Ethics and the Daily Language of Medical Discourse

Ethics and the Daily Language of Medical Discourse Medicine is and always has been a profession that relies heavily on narrative. [1] Considerable writing has been done about the psychiatric case study as literature, but the medical case report can also be approached from a literary perspective and studied with many of the same methodologies that one would apply to a literary genre. [2] The work of the French theoretician Jacques Derrida is especially applicable to medical discourse. In Of Grammatology, Derrida States that words, either written or spoken, are an alteration of an actual presence, that is, the immediate event or experience that is being put into words. [3] Language appropriates and inevitably alters reality by representing it and making it a reflection of the speaker's (or writer's) perspective. In this way, Derrida considers the use of language to be an activity of violence. The French word, with less of a physical connotation than the English cognate, serves to suggest the artificiality of language and the ways it can manipulate reality. (*1) This sense of violence can be seen in the creation of the medical report. At the moment of the medical event, the patient (in most cases) tells his or her "story" to a physician. The physician--for example, a physician in the emergency room--begins to manipulate that narrative by posing certain questions and organizing information to conform to the format of the medical report. If the patient is admitted to the hospital, the ER physician will probably present the "case" at morning report. A new physician, armed with the patient's medical record, sees the patient and adds to that record. The "case" is then "presented" repeatedly at morning rounds or attending rounds--often in the absence of the patient. With each retelling, the presence of the patient is further abstracted. The above description assumes the presence that is verbalized for the first time is the encounter of physician and patient. The presence, however, could also be seen as the experience that brings the patient-to-be, voluntarily or not, to the physician. Distinguishing between these two events, one centered in the consciousness of the patient and the other in the consciousness of the physician, raises an issue central to the theory and practice of medicine: Is the story being told in the medical report the story of the patient's life or of the physician's relationship with the patient's illness? The tension between these two possibilities is a frequent factor in various ethical dilemmas. Derrida remarks that when speech or writing replaces an actual presence, it becomes a "symbolic reappropriation" of reality that can "make one forget the vicariousness of its own function." [4] This raises particular challenges for medicine. The case report, by the very nature of its purposeful, carefully ordered creation, runs the danger of displacing (or replacing) in a reduced form the unorganized, overwhelming amount of information contained in the very presence of the patient. This reduction, in turn, can lead to the depersonalization of the patient. The common criticisms of physicians who refer to "the gall bladder in Room 204" clearly reflect an awareness of the dangers that threaten when words replace reality. Derrida indicates that this symbolic reappropriation is an attempt to organize, and hence "master" the present with words. In the medical report, that present can be either the patient or the patient's illness. In this process, the details of the patient's life that are chosen to be reported by the physician reflect the methods--and values--of medicine, which emphasize diagnosis and treatment and support a belief in the system and objectivity of medical "science." When this happens, the genre or text begins to control its writers. As Derrida observes: [T]he writer writes in a language and in a logic whose proper system, laws and life his discourse by definition cannot dominate absolutely. …