How to Change Lives with Words
Fabiana Carelli
Abstract
Since 2011, the GENAM, Group of Studies in Narrative and Medicine at the
University of São Paulo, Brazil, has been dealing with the comprehension of the
narratives that permeates every medical encounter. With an approach that come
from the narrative/literary studies and philosophy and has points in common with
the so-called Narrative Medicine, our researches try to focus on the narratives that
embody the building of meaning across healthcare practice, whether these
narratives are stories told by patients to doctors, by doctors to patients, by doctors
to doctors, etc. We consider narrative as an aesthetical phenomenon, understanding
“aesthetical” in the broad sense of (any) language production that aims to conceive
a form for the purpose of enhancing expression. In this direction, and based on the
concepts of peripeteia or reversal of circumstances (Aristotle, 1997); mimesis (I, II
e III), emplotment and narrative time (Ricoeur, 1990ab); illocutionary and
perlocutionary acts (Austin, 1975); and narrative identity (Ricoeur, 1995; Carelli,
2013), this presentation aims to develop the concept of narrative act, preliminarily
defined as a narrative action, by the narrator or the listener/reader, that, deliberately
or not, conscious or unconsciously, effectively changes the meaning of the story
told and, consequently, the course of the events. This concept is clearly inspired by
the process conceived by Paul Ricoeur as configuration, “the capacity of poetic
composition to re-figure […] temporal experience” (Ricoeur, 1990a: xi). Within
the life and death contexts of the narratives produced in the healthcare practice, this
so-called narrative act may, ultimately, change the outcome of a lifetime.
Key Words: Narrative act, narrative identity, narrative and medicine, narrativebased medicine, reversal of circumstances, peripeteia, GENAM, literature and
medicine
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1. A “fresh, clear, well-seasoned perspective”
In the admirable animation by the Disney Studios Ratatouille (2007), the
terrible gastronomic critic Anton Ego, the destroyer of culinary reputations, whose
voice is performed by the important actor Peter O’Toole, comes to the restaurant
Gusteau’s, in Paris, to prove the creations of its new chef, after the passing of its
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former cook and founder. In the kitchen, everybody trembles, for they know that
Ego’s word can bring fame or disgrace to a house. Then the waiter, hesitantly,
approaches the customer-critic (“It isn’t any client – it’s Ego!”, everyone says) and
asks him if he already know what would be his choice for that evening.
Blasé-aired, Ego’s answer is perplexing:
“- Yes, I think I do. After reading a lot of overheated puffery about your cook,
do you know what I’m craving? A little perspective!...”
The idea of Ego’s “fresh, clear, well-seasoned perspective” serves us as a mote
for the concepts I would like to develop along this paper, in our case not related to
the relationship between waiter and his customer, of course, but to the encounter
between the patient and the health professional that assists him (her).
2. Narrative and health
When a radiologist examines a tomography, he produces a report – that is, a
written text that has an eminently descriptive nature. When a clinician examines
the same tomographic image, he can produce a diagnosis – probably an oral text
(when he comments the case with another physician or even with the patient) and,
subsequently, a written text (when he writes on the file the test’s results and his
conclusions). This text is also descriptive, but it is structured according to logical
relations based on previously known models. If a specialist examines the same
image, he also produces a diagnosis which, like the above-mentioned one, can be
oral and/or written. Although this text is also predominantly descriptive and
structured according to a certain type of logic, the specialist’s parameters are
probably different from those of the clinician. In light of this scenario, it is
important to ask two questions. Firstly, what would be the differences among these
texts? Secondly: does the mode (in the broad sense: structure, genre, textual models
and other elements) in which these texts are constructed modify the possible
referential meaning(s) of the image itself? In what way?
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A field called Narrative-Based Medicine arose in the United Kingdom at the
end of the 1990s, supported by the publication of the book with the same title,
edited by Trisha Greenhalgh and Brian Hurwitz (Greenhalgh, Hurwitz, 1998). This
book originated a series of five papers that were subsequently published in the
British Medical Journal (Greenhalgh, Hurwitz, 1999; Greenhalgh, 1999) and
which try to answer the following questions, among others: why should we study
narrative related to medical practice? In what way can the study of signification
contribute to the clinical process of data interpretation and construction of a
medical diagnosis (and prognosis)? Why don’t doctors listen to their patients’
stories? What are the limits of objectivity in the clinical method? How can we
relate “evidences” and narratives in the constitution of an integrated diagnosis,
since medicine is – or should be -, by nature, integral in its view of the patient?
Generally speaking, we can imagine that reports and diagnoses like the ones
mentioned above, whether derived or not from image readings, and with an
eminently descriptive nature, will, at some moment of the clinical process,
compose narratives informed by them. In what way does this occur, and what types
of narratives are these?
Greenhalgh and Hurwitz give us some clues:
“The processes of getting ill, being ill, getting better (or getting
worse), and coping (or failing to cope) with illness, can all be
thought of as enacted narratives within the wider narratives
(stories) of people’s lives” (Greenhalgh, Hurwitz, 1999: 48).
The authors add that “Taking a history is an interpretive act; interpretation (the
discernment of meaning) is central to the analysis of narratives (for example, in
literary criticism)” (Greenhalgh, Hurwitz, 1999a, p.48), as, according to the
authors,
“In contrast with a list of measurements or a description of the
outcome of an experiment, there is no self evident definition of
what is relevant or what is irrelevant in a particular narrative.
The choice of what to tell and what to omit lies entirely with the
narrator [...]” (Greenhalgh, Hurwitz, 1999, p.48).
From the clinical standpoint, therefore, we might suppose that the construction
of a narrative about the patient’s illness (or about the ill patient – the order here is
discretionary, as the definition of who is the protagonist of the story depends on it)
occurs according to the power of choice of the person who tells it – in this case, the
doctor. He is the one who chooses what to tell and links the facts (among them, the
very description contained in tests and reports) according to models that are known
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and scientifically validated. He is the one who gives a tone to this narrative. Of
suspense? Of tragedy? Epic? Edifying? Self-help?
From the patient’s standpoint, there is also a story to be told. Whether or not
this story is taken into account in the narrative constructed by medical reason is
another problem, a problem that is equally relevant. Obviously, all these narratives
are part and will always be part of each patient’s life histories, before and, in case
the patient gets better or is cured, after the emergence of the illness.
Finally, we can also say that the narrative thread of the clinical process does not
focus only on the past; rather, it organizes the present and projects an outcome,
which is always imagined as a happy ending, but which is sometimes carried out in
a tragic way. The organized present and the projected future are related to
prescriptions and prognoses, respectively: sets of actions that are programmed to
produce certain types of effects – and it is possible to say that this also configures a
narrative.
This point of view has been slowly gaining adepts in the medical field along the
last decade and, in a more recent article, Meisel & Karlawish recognize and
criteriously point out some of the characteristics of the narratives produced within
the doctor-patient relationship, which, according to them, may and shall be used
for the enhancement of health practices and policies. Among these characteristics,
they affirm that “[s]tories are an essential part of how individuals understand and
use evidence” (MEISEL & KARLAWISH, 2011: 2022); and that “[a] narrative –
defined as a cohesive story with a beginning, middle, and end – includes
information about scene, characters, and conflict and raises questions and provides
resolution” (MEISEL & KARLAWISH, 2011: 2022).
3. Aristotle, point of start and end
In the Chapters X and XI of his Poetics (IV b.C.), Aristotle postulates an
important concept for literary theory and narrative analysis, that of peripeteia or
reversal of events, related to the threading of the fable actions:
“Of stories, some are simple and others complex, for the
actions too, of which the stories are imitations, are directly from
the start from these sorts. I mean by a simple action one in
which, while it comes about as continuous and one in the manner
defined, the change takes place without a reversal or discovery;
and a complex action is one out of which a change involves a
discovery or reversal or both together” (ARISTOTLE, 1997: 34),
says the philosopher. And he continues, in the following Chapter:
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“A reversal is the change to the opposite of things being
done, just as has been said [by others], and this, as we are saying,
in accord with what is likely or necessary. […]
And a discovery, as even its name implies, is a change from
ignorance to recognition, leading toward even friendship or
hostility in people bound for good or bad fortune. A discovery is
most beautiful when it happens at the same time as a reversal
[…]” (ARISTOTLE, 1997: 34-5)
In Time and narrative, Paul Ricoeur recovers and revisits the Aristotelian
concept of the poetic work as a threading of actions, of which both peripeteia and
recognition are part. Synthetically, we might say that, for Ricoeur, every narrative
efabulation occurs as a prefiguration of the “world of life” (“[a] preunderstand[ing
of] what human acting is, in its semantics, its symbolic system, its temporality”;
RICOEUR, 1990: 64); a configuration (“emplotment”; RICOEUR, 1990: 6 e
passim); and a refiguration (“intersection between the world of the text and that of
the reader”; RICOEUR, 1990: 80). Schematically:
Operation
Universe to which it
refers
Mimesis I (M1)
Prefiguration
“world of life” –
empirical facts, symbolic
and cultural categories
Mimesis II (M2)
Configuration
text itself (narrative)
Mimesis III (M3)
Refiguration
listener/reader
Kind of Mimesis
In the construction of any narrative, the passage from prefiguration to
configuration confers focus, order and meaning to the referentiality articulated by
it. In the end, the listener/reader that listens to/reads this narrative refigures it
according to his/her own points of view, beliefs and cultural universe. Says
Ricoeur: “We are following therefore the destiny of a prefigured time that becomes
a refigured time through the mediation of a configured time” (RICOEUR, 1990:
54; author’s italics).
When we consider the narratives produced within the health contexts in this
dynamics, we understand that a patient only makes sense, within the clinical
context, when he is configures by him/herself, and configured and reconfigured by
the health professionals that assist him/her. In this sense, take narrative as a form of
knowledge in the clinical practice is to recognize its mediating character as a
synthesis of the heterogeneous. Also, in Ricoeur’s words, “[in] this way poetic
discourse brings to language aspects, qualities, and values of reality that lack
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access to language that is directly descriptive” (RICOEUR, 1990: xi). According to
the French philosopher, to that it would correspond “a more radical power of
reference to those aspects of our being-in-the-world that cannot be talked about
directy” (RICOEUR, 1990: 80), that is, the eminently ontological reach of these
narrative configurations. Ricoeur develops the idea of an identity between being
and acting in his book Oneself as another, where he discusses the dialectical
relationship between “sameness” and “selfhood” (RICOEUR, 1995: 3). Through
this relationship, it would be possible to speak of a “human action ontology”,
rooted in our being-in-the-world and, therefore, narrable. This would be one of the
possibilities of an epistemic valorization of narrative within the medical context.
4. John Austin and the speech-acts
In his book How to do things with words, a compilation of lectures held by him
at Harvard University in 1955, John Austin, under the Pragmatics point of view,
postulates two series of concepts:
(1) that not all statements are made by its locutor in the sense of “describing”
certain state of things or “simply to state something, but in the sense of doing
something. With this statement, Austin criticizes certain philosophical point of
view according to which every statement would be a declaration, testified as “true”
or “false”, according to empirical parameters. As he says: “We were to consider
[...] some cases and senses [...] in which to say something is to do something; or in
which by saying or in saying something we are doing something” (AUSTIN, 1975:
12; author’s italics). According to this consideration, he willl distinguish between
“constative” speech-acts (those which envision to indicate or report something
related to reality or to inform something) (AUSTIN, 1975: 3) and “performative
speech-acts” (which “do not ‘describe’ or ‘report’ or constate anything at all, are
not ‘true or false’; and the uttering of the sentence is, or is a part of, the doing of an
action, which again would not normally be described as, or as ‘just’ saying
something”, AUSTIN, 1975: 5; author’s italics); and
(2) the distinction among locutionary acts (which have meanings); illocutionary
acts (which have a certain force in saying something); and perlocutionary acts
(which are the achieving of certain effects by saying something) (AUSTIN, 1975:
121; author’s italics).
Within the fields of health sciences, specially in the medical field, the
distinction between constative and performative speech-acts and, beyond that, the
difference among locutionary, illocutionary and perlocutionary acts is grounding,
as long as the medical science seems to us to be pervaded by a cartesian vision of
the phenomena and, consequently, of language. The physician, in his/her clinical,
often believes to be uttering eminently constative statements in constative speechacts. Nevertheless, it urges that this professional understands that not only his/her
patients come to the office uttering illocutionary and perlocutionary statements
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(that speak little or nothing about the empirical reality of his life of health
condition), but also that the same health professional utters, many times,
performative speech-acts in a way that Austin considers a “descriptive fallacy”
(AUSTIN, 1975: 3), under little or no conscience of what he/she is doing.
As discussed later by Paul Ricoeur in Oneself as another (1995), the theory of
the speech-acts was developed from Austin to Searle and was originated in the
distinction established at the first part of How to do things with words. As puts
Ricoeur in a grounding way, the speech-acts, or discourse-acts, as he prefers,
realize themselves according to a dialectics between transparency and opacity:
“Se, com os antigos e ainda com os gramáticos de PortRoyal, definimos o signo como uma coisa que representa uma
outra coisa, a transparência consiste em que, para representar, o
signo tende a se apagar e assim ser esquecido como coisa. Mas
essa obliteração do signo como coisa nunca é completa. Existem
circunstâncias em que o signo não consegue tornar-se também
ausente; ao se mostrar opaco, ele mostra-se de novo como coisa e
revela sua estrutura eminentemente paradoxal de entidade
presente-ausente” (RICOEUR, 1991: 57)
According to this, one of the circumstances of the “sign opacity”, e.g., when the
word is worth it for itself, and not for what supposedly represents, is in the
Austinian circumstances of the illocutionary and perlocutionary acts, which are
crucial for our argumentation.
5. The narrative act
In Time and narrative (II), when he speaks of the articulation of narrative
actions in time, or, in other words, of the narrative configuration, Paul Ricoeur
affirms what follows:
“The enrichment of the concept of emplotment, and
correlatively, of narrative time […] is most certainly a privilege
belonging to fictional narrative, rather than to historical narrative
[…]. This priviledge is due to the remarkable property narrative
possesses of being split into utterance [énonciation] and
statement [énoncé]. To introduce this distinction, it suffices to
recall that the configurating act presiding over emplotment is a
judicative act, involving a ‘grasping together.’ More precisely,
this act belongs to the family of reflective judgements”
(RICOEUR, 1990b: 61).
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From these reflexions on, Ricoeur states a footnote in which he aims to clarify
the concept of “reflective judgement”, based on Kant:
“O juízo determinante se insere inteiramente na objetividade
que ele produz. O juízo reflexionante concentra-se em operações
através das quais edifica formas estéticas e formas orgânicas na
cadeia causal dos acontecimentos do mundo. As formas
narrativas constituem nesse sentido uma terceira classe de juízo
reflexionante, ou seja, um juízo capaz de tomar como objeto as
próprias operações de natureza teleológica através das quais as
entidades estéticas e orgânicas tomam forma”. (RICOEUR,
2010: 103, rodapé)
From these reflexions on, this paper aims to postulate that:
(1) many of the utterances made within the health care context, even though the
strictly scientific thought believes the contrary, are performative utterances and,
according to this, sometimes illocutionary, other perlocutionary acts – which
includes the narrative utterances, e.g., those emitted in order to configure the
stories told by patients to the health professionals and vice-versa;
(2) grounded on the Aristotelian concept of peripeteia, we may say that the
introduction, in a certain story, of an unknown fact or of an intervention that
happens to establish a reversal on the meaning of the story itself is something that
is able to change the course of the events and prepare another kind of ending. This
act, in our consideration, is a perlocutionary speech-act, that kind of act that aims
to the achievement de certain effects by saying something, and the one that we can
define as the narrative act.
Bibliography
Aristotle. Poetics. New York/London: Penguin, 1997.
Austin, J. L. How to do things with words. 2nd ed. Marina Sbisà & J. O. Urmson
(eds.). Cambridge: Harvard University Press, 1975.
Carelli, F. “The other who is me: literary narrative as a form of knowledge”. Paper
presented at the conference “A narrative future for healthcare”. London: 2013.
Meisel, ZF & Karlawish, J. Narrative vs Evidence-Based Medicine – And, Not Or.
JAMA. 2011 Nov 9; 306 (18): 2022-2023.
Ricoeur, P. Oneself as another. Chicago: University of Chicago Press, 1995.
____. Time and narrative (I). Chicago: University of Chicago Press, 1990.
____. Time and narrative (II). Chicago, University of Chicago Press, 1990.
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Fabiana Carelli got her Master and PhD in Literary Theory and Comparative
Literature from the University of São Paulo, Brazil, and has been teaching,
researching and advising Graduate and Undergratuate students at this University
since 2004, within the Program of Comparative Studies in Lusophone Literatures.
Her fields of study include comparative literature and narrative in general,
narrative patterns, orality and literacy, literature and its relations with other forms
of language and knowledge, especially literature and film. Fabiana also
coordinates, with Carlos Eduardo Pompilio, MD, PhD, the GENAM (Group of
Studies in Narrative and Medicine) at the University of São Paulo, Brazil, which
has been researching since 2011 on the subjects of narrative and medicine under
literary, hermeneutic and philosophical approaches.