Choice Gp

Ethics and narrative

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:a

It seems remarkable that ethics was not taught at medical schools until recently. Medicine, as this BMJ shows, is shot through with ethical problems

A prisoner in California wants to donate his one remaining kidney to his daughter (p 7). The surgeons say no, following the first principle of medicinedo no harm. The girl's mother says: “This is a family matter about what is best for this child.” The hospital ethics committee is refusing to be rushed

deCODE Genetics, a private company, has just won the right to build a database of health and genetic information of the entire population of Iceland (pp 11,11. The aim is to understand the genetic basis of disease. The asset is extremely valuable because Iceland has been genetically isolated for 1000years, meticulous medical records have been kept since the first world war, and family trees have been worked out for most of the population. The government has voted for the database almost unanimously, but the Icelandic Medical Association and others are against.

A survey in North Korea has found that 16% of children under 7are acutely malnourished and 59% moderately or severely malnourished (p 12. This is an ethical and human rights issue, not least, because as recent Nobel laureate Amartya Sen has described, famine does not occur in countries with a free press and an effective opposition.

A Budapest doctor was asked on a flight home from Budapest to help with a man who under the influence of alcohol and drugs was running amok. Would you have sedated him with intravenous diazepam? The Budapest doctor did. Now he faces the consequences of the man dying (p 12).

GP choice

These are all ethical stories, and narrative, as a new series reminds us (p 48, is the basis of medicine. Patients come to doctors with stories. If we want to understand the patient then we must listen to the narrative, not just “take a history.” We “dream …remember, anticipate, hope, despair, believe, doubt, plan, revise, criticise, construct, gossip, learn, hate and love by narrative.” The study of narrative offers a possibility of understanding that cannot be achieved in any other way. Yet modern medicine has forgotten the importance of narrative. “At its most arid [modern medicine] lacks a metric for existential qualities such as the inner hurt, despair, hope, grief, and moral pain that frequently accompany, and often indeed constitute [my italic], the illnesses from which people suffer.” Narrative based medicine is not the opposite of evidence based medicine: rather it's an essential accompaniment.

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