap and build mutual trust (Hutto). An analogy could be made to Hume’s concepts between the wife as an impression and the doctor as an idea. Namely, the impressions consist of “perceptions which enter with most force and violence,” which is reflected in the wife’s fear of being a widow and single mother (Hume). Clearly, illnesses take a toll on people’s different roles in life and permanently reduces the optimism with which they approach their future—cautious of becoming too hopeful in light of a crippling condition. On the other hand, ideas are “faint images of these in thinking and reasoning” which portrays a deliberative, introspective mindset (Hume). One is too reactive and the other is too stoic, so a middle ground must be reached for optimal comfort for the patient and treatment by the doctor.

Hume’s concept of sameness and Kant’s distinction between people and things uphold the vital need of treating patients as constantly changing beings as opposed to static objects. Hume writes “we have a distinct idea of an object, that remains invariable and uninterrupted through the supposed variation of time; and this idea we call sameness.” A parallel concept exists in Kant’s philosophy as he asserts, “beings whose existence depends not on our will but on natures, have nevertheless, if they are irrational beings, only a relative value as means, and are therefore called things.” Each concept points to a far deeper, more complex conclusion: all patients cannot be treated the same because they are intrinsically variable and constantly changing. Not only this, but treating patients identically is doing a disservice to their respective identities by failing to consider the impressions that most affect their minds and providing the treatment and comfort that is best suited for them (Hutto). Such agency should not only be exercised correctly by doctors, but thoroughly and consistently to ensure that there is a personalization of medical experience. Charon anecdotally refers to this when she discusses an instance with a patient in which she was to conduct a physical exam when he informed her of negative past experiences at hospitals (Charon 12). This forced her to recognize him as a changed person from that experience, someone who developed a sensitivity to environments like this one, and to adjust her practice accordingly. If she were conducting her routine physical examination as she would with any other patient, she would have the potential to deeply harm the existing patient-doctor relationship and likely worsen any of his existing traumatic issues. Though medicine usually takes on a methodical, traditional stance which closely follows procedures developed from empirical data and experiments, there are elements of its practice that could be tweaked as it is a medium of human interaction. In essence, “Like narrative acts, clinical practice requires the engagement of one person with another person and realizes that authentic engagement is transformative for all participants,” (Charon 11). This exhibits the effect that narrative medicine has on doctors as well because they feel personally invested in the well-being of their patient and understand further that their medical advice is not solely correct or incorrect, rather it is one of many things that the patient has undergone. Medicine does not exist in a vacuum or exclusively in theory, it is constantly practiced on real people and should consequently have a stronger moral, ethical, and humane backbone to support it.

According to Epicurus, prudence dictates choices that are made in favor of pleasure; namely, the ultimate goal, is to avoid pain and make rational, yet thoughtful decisions to fulfill that requirement. Epicurus defines pleasures as “the absence of pain in the body and of trouble in the soul,” which shows that it is the responsibility of the practitioner to also put the mind at ease, because the mind affects physical matters. In striking the delicate balance between emotional depth and rationality, we must act virtuously to ensure that as “virtue then is a state of deliberate moral choice consisting in a mean relative to us, the mean being determined by reason,” (Epicurus). Simply put, the burden of deliberate moral choice is placed on the practitioner to strengthen the patient’s frame of mind and provide the appropriate advice to treat the condition effectively. Epicurus also states that at times people endure pain and even suffering, though they are considered great evils, for the sake of a greater good in the end. An example of this could be as follows: A cancer patient becomes diagnosed with stage two breast cancer for which chemotherapy is an important step in remission. The patient is greatly resistant to the concept of chemotherapy. Upon hearing her story, the doctor realizes that the patient is most concerned about the hair loss, something she considers a fundamental part of her identity. Ultimately, weighing the costs and benefits with her with specificity and personal understanding, the doctor is able to talk with her to sort out a solution using cold caps to lessen hair loss, while convincing her to start sessions. This is a prime example of enduring pain for a worthwhile end while employing narrative medicine. By just providing an incremental amount of context through prudent deliberation, lives can be positively touched and changed permanently.

Ultimately, each of these philosophies reflects the merits of narrative medicine as it takes a practice that is normally ultra-methodical and rigid and instead, attempts to “make contact” in a unique way that requires the human soul. However, this raises the question of how narrative medicine might invite and attract providers’ personal biases upon hearing the stories of the ill. Certain cognitive and psychological blindspots from physicians can possibly form dislike towards patients instead of sympathy, thus affecting the quality of care. It also raises the question of whether this emotional attachment formed to patients can negatively affect practitioners if a patient passes away or condition worsens. Guilt is already a major feeling associated with medical care as the expertise can come down to life or death—could a connection worsen that feeling? Doctors are putting themselves in vulnerable positions in spite of being fallible, emotional human beings. Despite this, realizing that people are constantly shaped by their pasts makes it important to make prudent decisions and to consider the varying fragments of the patients’ identities—namely, a fundamental fear of death—for treatment.

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