University: Virginia Tech
Description of Work:
The outbreak of measles at Disneyland in early 2015 brought vaccination controversy to the forefront of the news, and reporting has ranged from fearful concern to vitriolic accusation. It has been a reminder that a discourse of crisis pervades media reporting on and public health responses to both vaccination and infectious disease. Given that vaccination rates remain high in the U.S., what accounts for the current discourse of crisis concerning vaccination and, in particular, antivaccinationism? Is the current period anomalous in the apparent widespread distrust of vaccination? If it is, how have historical conditions changed perceptions of vaccination? If it is not, how should we understand the public debate about vaccination as we experience it today—in the media, in the doctor’s office, on the playground, and on the Internet?
My project, Vaccination and Vaccine Skepticism: A Rhetorical History, aims to address these broad questions by examining public controversies about vaccination as they have emerged historically in the United States. Doing so allows us to understand vaccine skepticism as both longstanding and historically specific. The discourse of crisis that characterizes our own era is specific to contemporary biomedical and social concerns, but also relates to an extended history of resistance to vaccination that does not easily fall within the catch-all category of scientific illiteracy, as many would suggest.
The project that I submitted for consideration to this symposium concerns the development of the concept of rhetorical medicine, which is linked to my project on vaccination resistance through the elaboration of rhetorical approaches to understanding medical discourse and practice.
From Narrative to Rhetorical Medicine
Originally offered by Rita Charon in a series of articles and then her book Narrative Medicine, the practice of narrative medicine addresses what Charon and others see as dehumanizing tendencies in contemporary medical practice. Charon argues that narrative methods can help bridge divides between doctors and patients. The purpose of her published work is to demonstrate the better care that physicians can offer if they are competent in narrative. Competency in narrative is developed through careful reading and writing—that is, skills developed in the literary classroom, although the program in Narrative Medicine at Columbia University’s College of Physicians and Surgeons, where Charon’s program is located, also includes courses in art appreciation and social sciences.
Narrative medicine aims to bridge divides between doctors and patients that are created by technologically-oriented medicine. Yet narrative medicine embodies within it the tendency to idealize the power of literature to humanize physicians. This tendency toward idealizing narrative knowledge emerges in Rita Charon’s work. In “Attention, Representation, Affiliation,” she writes, “[Henry] James called it ‘the great empty cup of attention.’ How did he know about that emptiness? How did he know that, in order for one to heal the other, one has to empty oneself of thought, distraction, goals? One has to donate oneself as the amphora, the clay vessel that resonates with the sound of the breath, the sound of the self. . . . Do we not feel exhilarated when we can achieve this empty attention, when we can place ourselves at the disposal of the other, letting the other talk through us, ventriloquize, find the words in which to say that which cannot be said?” (ARA 263; emphasis in original). What I am calling “idealization” is the reverence accorded a famous author and the idealized image of the doctor as empty vessel waiting to contain the story of the patient. In the final sentence, the notion that narrative medicine is for us, those who are “exhilarated,” demonstrates that from the vantage point of narrative medicine, the doctor is represented as a listener-priest, brought to new heights of awareness by the power of selflessness. The practice of narrative medicine as the enactment of becoming that “empty chalice” is an idealized practice.
This idealization of the role of narrative to repair the problems of medicine keeps the focus of those problems on the doctor-patient pair and suggests that the quality of the relation between the two is the primary measure of medicine’s success. Fusion of the goals of doctor and patient thus appears to be the relationship sought. Thus, while the features of narrative that are coincident with medicine or through which practitioners can improve their skills in affiliating with patients appear to demonstrate the value of narrative medicine itself—that is, because there are features of narrative that seem to coincide with features of medicine and because attention to narrative competency appears to elevate understanding of those same features in medicine—narrative medicine also invests itself in a model of medical repair and compensation.
Rhetorical medicine emerges from the advancements of narrative medicine and reorients it toward a more explicitly rhetorical focus. Because rhetoric encompasses narrative (that is, narrative is a rhetorical feature of texts and writing), rhetorical medicine can be understood as a broader effort that includes narrative medicine within a range of approaches. Narrative is a structure of textual organization. As such a structure, narrative organizes texts in particular ways. Thus, narrative is a particular kind of framing for the communications that emerge from or are relevant to the clinical encounter, but it is not the only rhetorical frame that might be pertinent.
Rhetorical medicine, like all forms of rhetorical practice, requires listening as an element of communication—indeed, rhetorical listening is a developing concept in the field. For Krista Ratcliffe, rhetorical listening is a way to focus on understanding that does not overly homogenize differences nor overly emphasize similarities. Rhetorical medicine requires rhetorical listening as a basic competence and, importantly, it replaces empathy, or affiliation, with improved communication as a goal of the doctor-patient relationship. It also requires an understanding of key features of the rhetorical situations affecting doctors, patients, and allied health care professionals.
Rhetorical competence therefore involves the capacity to identify and understand the rhetorical situation, which is defined by the exigence, constraints, and audience of any given rhetorical encounter. A rhetorical situation is one in which there is a problem calling for a discursive response (Bitzer). Because communication is necessary to solve the problem, difference is implied as an element of the rhetorical situation. The clinical encounter is a rhetorical situation par excellence.
Narrative structures a relation between two people—the storyteller and the listener. A rhetorical approach brings in the situation of culture and brings it to bear on the clinical encounter. To be an effective communicator (which means also to be a good listener), the health care worker must understand the constraints that make up that clinical encounter. The constraints include the belief systems of the patient and the health care workers as well as the structural organization of health care—short clinical encounters, a maze of bureaucracy, lots of technology and testing, and uncertainty masked by complex treatment protocols and vague statistical language about prognosis.
Thus, hidden within a narrative approach to clinical knowledge is a rhetorical one—reading narratives and becoming competent in understanding their construction is a way to learn about rhetorical situations. Characters are always moving in and out of rhetorical situations—situations that demand speech or discourse in order to solve a problem. Narratives themselves can constitute rhetorical situations. Narrative knowledge is necessary to understand the rhetorical situation—but it isn’t enough, or it isn’t the only way.
This paper develops these themes with a deep reading of Rita Charon’s Narrative Medicine and ancillary texts defining this burgeoning movement within medicine, realigning narrative medicine with rhetorical theory and practice and thereby introducing rhetorical medicine.