” Narrative Reciprocity By Ri ta C ha ro n

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have become curious about reciprocity within clinical practice. A vast topic that mobilizes considerations of money, knowledge, kinship, power, culture, and uses of the body, reciprocity is a strong means by which to achieve the egality required of just health care. Within health care, reciprocity might enable not only so-called shared decision-making and patient autonomy. It might open the door to mutual acknowledgement of the value of each participant’s beliefs and habits. It might appear as a humble realization that no one understands what health is and a concurrent welcoming curiosity about one another’s conception of how the body and speech and mind work. From the intimate to the international levels of care, such forms of reciprocity may culminate in the radical and powerful state of reciprocal recognition. Only when all participants in a care situation give and receive can the power and resources of all parties be seen to matter. The ethos of reciprocity grounds care in a respectful generosity in which neither the giver nor the receiver is diminished by the gift. Neither confirmed nor reinforced, the power hierarchy is seen through and, perhaps, eventually, undermined or even revoked. This is the way to avoid the curse of slave-master thinking. This is the way to treat all with regard and freedom. With reciprocity, not only do all participants share in the power and the giving; they share in being fundamentally transformed in the process of care. Potentiating each participant, reciprocity may lie at the heart of narrative ethics and perhaps is even the ultimate goal of a narrative approach to ethical deliberation. In this short essay, I will focus on one aspect of reciprocity in health care: the narrative and potentially recip-

Rita Charon, “Narrative Reciprocity,” Narrative Ethics: The Role of Stories in Bioethics, special report, Hastings Center Report 44, no. 1 (2014): S21-S24. DOI: 10.1002/hast.264

rocal nature of attention in health care. A critical element in the development of therapeutic alliance, clinical accuracy, and effective practice, attention requires a donation of the self as a vessel into which can enter that which is perceived or, from the other side, a penetrating of that which is perceived so that one sees it from within its own vessel. It is a muscular form of beholding. Paul Cézanne writes in a letter to his artist colleague Emile Bernard that “[o]ne should penetrate what one has in front of one.”1 Attention involves ingress, indwelling, habitation, and, on the other side, welcome, exposure, hospitality. One enters the house of the other, however that might be understood, bows to its rules, experiences its ways, surrounds oneself with its climate. Not just a matter of imagining or fleetingly “adopting” the perspective of the other for the sake of correcting one’s own, attention brings alive the one for the other. It is a form of suscitation—one breathes with the other, animating the other, while the other is still already alive. When reciprocal, this indwelling and animation happen simultaneously for both. Not mystical or goofy, the process of attention inheres in concrete observable situations in which one subject accompanies another with curious, selfless commitment. In William Maxwell’s novel So Long, See You Tomorrow, the ten-year-old unnamed protagonist walks slowly alongside his young grieving father, the son’s arm around the father’s waist. They have just lost their mother and wife to the flu pandemic of 1918. The boy has to figure out in which direction the father will walk—from the dining room to the living room, from the living room to the library—as if they partake in a slow mournful dance in which the son lets the father lead and the son lovingly follows. “I only tried to sense, as he was about to turn, which room he was going to next so we wouldn’t bump into each other. His eyes were focused on things not in those rooms, and his face was the color of ashes.”2 In this scene of pain and

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loss, the danse macabre allows the little boy to ally with or even, maybe, support his father. I recently had the privilege to read the manuscript of a midwife’s memoir, in which she describes her practice of knitting a baby cap while sitting with the birthing woman. Throughout the pulsatile stages of labor’s contraction and relaxation, when her presence is not needed at the bedside, the midwife sits some feet away from the woman, knitting. She configures the soft pliable cotton yarn into a garment of warmth and protection for the child yet to emerge from his or her swimming dark, configuring as well a purled texture of anticipation, readiness for whatever comes, realism, and hope. That knitted cap will stand as not the symbol but the evidence of the midwife’s steady, wordless attention throughout the rapids of birth.3 What is at stake in both these examples is presence, recognition, and donation of the self to the situation of the other. It is a supple habit with which one perceives, enters, echoes, and then, as a result, understands the position of the other. Seeing a patient in clinical practice does not automatically result in attention. As a general internist in a busy urban primary care clinic, I have to do many things at once every time I welcome a patient into the room. I am of course embroiled in the necessity to act. I am confronted with the need to analyze, to judge, to decide. I am beset with states of uncertainty, doubt, and with the feeling of stupidness, disappointment, admiration, triumph, or love. Artist and aesthetic theorist Roger Fry, member of Virginia Woolf ’s Bloomsbury circle whose biography Woolf wrote, writes, “The more poignant emotions of actual life have, I think, a kind of numbing effect. . . . [T]he need for responsive action hurries us along and prevents us from ever realizing fully what the emotion is that we feel. . . . It is only when an object exists in our lives for no other purpose than to be seen that we really look at it.”4 So in the midst of my clinic session, I’ve taught myself to attend—to behold and to separate the beholding from the acting. I literally sit back in my chair. I do not turn the computer on at the beginning of the visit. I do not write or type. When I gaze at my patient, I find that I do what I do while gazing at the Baie de Marseilles, vue de l’Estaque of Cézanne, while attending a jazz piano recital of Fred Hersch, or while standing at Ground Zero. I receive these works or this place and am summoned out of my ordinary self by virtue of their integrity, their solemnity, and their beauty. This happened recently in my practice in the care of a couple from Albania. Mrs. N. suffered from a dense hearing loss in her left ear. The social worker and I worked long and hard to get bureaucratic clearance for my patient, who had neither insurance nor U.S. citizenship, to get all the diagnostic procedures required for the evaluation by an ear, nose, and throat specialist. The couple barged into my ofS22

fice some weeks later, both of them weeping, traumatized, having been told at the ENT clinic that Mrs. N. had a brain tumor. I knew that the ENT clinic was unlikely to have an Albanian interpreter and that my patients’ command of English might not have been adequate for absorbing complex clinical news from strangers. I quickly pulled up the ENT clinic note and realized they told the couple that the patient needed to undergo an MRI to find out if she had a brain tumor. I was able to convey this news clearly to the couple, and the MRI soon undergone proved that she did not have a tumor. In the process of this whole transaction, I became very much affiliated with both husband and wife, taking their side in the contretemps with the ENT clinic. As I often do, I wrote a description of this train of events in the context of an already complex clinical relationship with Mr. and Mrs. N. I was able, by virtue of writing it, to understand how powerful for me had been the experience of caring for this couple over the past several years. I discovered that writing not only helped me to see the couple with clarity but also enabled me to see myself in the mirror of their gaze as a dependable and affiliated clinical partner. I showed the couple what I had written about us, explaining that they had helped me to understand something about myself in the process and that the writing functioned as a self-portrait as well as a clinical portrait of the three of us. They were surprised and solemnly excited to be engaged in this process with me and were happy to agree to my suggestion that I submit this short essay for publication in a medical journal.5 I have incorporated writing into my practice in any number of forms, from primary-process writing about clinical situations that helps me to expose my thoughts (and that no one sees but me and, perhaps, a trusted reader) to extensive narrative descriptions of clinical encounters that I mail to patients or read aloud to them on subsequent visits. Often, patients write back in various forms. I typically give patients copies of the notes I write and upload into the electronic medical record, so that they not only have an ongoing chronicle of what I think is happening in their care but also so that they can correct, contest, enrich, or enlarge that which I have tentatively understood about our work together. I am coming to some understanding of what happens in the course of my clinical writing and why it might support attention and, in turn, why it may permit reciprocal recognition. No matter who holds the pen, the creative act of writing brings the perceiver in unique contact with the perceived. In any act of representation, whether writing or painting or sculpting or composing, one surrenders oneself as a maidservant to the observed. One lets oneself be taken up and used in the service of the representation. The resultant representation is an expression of the consequence January-February 2014/ H A S T I N G S CE NTE R RE P O RT

By writing about situations with patients, I have seen the almost inevitable dimension of reciprocity. As I gaze at a patient, trying to recognize his or her situation, I am “gazed back at,” recognized as someone who can recognize. of the beholding. No act of beholding and representation is replicable, for the outcomes of such acts depend on the perceived, the perceiver, and the perceiving situation—its temporal, spatial, and meaning-making situation. Without the representation, there can be no attention. This is true and not often thought about. Philosopher Nelson Goodman reminds us that what we look at when we look at an object is “the object as we look upon or conceive it, a version or construal of the object. In representing an object, we do not copy such a construal or interpretation—we achieve it.” 6 While taking a break from writing Roger Fry’s biography in 1939, Virginia Woolf wrote a memoirish recollection called Sketch of the Past. In it, she describes her felt experience of writing fiction: “[O]ne day walking round Tavistock Square I made up, as I sometimes make up my books, To the Lighthouse; in a great, apparently involuntary, rush. One thing burst into another. . . . I wrote the book very quickly; and when it was written, I ceased to be obsessed by my mother. . . . I suppose that I did for myself what psycho-analysts do for their patients. I expressed some very long felt and deeply felt emotion.”7 So Cézanne, Roger Fry, and Virginia Woolf agree that the artist is doing something with and to actual life. These artists are not copying actual life. Instead, they are accepting the value of their own experience of actual life. They are, in a true manner of speaking, living it. The imaginative life is not a cul-de-sac to the actual life or an elective pleasure in which some indulge. It is the means by which human beings know what they are doing in life. It is the means by which we live. When events of perception and representation are mutual, with each participant willing to penetrate and accompany the other, reciprocal recognition can be achieved. Mr. and Mrs. N. helped me to articulate the mutuality of recognition, what Hegel alerted us to in The Phenomenology of Spirit and what Hannah Arendt, Simone de Beauvoir, Judith Butler, and Eve Kosofsky Sedgwick, among many, have written about since.8 Furthermore, it may be that representation not only helps develop attention and reciprocity but also establishes the capacity for attention and reciprocity in the first place. Gradually, my practice of internal medicine has invited me and my patients into scenes of reciprocal recognition. By writing about situations with

patients, I have seen the by now almost inevitable dimension of reciprocity—as I gaze at a patient in an effort to recognize his or her situation, I am “gazed back at,” being recognized as someone who can recognize. This process launches me on an ever-building spiral of self-making or, rather, self-seeing while repeatedly excavating the capacity within myself for future acts of the recognition of others. Who knew that taking the MCATs would be the prelude to this high-stakes, unending, perilous, luxurious process of sight and growth and being that is at the same time right and fitting and helpful to others? Not only the isolated moment of recognition is reciprocal. In a well-going process—be it a clinical relationship, a teaching and learning relationship, a collaborative partnership, a reader-writer relationship, or a love relationship—an ethos of reciprocity offers a radical alternative to the framework of unequal power or resources. The ethos of reciprocity frees us from the dilemma of “for whose good?” Whether one examines my clinical relationship with Mr. and Mrs. N. or the decades-long international health partnership between Indiana University Medical Center and the Moi Hospital in Kenya, one conceptualizes all participants as givers and receivers, as each having a fundamental stake in and contribution to the engagement and each having a means of fundamental growth by virtue of the process.9 A radical reciprocity illuminates and helps one to navigate the deadly shoals of cultural superiority, beholdedness to deep pockets, imperialism in its many guises, the use of others, the 1 percent. The subaltern position need not, perhaps, endure.10 The last time Mr. and Mrs. N. were in my office, Mrs. N. shyly showed off her new hearing aid and her new hearing, while proudly regaling me with the stories of her recent hand-over-heart taking of the U.S. citizenship oath. These ambulatory thoughts suggest to me an obligatory component of representation in our practice of narrative ethics, not as a means of reporting or recording but as an aesthetic act of discovery. Although routine clinical medical practice may not be yet ready to establish the place of creativity and, even, beauty in its realm, the practice of ethics, informed as it is by introspection, an awareness of values, and an acute attention to power dynamics, might be open to suggestions of representational avenues toward a healing reciprocity. Beauvoir’s ethics of ambiguity, Sedgwick’s

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reparative reading, and Cézanne’s aesthetic penetration together build toward a powerful, age-old path, through practice, toward humble sight and welcomed sighting. The practice of narrative ethics, then, might be contemplated as one that rests on the telling, the telling that rests on the listening, and the development of the great skills necessary to tell and to listen. My own narrative medicine practice builds on my continued schooling in close reading and creative writing so as to receive what others tell, so as to represent—and thereby undergo—that which I live. These are the skills fundamental to narrative medicine as I practice it and as our growing discipline teaches it. By extension, perhaps, a narrative ethics may well become one characterized by the telling, the listening, the giving, the receiving that mark and create the permeable boundaries between sickness and health, that mark and create the permeable boundaries between self and other. I cannot predict where these thoughts will lead us. I have been taught through the repeated experience of being summoned out of my ordinary self by beholding a patient in his or her full situation that the care of the sick is a work of art, a work of art requiring all the creative powers of sight and discovery at my disposal. Gradually, my narrative medical practice has shown me that the resources of the self mobilized by the care of the sick do not stop with scientific knowledge and technical skill. The care of the sick recruits one’s always new capacity to behold without using up, to become an instrument for the other’s use. The blessing over the Hanukkah candles, those candles that mysteriously continued to glow long after the lamp oil ran out, can rest as our final shared thought: “These are not to be used for ordinary purposes. We are only to behold them.” No exploitation, no blowing out, no stealing of light, no lighting for self—the attention of a narrative ethical practice develops on behalf of the one who seeks

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care and is purified and mirrored and magnified and made to last forever. Acknowledgment

Rita Charon’s time is supported in part by National Institutes of Health grant R25 HL108014. 1. P. Cézanne, “Cézanne’s Letters to Emile Bernard,” in The Courtauld Cézannes, ed. S. Buck et al. (London: The Courtauld Gallery in Association with Paul Holberton Publishing, 2008), 14665, at 153. 2. W. Maxwell, So Long, See You Tomorrow (New York: Random House/Vintage, 1996), 8. 3. D. Tabas, “Belly Buttons and the Torah: A Midwife’s Metaphorical Guide to Finding Holiness and Wholeness Within” (unpublished manuscript, 2013). The author has given me permission to cite from this work. 4. R. Fry, Vision and Design, ed. J. B. Bullen (Mineola, NY: Dover Publications, 1981), 19, 18. 5. R. Charon, “The Reciprocity of Recognition—What Medicine Exposes about Self and Other,” New England Journal of Medicine 367 (2012): 1878-81. 6. N. Goodman, Languages of Art: An Approach to a Theory of Symbols (Indianapolis, IN: Hackett Publishing Company, 1976), 9. 7. V. Woolf, “A Sketch of the Past,” in Moments of Being, 2nd ed., ed. J. Schulkind (San Diego, CA: Harvest/HBJ Book, 1985), 81. 8. G. W. F. Hegel, The Phenomenology of Spirit, trans. A. V. Miller (Oxford: Oxford University Press, 1977), 111-12; J. Butler, Giving an Account of Oneself (New York: Fordham University Press, 2005); H. Arendt, The Human Condition (Chicago: University of Chicago Press, 1958); E. K. Sedgwick, Touching, Feeling: Affect, Pedagogy, Performativity (Durham, NC: Duke University Press, 2003); S. de Beauvoir, Ethics of Ambiguity, trans. B. Frechtman (New York: Citadel, 1976). 9. R. A. Unmoren, J. E. James, and D. K. Litzelman, “Evidence of Reciprocity in Reports on International Partnerships,” Education Research International no. 603270 (2012): 1-7. 10. G. C. Spivak, “Can the Subaltern Speak?” in Marxism and the Interpretation of Culture, ed. C. Nelson and L. Grossberg (Urbana, IL: University of Illinois Press, 1988), 271-313.

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Narrative reciprocity.

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