The last three articles in this series explored what I have called a “holistic revolution in biomedicine” in the form of narrative medicine—an approach to the clinical encounter designed to address ethical and practical shortcomings of the biopsychosocial approach. It is often confused with motivational interviewing, or a form of psychological profiling or compassionate listening. It is none of these, but it is more, based on a set of carefully honed protocols and principles standing on rich research.

This final part of the series takes a critical look at the relevance of narrative medicine for manual therapy professions, especially in the context of big questions surrounding ethical practice. Why should you use it? Does it matter or is it just another fad? Why is it based on “narrative ethics” (and what are “narrative ethics?”)? If you do want to use it, where do you start?

Do No Harm

Especially since the pandemic broke out, the question of ethics has been repeatedly raised in many manual therapy circles. Whether to practice, how to think about scientific research, opinions on potential treatments, and, of course, the all-contentious vaccine have all been filtered through a lens of what is and is not “ethical.” Ultimately, ethical practice rests on the principle “do no harm.”¹ Obvious, right?

We know in modern communication—from social media sound bites and slogans to in-depth research articles—few things are ever clear. And the first problem with “do no harm” is, what do you define as harm?

Will you do greater harm by refusing treatment to someone in need or by risking viral exposure? To answer questions like this, medical science proposes the idea of relative risk. For example, for someone at risk of stroke, there are algorithms, based on input from thousands of research studies, weighing the relative risk of stroke based on their health profile, compared to treatment options such as taking a daily aspirin to thin the blood and reduce stroke risk (but it might increase the risk of internal bleeding). The word relative here means the risk of stroke relative to the risk of bleeding based on a patient’s profile, so it focuses only on the relationship between those two risks using data supported by evidence. A doctor may prescribe aspirin or not depending on those numbers. If we could use a similar algorithm for the question of relative risk of viral exposure versus the misery of chronic pain that may be alleviated by massage, it might be easier to come to a decision. However, COVID-19 is too new, and too unstable, to have enough data to input about its relative risk. Based on what we know, it seems safer to avoid exposure. But what about that chronic pain patient? Might missing their treatment push them over the edge into opioid abuse? Might it lead them toward damaging behaviors? Might they lose hope of ever getting better? Since we don’t have the numbers to crunch, we must rely on experience and the evidence we do have, and make a professional and informed guess at the relative risk. For most, the harm generated by missing a massage (even for a chronic pain patient) seems minimal compared to the risk of contracting COVID-19, infecting several others, and possibly, indirectly causing the death of one or more people. Again, it seems obvious. Or does it? Currently, the answer depends on what you believe.

People still unconvinced about the dangers of the virus—and that includes many practitioners—might disagree. Others may accept the dangers of the virus, but consider they have taken all necessary safety precautions, thus reducing the relative risk to a minimum. Then there’s the elephant in the room: Is this really more about losing one’s livelihood and professional identity, and less about the ethical predicament? Where does risk cross the line into “harm,” and whose “harm” matters more? Is the inconvenience and difficulty of having to pivot professionally actually “harm”? (What if my family starves?) Is the sense of “abandoning” a patient in need unethical? (What if they run for the opioids? What if they lose the will to carry on?)

I’m using this current and very thorny issue of COVID exposure as an example, but the truth is that in manual therapy there are many similar ethical dilemmas raised, and sometimes, they’re weaponized as arguments for and against particular modalities (Is there evidence?) or preferred approaches (manual therapy sucks!),² and these usually end up as vicious debates that go absolutely nowhere.

These are difficult questions and they cannot, with the best will in the world, be reduced to memes, social media slogans, or a list of “rules” generated by people supporting either ideology. We can shout all we like on the internet, call people out, shut down conversations, and wave around terms like ethical and unethical, follow the science, evidence, and so on, but that doesn’t make us right. It just destroys any possibility of actual communication or learning.

So, how can they be answered? Is it even possible to cut through this noise? And if this isn’t what applied ethics looks like, what does it look like? The good news is that narrative medicine gives us a way to cut through the noise. Warning: it involves openness, listening, and humility. Here’s how it works.

Narrative Ethics (Again)

Narrate means to tell a story. Narrative ethics is checking out an individual story and weighing how the main principles of bioethics apply to the clinical decision-making in response to that story. In Part 1 of this series (“Listen, My Body Electric,” Massage & Bodywork, March/April 2021, page 42), I wrote that narrative ethics starts “with the individual patient and adapts how the medical knowledge base could be appropriately applied to their particular situation.” It developed precisely to deal with situations where there are no clear-cut answers, but where ethical decisions must be made.

If we go back to our example looking at the relative risk of stroke versus blood thinners and relative risk of bleeding, you might note the only thing we factored in was the patient’s health profile and the algorithm based on all known evidence. We did not factor in the patient’s (true) story:

An elderly patient had suffered from mostly controlled ulcerative colitis since early adulthood. They also had partially controlled atrial fibrillation—a heart arrhythmia increasing the risk of stroke. They had recently received an unexpected cancer diagnosis, which caused the arrhythmia to flare, and days later, they experienced two transient ischemic attacks (often considered a forewarning of a major stroke to come). The hospital cardiologist and neurologist both recommended beginning the use of aspirin or a stronger blood thinner, warning the stroke risk was severe, but the patient was fearful of the bleed risk due to the colitis, which had been flaring for some months. On refusing the medication, the patient was dismissed by both specialists as “difficult” and “stubborn.” Both refused the patient’s requests to discuss the relative risks and alternative options. The patient discharged themselves, expressing suicidal ideations. Within a week, they were rushed to the ER with uncontrollable gastric (gut) bleeding and only just survived emergency surgery after massive blood loss. Postsurgery, the patient was sent home with no medication to control their heart arrhythmia and were not consulted about follow-up care. A week later, they had a major stroke. On arrival back in the ER, the resident physician said to the family, “What, atrial fibrillation and no blood thinner? Of course they had a stroke; what, were they stupid?” Following a brain scan, the neurologist recommended permanent, palliative sedation citing—without a patient interview—the patient was not capable of making informed decisions. The family refused. The patient regained full lucidity and pursued physical rehabilitation from the stroke until the other conditions led to their passing.

This sad story is an example of an impossible ethical dilemma for patient and clinicians alike, and one in which nobody listened to the patient. Did these physicians “follow the science” and “evidence”? Indeed, they did. Yet, were the principles of medical ethics respected? Look back at the Summary of Bioethical Principles (see page 47) . They were not. It would take a book to explore whether willful neglect could be considered a factor, but the principles of beneficence, patient autonomy, and justice were all steamrolled by reducing the decision to the result of an algorithm.

How do narrative ethics factor in? If these physicians looked only at the biological factors involved, based on the algorithm alone, their advice was correct. However, bioethics require patient autonomy to be involved, and a correct exploration of the psychosocial factors was warranted based on that preference. This resolves the either/or dilemma because the patient’s preferences, fears, and beliefs should, in this context, have been more important than the result of an algorithm. If the physicians in this story had applied narrative ethics, they would firstly have addressed the patient’s psychological condition and listened to their fears in the context of their psychosocial background. They would have looked at the reasoning and beliefs behind the patient’s fears and decisions. And they would have provided information in a manner that matched the patient’s ability to understand it—that fit with their story. The founder of narrative medicine, Dr. Rita Charon, notes that sometimes narrative practices “are the therapy itself.”⁴ That does not mean talking therapy! It means that helping the patient to understand, face, and think about their options when they are actually in the situation of facing critical illness will help them make the decision that is right for them. Being able to tell their story and discover for themselves where they stand within it is a therapeutic option in itself.

In the example of the manual therapy clinic in the COVID era, this does not mean you should put yourself or anyone else at risk by giving in to a patient’s plea for treatment, but that you should treat their stories, the process of their narration, and your compassionate response to them as part of the treatment—a large part of which is their becoming conscious and able to articulate their interoceptive state, which in itself is valuable to assessment. This can be delivered remotely, as can self-care and self-treatment strategies if a patient is receptive. If they are not receptive, reserve judgment and hear them out. Allow them to find out why they are resistant. This offers a safe middle road that does in fact respect all the ethical principles at stake and gives your patient back their autonomy—which is all too often lost in the face of crushing pain.

Social Justice

A further dimension of narrative ethics and their practical application is the question of social justice. We have become sensitized to the many levels at which inequalities persist in society, and have come to curate and alter the language we use in an effort to promote equality and enshrine these values in society. But words are empty unless we put action behind them. Dismissing a “difficult” patient without looking at their story automatically creates an injustice, even if they are privileged in every other way. It is a unique setting where they are vulnerable; therefore, inequality is built in to the therapeutic encounter. If they are also members of any given minority or specific community with social justice concerns, then not factoring their narrative into the encounter is an act of injustice however carefully we choose our words. These are principles that in many places are fundamental to even getting a place in medical school, yet they often get forgotten in actual practice.⁵

Narrative medicine practitioners make the point that even when applying the biopsychosocial approach to the letter, we are still at risk of error if we look at a patient as a member of a group rather than a unique individual. Several decisions that impacted our stroke patient were made purely on the basis of their age, for example, applying a judgment based on the physician’s (probably subconscious) experience of “all old people.” The patient defied that judgment, but it severely impacted every encounter with their physicians. Held up against the ethical principles, it is clear that it fails them. Likewise, applying any ideology to a therapeutic encounter will apply our own beliefs to the patient, rather than allowing the space for them to present themselves on their own terms. Narrative ethics provides a simple way to avoid this: Make no judgment at all, and allow the patient’s narrative to determine what is and is not real or important to them. Then, present the options available in terms and in a tone that fit their narrative. Attempting to overlay any narrative of our own on a patient encounter automatically continues the inequalities we wish to avoid.

Lost in Translation

Narrative ethics evolved to provide a third way out of these problems, and narrative medicine developed as a protocol to handle a patient’s narrative in a controlled, ethical, and medically sound manner. Neither is widely understood because the words are too long, the ideas too difficult, the training less fun than a weekend spent on another modality. Above, I talk about why things go wrong, and language is where things go wrong: how we talk to each other, and the value judgments we make as we choose our words. What we often forget is the impact of those words.

Conversations about health care take place on four main levels (see page 50). The level at which the conversation occurs will often determine its outcome. Language really does matter (look back at our patient story if you’re unsure why).

The narrative medicine approach to this research article would begin from the position in the last column, but instead of suggesting (practically imposing) pain neuroscience education (PNE) as a decision of the clinician, it would start from the position of the patient by asking questions. For example, “What would you like to know about your pain and how your body produces this feeling?” And “What would you like to say to your pain?” By working through the answers, the patient will already have started to “know about their pain” from the inside, developing interoceptive awareness they can articulate, and the clinician can introduce information as needed, tailored to the patient’s concerns as they arise. This respects all aspects of the bioethical principles, and represents truly individualized, ethical care, which starts in every communication and not just in the clinic.

Summary of Bioethical Principles³

Respect for Patient Autonomy: The final decision must be theirs and made freely

Nonmaleficence: Do no deliberate harm

Beneficence: Have the patient’s best interests as a priority

Justice: Eliminate discrimination in health-care provision on the basis of sex, race, age, beliefs, sexual orientation, or any additional factors

The Four Levels of Health-Care Conversations

Notes

1. See Sasha Chaitow’s “Listen, My Body Electric: Narrative Medicine and the Holistic Revolution in Biomedicine Part 1,” Massage & Bodywork, March/April 2021, pp. 42–49 for a deeper discussion of medical ethics, their development, and their relationship to narrative medicine.

2. Adam Meakins, “Manual Therapy Sucks!” www.thesports.physio/manual-therapy-sucks.

3. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (Oxford: Oxford University Press, 1979); “National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, Department of Health, Education, and Welfare, The Belmont Report,” No. 78-0012 (Washington D.C.: US Printing Office, 1978).

4. Rita Charon et al., The Principles and Practice of Narrative Medicine (Oxford: Oxford University Press, 2016): 129.

5. The Medic Portal, “Medical Ethics: Justice,” www.themedicportal.com/application-guide/medical-school-interview/medical-ethics/justice.

6. M. Richter et al., “Effect of Additional Pain Neuroscience Education in Interdisciplinary Multimodal Pain Therapy on Current Pain. A Non-Randomized, Controlled Intervention Study,” Journal of Pain Research 13 (2020): 2,947–2,957.