Schultz Dawson Stafford, Flasher Lydia Victoria
University of California, Santa Cruz, California, USA.
J Med Philos. 2011 Aug;36(4):394-409. doi: 10.1093/jmp/jhr032. Epub 2011 Sep 7.
This paper provides a brief overview and critique of the dominant objectivist understanding and use of illness narrative in Enlightenment (scientific) medicine and ethics, as well as several revisionist accounts, which reflect the evolution of this approach. In light of certain limitations and difficulties endemic in the objectivist understanding of illness narrative, an alternative phronesis approach to medical ethics influenced by Charles Taylor's account of the interpretive nature of human agency and language is examined. To this end, the account of interpretive medical responsibility previously described by Schultz and Carnevale as "clinical phronesis" (based upon Taylor's notion of "strong" or "radical evaluation") is reviewed and expanded. The thesis of this paper is that illness narrative has the ability to benefit patients as well as the potential to cause harm or iatrogenic effects. This benefit or harm is contingent upon how the story is told and understood. Consequently, these tales are not simply "nice stories," cathartic gestures, or mere supplements to scientific procedures and decision making, as suggested by the objectivist approach. Rather, they open the agent to meanings that provide a context for explanation and evaluation of illness episodes and therapeutic activities. This understanding provides indicators (guides) for right action. Hence, medical responsibility as clinical phronesis involves, first, the patient and provider's coformulation and cointerpretation of what is going on in the patient's illness narrative, and second, the patient and provider's response to interpretation of the facts of illness and what they signify-not simply a response to the brute facts of illness, alone. The appeal to medical responsibility as clinical phronesis thus underscores the importance of getting the patient's story of illness right. It is anticipated that further elaboration concerning the idea of clinical phronesis as interpretive illness narrative will provide a new foundation for medical ethics and decision making.
本文简要概述并批判了启蒙运动（科学）医学与伦理学中对疾病叙事的主流客观主义理解及应用，以及一些修正主义观点，这些观点反映了这种方法的演变。鉴于客观主义对疾病叙事理解中固有的某些局限性和困难，本文考察了一种受查尔斯·泰勒关于人类行为和语言解释性质论述影响的医学伦理学实践智慧方法。为此，回顾并扩展了舒尔茨和卡内瓦莱先前描述为“临床实践智慧”（基于泰勒的“强”或“激进评价”概念）的解释性医疗责任论述。本文的论点是，疾病叙事既能使患者受益，也有可能造成伤害或产生医源性影响。这种受益或伤害取决于故事的讲述和理解方式。因此，这些故事并非如客观主义方法所暗示的那样，仅仅是“好听的故事”、宣泄的姿态，或科学程序及决策的单纯补充。相反，它们为行为者开启了各种意义，为解释和评估疾病发作及治疗活动提供了背景。这种理解为正确行动提供了指标（指引）。因此，作为临床实践智慧的医疗责任首先涉及患者与医疗提供者对患者疾病叙事中所发生事情的共同构建和共同解释，其次涉及患者与医疗提供者对疾病事实及其意义解释的回应——而不仅仅是对疾病的原始事实的回应。诉诸作为临床实践智慧的医疗责任因此强调了正确理解患者疾病故事的重要性。预计对作为解释性疾病叙事的临床实践智慧这一理念的进一步阐述将为医学伦理学和决策制定提供新的基础。
