Dawson S. Schultz

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

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as clinical phronesis, i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of virtue ethics, yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their disengaged form (reflecting the malaise of modern medicine). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the silent world of doctor and patient — provides may deny or refuse any given connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of calculative reasoning only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can save the life of medical ethics — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can prevent the death of medical ethics.

This dissertation critically examines two possible approaches to interpreting the meaning of freedom--"reason" and "dread." My thesis is, first, that, although freedom has most often been understood conceptually in the reflection of Western ethics in terms of reason or rationality, this framework nonetheless partially obfuscates "what is going on" primordially in the experience of freedom, that is, in the eventfulness of freedom's own occurrence in the human world of life and death; secondly, that this occurrence can be understood more fully in terms of the event of its own actual occurrence--its own eventfulness--than in rational terms; thirdly, since the context or framework of freedom's occurrence is dread--the felt immediacy of the threat of nonbeing in existence --its significance can be understood more completely in terms of dread than reason. ;Specifically, several seminal interpretations of freedom--those of Aristotle, Kant, and Paul Ricoeur--are critically accounted and some of their difficulties are described. Then a novel account of "freedom in dread" is formulated in reference to the Grand Inquisitor's understanding of this phenomenon in the "Legend" from Dostoyevsky's The Brothers Karamazov. The two characters are shown to symbolize two radically opposed "ways of freedom" which I call "Worship" and "Risk" . Worship and Risk are characterized as two primordial ways of responding to freedom as dread, that is, to the terrible eventfulness of our own occurrence in the world. Several implications of these two "ways of freedom" are explored and this conception is compared to the three interpretations of "freedom in reason"--those of Aristotle, Kant, and Paul Ricoeur