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The missing future tense in medical narrative
  1. L G Olson1,
  2. W Terry2
  1. 1School of Medical Practice and Public Health, University of Newcastle, Newcastle, UK
  2. 2Weill Medical College in Qatar, Cornell University, Doha, Qatar
  1. Correspondence to:
 Dr L G Olson
 148 Chemin de la Planche Brulée, 01210 Ferney-Voltaire, France; les.olson{at}wanadoo.fr

Abstract

Medical narrative is normally assumed to be a past tense narrative. Patients’ and students’ past tense narratives should be supplemented by future tense narratives, and in particular by what we call hypothetical narratives—narratives such as those offered by a medical student in response to the instruction “Tell me a story about when you are a doctor”. These narratives are suggested to be especially useful in clinical and educational contexts because they offer greater insight into the narrator’s hopes and expectations than past tense narratives, which can be helpful in planning management and teaching. The narrator’s ethical principles are also exposed more clearly than when using the past tense narrative. Some ethical concerns raised by analysing narratives offered by patients or students, as if they were literary narratives, are avoided by hypothetical narratives. This suggestion is based on Ricoeur’s account of the ethical importance of veracity in narrative, or “attestation of what has occurred”. The patient/doctor or student/teacher relationship is found to have an implicit concern for the narrator’s intention that makes the assumptions underlying literary analysis untenable.

  • narrative medicine
  • narrative ethics
  • patients’ narrative
  • medical students

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Medical narrative, modelling itself on literary narrative, naturally takes the past tense. In everyday life, however, most of us are more concerned about the future. In sickness, for example, tomorrow’s symptoms cause distress that is more pressing than yesterday’s. In medical narrative our perspective on the future is reversed: the future is a place from which we look back, and it is assumed that the stories we tell about tomorrow’s symptoms will be told in the past tense. So, Arthur Frank1 notes “... people are not asked, after the shock of diagnosis has dulled sufficiently, what do you wish to become in this experience? What story do you wish to tell of yourself? How will you shape your illness, and yourself, in the stories you tell of it?”

Similarly, Miles Little and his colleagues2 define future memory: “... the kind of memory we may anticipate constructing, either of our own free will and choice, or because of events which determine our future in ways beyond our control. This is more than simply “anticipation” of future events. [...] It is reflection on the memory of an event which allows us to assign meaning within the context of the myriad events that make up our lives.”

Although Frank and Little imagine patients thinking about the future, the stories they imagine them telling are in the past tense. The aim of this paper is to suggest that this concentration on past tense narrative is unnecessarily limiting, and that there are important things to be learnt from listening to what people say now about the future.

Many ways to speak of the future do exist, but we wish to discuss only one of them. We will discuss stories told about a definite future, which the narrator has reason to expect to become real, and we will call these hypothetical narratives. Examples are the narrative a medical student produces when asked to “Tell me a story about when you are a doctor” and the narrative a patient produces when asked to “Tell me a story about living with your illness in two years”. We wish to distinguish between hypothetical narrative defined in this way and speculative narrative and fantasy, in so far as these modes of narrative relate to futures that the narrator has no good reason to anticipate becoming real—for example, “Tell me a story about when you win the lottery.”

We will later draw attention to the important ethical and practical advantages of eliciting and analysing hypothetical narratives as compared with past tense narratives. At this point, we want to draw attention to a remark by Paul Ricoeur3: “... if these works [of art] are creations, it is because they are not simple projections of the artists’ conflicts but are outlines of their solutions. [...] It is a prospective symbol of personal synthesis and the future of man rather than a regressive symbol of his unresolved conflicts.”

We take this remark to summarise as lucidly as possible a key reason why the analysis of narrative is helpful in a medical context: it allows us access both to the conflicts and difficulties the narrator faces and also to the solutions that the narrator can envisage.

Past tense narrative makes the difficulties explicit but the solutions only implicit, and we suggest that this is a mistake of emphasis in the clinical and educational contexts. In these contexts one of the professional’s purposes is to help the patient or student formulate an effective solution, and in hypothetical narratives the solutions—or the fact that the narrator can envisage no solution—are explicit. The solutions ordinary people envisage for their problems may be, as the examples we present will illustrate, unrealistic or morally flawed. This makes many hypothetical narratives poor art, but valuable when told by people, such as patients and students, in whose expectations and moral sense we have an interest that goes beyond the aesthetic.

EXAMPLES OF HYPOTHETICAL NARRATIVE

We will now present examples of hypothetical narratives of patients and medical students to allow readers to see what we are talking about.

The patients’ narratives were collected from four consecutive newly referred patients seen on a single day in an outpatient clinic for respiratory and sleep disorders run by one of the authors (LGO). At the point in the discussion of their illness where their strategies for dealing with everyday difficulties had been elicited, each patient was asked to “Tell me a story about dealing with your illness in two years”.

The students’ narratives were collected from five consecutive medical students seen individually by LGO for remedial teaching and mentoring. Each of them was asked to “Tell me a story about when you are a doctor”.

The narratives were written down immediately after they were spoken, and are presented here complete and without editing. Each patient and student gave consent for publication after they had completed the narrative and had considered the light it may cast on them. Under current Australian guidelines, the approval of an institutional ethics committee was not necessary for the collection and publication of the narratives.

Hypothetical narratives of patients

In some cases the narratives showed realistic aims, which could be achieved by adjustment of management.


 I want to go with my wife to see Uluru, and we are going to walk up it. She’s got a bad hip so we make a good couple walking. I will be really good with the rehab and the puffers for a couple of months before, and I will take it easy when we get there and take my time, and I won’t worry about how long it is taking ... and we will do it (58 year old man with chronic lung disease)
 
 I don’t know ... It won’t be much different will it? My lungs won’t get better, I know that. Maybe if I have the oxy[gen] at home then ... I will be able to get up and have a shower and get dressed without the nurse coming in. How’s that? (75 year old man with chronic lung disease)

Other patients disclosed unrealistic hypothetical narratives, which all but guaranteed therapeutic failure if success was to be judged by the patient’s expectations.


 I will keep very positive and active and exercise my muscles all the time, and that will keep me from getting worse and maybe better. So I won’t be in the wheelchair in two years (65 year old man with motor neurone disease)
 
 In two years I won’t have this problem. After the surgery losing weight will be easy ... I won’t have this problem then (28 year old man with morbid obesity and obstructive sleep apnoea awaiting gastric banding)

Hypothetical narratives of medical students

Students’ narratives often provided insights into the their current difficulties, and sometimes disclosed “solutions” which they will need to move beyond. When the narratives were discussed with the students, it was apparent that they had been unaware of the depth of the feelings which their narrative had disclosed.


 One day someone will come in, and they will have something really simple, and harmless, and I won’t be able to fix it but I will make them feel better (third year student with recent assessment failure)
 
 We had a patient with a right ventricular infarct … I told them what it was and they bagged me out, especially the NUM, K. So another one will come in, and I will know what to do, but this time I can make them give the right treatment, and then I will say to her ‘In future K, you do as you’re told’ (fourth year student)
 
 I’ll have my own solo practice, and to the patients I will be their doctor … their special doctor … and I can do what I think’s right and no one will ask questions or tell me I’m wrong (fourth year student with recent assessment failure)
 
 I will be a medical oncologist. I will see one of your patients with lung cancer only I will be able to do them some good (fifth year student)
 
 I will be walking down the main corridor out there, going to see someone in the wards, and there are the relatives and the patients on the trolleys going to x ray, and the hospital smell, and these relatives will see me and think “I wonder if that is the doctor they called to see mum” ... and I will be ... I love that thought (fourth year student)

USES OF HYPOTHETICAL NARRATIVE

Jerome Bruner4 has written that “ ... truth and possibility are inextricable in narrative”. This interweaving is constitutive of literature, but our argument is that when we are dealing as professionals with patients and students accepting the inextricability of truth and possibility—treating these narratives as literature—limits their utility.

Hypothetical narrative offers a more focused view of a person’s expectations of the future than past tense narrative. As in the examples we present, hypothetical narrative can be helpful in a medical context because treatment needs to focus on future needs. For routine clinical purposes we suggest that this is an important advantage of hypothetical narrative.

Routine clinical work is not the only use of patient narratives, of course, and Arthur Frank, in particular, has emphasised the role of past tense narrative in helping survivors of illness integrate their illnesses into an understanding of their lives. Frank himself, however, reports that some patients reject his emphasis on past tense narrative:


 “Why isn’t it enough”, she asked, “to have cancer and go through treatment. Why do we then have to do more?” In the context of the talk I had just given, “more” meant finding some meaning in illness and then finding ways for that meaning to change one’s life.5

Hypothetical narrative offers a way of getting patients of this inclination into the narrative community or, if that is our interest, into the narrative database.

The hypothetical narratives we collected from students often provided helpful insights into a student’s anger or anxiety (for example, the first student’s hypothetical narrative presented earlier). The most helpful hypothetical narratives by students are, however, those that gave insights into ethical principles (for example, the second and third students’ narratives). Past tense narrative may include ethical decisions, but in the past tense the narrator can invoke constraint, misinformation, or—as a last resort—misjudgement if the decisions are unsatisfactory. These options are not available in the future tense. This argument was first put forth by William Hazlitt. Our attention was drawn to Hazlitt’s ideas by Porter6. Noting Locke’s demonstration that our knowledge of ourselves as persisting individuals is based on memory, and is accordingly fragile, Hazlitt7 asked how we are related to our future selves. Locke’s answer was that imagination is our link to the future, and he drew from this the conclusion that it is in our imagined future that our ethical nature can be seen most clearly: “The objects in which the mind is interested may be either past, or present, or future. These last alone can be the objects of rational and voluntary pursuit; for neither the past, nor present can be altered for the better, or worse by any efforts of the will. It is only from the interest excited in him by future objects that man becomes a moral agent, or is denominated selfish, or the contrary, according to the manner in which he is affected by what relates to his own future interest, or that of others.”

Heidegger8 also places the relationship of our present with our future selves at the centre of his thought, and gives that relationship an ethical dimension. Heidegger’s approach to this matter is a larger topic than we have space to consider, and it must suffice to note here that his understanding of the relationship between our present and future is emphatically non-hypothetical. For example: “The ripening fruit, however, not only is not indifferent to its unripeness as something other than itself, but it is that unripeness as it ripens. The “not yet” has already been included in the very Being of the fruit, not as some random characteristic, but as something constitutive. Correspondingly, as long as any Daseini is, it too is already its “not yet”. That which makes up the “lack of totality” in Dasein, the constant “ahead-of-itself”, is neither something still outstanding in a summative togetherness, nor something which has not yet become accessible. It is a “not yet” which any Dasein, as the entity which it is, has to be.”

Certainly, the definition we have given of hypothetical narrative as concerning a future inherent in the present (and in this way differentiated from fantasy), echoes Heidegger’s notion of the “not yet”. The element of inevitability in “being-towards” seen in the ripening fruit, however, has its human counterpart in the notion of resoluteness: “In resoluteness, the Present is not only brought back from distraction with the objects of one’s closest concerns, but it gets held in the future and in having been.”(Heidegger,8 page 387) There is for Being only one authentic future, identified in the “moment of vision”. Hypothetical narrative as a means of identifying several possible futures, among which the narrator may choose on ethical and practical grounds, is ruled out as paradigmatically inauthentic.

Jerome Bruner4 has referred to the admixture in narrative of a range of possibilities as “subjunctivisation”. He points out that the consistent presence of the subjunctive, expressing what may or ought to have been, accounts for much of the narrative’s ability to represent “negotiated meanings”. The problem, from a clinician’s or teacher’s point of view, is to know how subjunctivised a particular patient’s or student’s narrative is. Further, as Bruner notes in relation to the non-professional narrators he has studied, some people subjunctivise a lot and some do it sparingly (Bruner,4 page 132). To recast the argument made above in Bruner’s terms, hypothetical narrative may offer a way of unobtrusively directing the narrator to tell a subjunctivised story, with all the interpretative opportunities that follow.

Expectation shapes both experience and behaviour. It is a matter of common experience that as we approach important events we imagine how they will be—that is, we create hypothetical narratives. These narratives can be helpful or damaging to their creators, according to whether they promote or inhibit good performance. Eliciting hypothetical narratives can give access to the narrator’s expectations, not only about the future in general (“Tell me a story about when you are a doctor”) but also about specific events in the future (“Tell me what the assessments next week will be like”). It turns out that many students have hypothetical narratives of failure, which are obviously unhelpful. (The techniques of positive imagery used by sports psychologists are, of course, the other side of this coin: hypothetical narratives of success.)

Hypothetical narratives may also create conflict with others who are ignorant of the role the narrator has assigned them (most of us have said, or heard, words to the effect of “I was hostile because I thought you would be angry”). So, hypothetical narratives about specific events can create interpersonal difficulties, as when in Jane Austen’s Pride and prejudice, Mr Darcy approaches Elizabeth Bennet to propose marriage under the influence of a hypothetical narrative, the inaccuracy of which causes her to reject him with anger and disdain.

ETHICAL ISSUES RELATED TO HYPOTHETICAL NARRATIVE

We have so far discussed the uses of hypothetical narrative for the professional purposes of clinicians and teachers. We now wish to turn to some ethical issues arising from the use of narrative in professional contexts.

It is a commonplace of literary analysis that all narrative embodies negotiated meaning. It is for this reason that it seems natural to treat the past tense narratives of patients or students as literary texts, applying to them methods developed for literary narratives. The case we wish to make is that in the case of narratives by patients and students, this will not do. The reason is the ethically distinctive nature of our relationship with patients and students.

The suggestion that there are two forms of narrative, whose differences we ought not to obscure for ethical reasons, was made by Paul Ricoeur.9 He writes of “the memory crisis produced by the horror of history” and goes on: “What in the memory crisis makes this a crisis is the obliteration of the intuitive side of representation and the threat that is joined to it of losing what can be called the attestation of what-has-occurred, without which memory would be indistinguishable from fiction.”

We take Ricoeur’s meaning here to be that if we are asked, for example, whether it makes a difference if there really were gas chambers at Auschwitz-Birkenau, we ought to answer that it does. In the case of this question, “attestation of what-has-occurred” has a significance independent of any interpretation of the answer as narrative. An example of a narrative in which this question arises is that by Primo Levi10: “... the truck stopped, and there was a big gate, and above it a sign brilliantly lit (and the memory of it still torments me in dreams): ARBEIT MACHT FREI, work makes you free.”

It matters that it is true that in those days the sign was brilliantly lit. Levi is not responsible for this fact, but he is responsible for the truth of what he has related. Of course, literary analysis will draw attention to the echoes of Dante here and throughout Levi’s narrative, and these are, no doubt, part of a web of negotiated meanings. But there is a difference between Levi recording the brilliant lighting of the sign above the gate to Auschwitz, because that contrasts with the dark letters of the inscription on the door to Dante’s hell, and inventing the brilliant lighting to create that contrast. The dark letters are Queste parole di color oscuro (Inferno 3:10). It seems to us that, in contrast, Levi was free to write “and the memory of it still torments me in dreams” because that echoes Inferno 1:6 (che nel pensier rinova la paura), whether he had such dreams or not.

The difference between recording and inventing—between “truth and possibility”—is the threshold of “attestation of what-has-occurred”. The importance of the difference between recording and inventing is that a narrative’s status as attestation trumps literary analysis, and the precondition to acceptance as attestation is veracity. We take Ricoeur’s anxiety on this point to arise from the risk that literary analysis will instead trump attestation, and that noticing the echoes of Dante in Levi’s writing will obscure the moral significance of the facts he relates, or even make it possible to behave as if they were not facts at all.

We suggest that the narratives by patients and students can be treated as examples of “intuitive” narrative in Ricoeur’s sense, and that they can be narratives of “attestation of what-has-occurred” in that person’s life. Ricoeur’s distinction between memory and fiction is, therefore, important in these narratives, just as in narratives of the extermination camps. The reason is the same in both cases: the veracity of narrative is important to those who have an interest in the life of the narrator in the same way that the veracity of the narrative of what occurred at Auschwitz-Birkenau is to all of us.

The difficulty lies in knowing when a narrative’s claim to be “attestation of what-has-occurred” is valid. We can, of course, guess, or proceed “as if”, but we suggest that the basis of Ricoeur’s anxiety is that guessing creates a moral hazard. The moral hazard of guessing arises not from the risk of guessing wrongly, but from willingness to guess at all. To see this, consider two narratives: one which says that there were gas chambers at Auschwitz-Birkenau, and the other, which says that there were no gas chambers. A naive reader may weigh up their arguments and the evidence they present, and reach the wrong conclusion about which was attestation and which fiction. This factual mistake need not be an ethical mistake. But a reader who does not recognise, given what is at issue, that the difference between attestation and fiction is too important to be merely guessed at always makes an ethical mistake, even if he or she guesses correctly.

A further ethical hazard in dealing with narratives by patients and students is that of unfair appropriation. It is unusual for patients and students to volunteer a narrative: normally, their narration is solicited. The basis of this solicitation is an assurance, often explicit but in any case implicit in the patient/doctor or student/teacher relationship, that we are interested in the narrator’s understanding of the situation. To put this another way, recruitment of a patient or student narrator may, and perhaps should, imply an assurance that we accept the “intentional fallacy” (the view that the meaning the author of a text intends it to have is authoritative).

Hypothetical narrative avoids these difficulties. Hypothetical narratives are fiction, are known by the author to be fiction, and can with unquestioned legitimacy be read as fiction. Their interpretation is affected neither by the need to allow for the imperative of attestation nor by the ethical obligation to give primacy to the narrator’s intention.

Hypothetical narrative not only protects patient or student narrators from readers who may misconstrue their attestation as fiction, but also protects readers from narrators who may misrepresent fiction as attestation. If Ricoeur’s notion of “attestation of what-has-occurred” establishes a space in which a narrator can legitimately disclaim responsibility for the facts narrated, that space is subject to abuse. In particular, as we noted above, narrators can appeal to facts for which they are not responsible to explain or excuse the past. As it can be difficult to tell whether a past tense narrative is attestation or fiction it is difficult to know whether this appeal to the facts is fair or an abuse. This uncertainty is also bypassed by hypothetical narrative (as by other forms of declared fiction). In the future tense, there is nowhere to hide: hypothetical narrative eliminates the risk not only of ignoring the claims of attestation but also of inappropriately allowing them.

REFERENCES

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Footnotes

  • i Dasein is an idea conceived by Heidegger in Being and Time. It is derived from “da sein”, which literally means “being there”.

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