Asking the RightQuestion about Pain:Narrative and PhronesisArthur W. Frank
A project shared by humanities in medicine, bioethics, socialscientific studies of medical practice, and related studies can be summarized by the following question: How can we reduce the gapbetween suffering caused by the body's deteriorations, whether theresult of illness, disability, or aging, and the total suffering that attendsthese deteriorations? In approaching this question, a significant clinical,scholarly, and personal ideal is thinking with a story, as opposed to themore conventional academic and scientific approach of thinking aboutstories.' Thinking about stories is useful, and I will engage in that kindof thinking in this article; but a problem arises in what gets lost whenstories are only thought about.
Like most distinctions-including my distinction above betweennatural and socially incurred suffering-thinking with and about storiesmarks a continuum, not a dichotomy, but the terms suggest realdifferences of interest and method. Thinking about stories impliesmaking a story the object of the gaze of an expert who produces ananalysis. Analysis requires stable objects, so the story that exists in thetransitory activity of telling becomes fixed as a narrative text. Thinkingwith stories involves a hermeneutic of mutual engagement; a story isone aspect of a complex of nested relationships that remain in process.Thinking with stories involves taking one's own place in that process,in which all participants will continue telling stories about each otherand about themselves?
In thinking with stories, one story necessarily leads to another, justas the attempt to define a word leads to other words that requiredefinition. A person stops looking up subsequent definitions not because some end has been reached, but because she or he has the feelfor the word that started the process-or has simply had enough. A
story about thinking with stories can be crafted to provide an illusionof closure, but at the end it would be more honest to continue on toother stories. At the end of this article I create recognizable closure bythe academic device of giving the preceding process a name with aphilosophical pedigree. This ending is only another sort of beginning,though the reader will probably have had enough and will appreciatemy stopping.
In this article, I want to think with a story specifically about pain.The story is told by Vanessa Kramer as part of a speech she gave, inthe mid-1990s, to a group of cancer survivors; Kramer herself was livingwith metastatic breast cancer. Within her own story Kramer narrates astory that her aunt told her, and here we find the nesting of stories andrelationships. Kramer tells the story as a conversation with her aunt; ineffect, she brings her aunt to the meeting. Her aunt's story is, in onereal sense, that woman's own story. But in just as real a sense, the storyserves as Kramer's medium for expressing what is happening to herself,and it offers her listeners a way of organizing their experiences. Thequestion of whose story this is becomes complicated. Ultimately, thestory seems to be no one's own; it exists amid all these relationships,which the story itself works to shape.
Kramer's aunt-to whom she does not give a name, so I will notname her either-has just had exploratory abdominal surgery, whichdiscovered cancer so extensive that she was told "nothing could bedone.":' The story, presented here as a fixed text, describes her postsurgical treatment:
It was late in the evening, and the staff was efficiently bustlingaround her [the aunt's] bed setting up an automatic dispenser forpain control drugs.... Everything was in place, the staff went away,and my aunt was left to ride the roller-coaster of her own thoughts,but the first time she pushed the button, the machine, to use herwords, "blew up."
This event produced prompt and intense activity. "Do youknow," she said, "I had six of them in there ... all trying to fix themachine. They seemed to take an eternity." (When we are in greatpain like this, eternity has a way of opening up under us, and overus, and to the side of us.) In the end, the machine was deemedimpossible to repair, and the crowd of people left, wheeling it withthem, leaving my aunt alone. "They were all totally avoiding me,"she said. "It made me feel so alone, so utterly alone. I felt as thoughI must be the only person this had ever happened to."
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After a while a nurse came in, all efficient and professionalwith a questionnaire. This was presumably a standard questionnaireto establish a course of pain control. My aunt said, "You'll neverguess what the first question was: 'What do you perceive to be thesource of your pain?'" My aunt felt as though she had been caughtin an absurdist play. How could the nurse not see? There's alwaysphysical pain after this kind of surgery. There's always emotionaland psychological pain when treatments fail.
But here the thread of mortality that is within all of us, all ourlives, was emerging and becoming clearly apparent in her. Everyonein the room knew it was so. But once the technology broke down,from my aunt's point of view, that particular group of health careprofessionals was left resourceless. As my aunt said, "No one madeeye contact with me. No one reached out to touch me."?
That final, poignant line-"No one reached out to touch me"expresses the social increase to suffering. Kramer's aunt is dying, andboth the physical disease processes and her sense of her life coming toan end cause suffering. My concern is how the way she is treated-theacts of omission and commission at her bedside-increase her suffering.How do the good people at the bedside, and I assume they arc goodpeople who went into medicine because they wanted to reduce suffering, end up acting in ways that make things worse?
Thinking About the Story
When I wrote The Wounded Storyteller in 1995, my purpose was toenhance the capacity of clinical professionals to listen to stories likeKramer's. To that end I proposed a typology that would give workingclinicians a sense of what to listen for. Frameworks facilitate thinkingabout. Without a framework to contain it, a story can be easily dismissed as a one-off occurrence, a sad tale that has little claim on thelistener. Claims can be instrumental, calling on the listener to dosomething, but the more consequential claims require the listener tobecome someone different, to understand his or her place in the worlddifferently, because he or she now exists in a new web of relationships.When the story's claim becomes personal, thinking shifts from about towith, and the framework that enabled the initial listening can fade intothe background.
The Wounded Storyteller proposes that particular illness storiesweave together three recognizable types of narrative-restitution, chaos,
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and quest-one of which usually predominates. Kramer's aunt is inpain, and medicine promises to restore her to her previous, pain-freeexistence. That narrative of restitution, including the means of achievingrestitution, shapes what people are able to experience at the bedside.What does not fit the narrative does not register as experience; whatfalls outside of narrative becomes as invisible as Kramer's aunt, whosays that the staff was totally avoiding her. She seems to have droppedout of their narrative even before the story of the pain-medicationmachine begins; once the narrative centers on restitution, the machinebecomes the central actor and the object of the staff's attention. Theirstory is that the machine serves the end of restoring the patient's painfree existence, but really the patient is something that the machinerequires, not vice versa.
The machine's breakdown is more than mechanical; it is a narrative breakdown as well. Mechanical breakdowns can be fixed with morework, but narrative breakdowns have the effect of making any furtheraction seem impossible. No wonder the staff runs away.
Restitution stories can represent the noblest aspirations of medicine, but they cause trouble when they deny mortality. Daniel Callahanoffers a fine example when he quotes a biotech CEO saying, "Death isa series of preventable diseases."> What we see at the bedside ofKramer's aunt is the narrative imperialism of restitution; no other storyis allowed into the room. That imperialism creates this absurd scene ofthe nurse asking a patient who has just had major surgery and has beentold that she will die sooner than later from cancer what she perceivesto be the source of her pain.
Asking about the perceived source of pain can be a good question.Like any tool, it is perfectly useful in the right situation. But here thequestion is applied indiscriminately, asked in the wrong way and at thewrong time. TI,e nurse does not speak from her own perceptions andsensibilities. Instead, she recites a script that includes the question,"What do you perceive to be ... ?" She follows this script instead ofattending to her patient. Medicine likes to use this word, "attending,"but turns it into a noun, losing the moral significance of the verb, "toattend to," in the sense of paying close attention.
Those among the medical staff cannot see how absurd they lookto the patient because they cannot imagine the story from her perspective. This lack of narrative imagination generates mutual alienationbetween patient and caregivers. Each appears strange to the other: thepatient finds the staff absurd, and they would probably respond bysaying that her reaction fails to understand their work. We can suppose
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that room also contained some clinicians who did imagine differentnarratives and did feel absurd actirig as they did, but who believed they
had to remain silent. They are alienated from their profession and,ultimately, from themselves.
The bedside scene totters on the edge of being a chaos story, thesecond general type of illness narrative. In chaos, time collapses into aneternal present-the eternal present that Kramer describes is one ofacute pain. Spatial relationships also collapse. People who are living inchaos experience others coming at them, pressing in on them withdemands that seem threatening. The temporal sequence of these demands is incessant: before one can be responded to, another is asserted.The world of chaos is one in which order and control are lost and havebeen replaced by jabbing, aggressive, continuous demands, withoutsequence.
Narrative seeks to redeem life and pain from chaos by creatingsequence. Frank Kermode writes that narrative is the attempt to humanize time "by giving it forrn.:" In narrative form, one event seems tobelong before and after others-not to happen randomly but to makesense exactly there. Temporal sequence implies causal priority: oncenarrative sequencing asserts that one thing belongs first, another thingcan be deferred until later; it can wait, and the possibility that thingscan wait humanizes life.
Chaos stories are antinarratives in that they are told from withindehumanized time-time without order and thus without meaning. Fortunately, Kramer's aunt seems too wise and possessed of too good asense of black humor to fall into true chaos. When she turns herexperience into the telling of a story, and when her equally wise niecevalidates the story, their relationship of storytelling humanizes the chaosof what has happened to her. Through her story she reinserts herselfinto a humanized temporality and gives herself reassurance that she hastime. Teller and listener together transform medical insensitivity into anabsurdist joke. Later, when Kramer retells her aunt's story to a meetingof cancer survivors, she implicitly teaches them how to tell their ownstories and keep themselves out of chaos. Stories rehearse future eventsas much as they recollect what is past? By "rehearse," I mean thatstories anticipate which narrative frameworks will be useful in shapingfuture events so that we can survive them.
The third kind of general illness narrative is the quest narrativein which people understand illness as a source of some insight. Thisinsight has value not only for the person who acquires it at great costbut also for the healthy, those who live cocooned in the belief that only
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others exist on what Susan Sontag calls the "night-side" of life." Thequest narrative is animated by the belief that healthy society suffers butdoes not realize it is suffering. The guest aspires to bring to both ill andhealthy the insight that it is an illusion to divide life into two sides,light and dark or whatever set of metaphors one chooses. The "threadof mortality," as Kramer calls it, persists, always part of life, and ifpeople could learn to live with it instead of living in fear of recognizingit, then not only would health care be humanized but life in generalmight become a great deal more humane. Death is not a series ofpreventable illnesses; rather, life is an unpreventable death, and that isall right. In quest stories, the person who has come closest to deathreturns to tell us not to be afraid; death is as necessary to our renewalas sleep and winter.
This quest spreads to all who recognize the story's claim on themand who witness the story by continuing to tell it. No story is anyoneperson's own because the story is always already told in a relationship.When we acknowledge that the story has a claim on us-and thepronoun has to be first person-then we cease thinking about the storyand start to think toitlt it. The analytic framework fades into thebackground, and one story leads to another.
Fear and Redemption in the Quest
My recent thinking about stories revolves around what I call theG twins. (I learned from The Wounded Storyteller that if you proposeanything that looks like a typology, shape the language so that commentators will have to realize it is a trope, not a theory.) The G twinsare rarely all that is going on in a story, but they are usually animportant part. One G stands for the monster Grendel from the epicBeowulf and the other stands for the Holy Grail. Grendel and the Grailare not types of narratives so much as they are presences or forces thatpervade many narratives, taking different forms. Grendel representswhat we believe can destroy us.? The Grail represents some force thatcan heal and redeem us. We fear Grendels; we desire Crails,
In the epic Beowulf, what animates the action is that every nightGrendel creeps into the safe space of the common hall, where everyonesleeps, and carries off one of the warriors. Beowulf's guest is to killGrendel and restore safety to the hall so that the warriors can sleep inpeace. The epic might be a restitution story if it ended after Beowulf'ssuccess, but it includes a second episode in which the older Beowulf is
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killed by a dragon. POl' the ancient Anglo-Saxons. any restitution wasunderstood as provisional. At best, the hero can keep chaos at bay, andeventually that work will kill anyone. All gods have their twilight.
Somewhere in almost every story is some force bringing with itthe possibility that the events in the story might develop in a way thatwill destroy the characters. That force has to be kept away, at adistance, out of the safe space within which there ought to be light andkinship. Among those of us living in relatively secure, first-worldenvironments, serious illness that incapacitates or kills is the Grendelthat many people fear most often.
If most stories have some Grendel force, they differ crucially as towhether or not they can name their fear. Stories like Beowulf dealexplicitly with the intruding force of loss and suffering; they give thatforce a name, and naming humanizes fear. Other stories refuse to namethe threatening force. These stories are performed in order to keep theGrendel force outside of the telling of the story and thus beyond thehorizon of articulate recognition of teller and listeners. These stories areartfully constructed to prevent anyone from having to admit to anyoneelse what each recognizes but remains silent about; it is as if theintegrity of the storytelling community depends on not naming theGrendel force. That tacit agreement to silence is what Vanessa Kramerdescribes going on among the professionals at her aunt's bedside.
In that postoperative setting, the questionnaire about pain perception, however valid it might be for some purposes at some other time,works as a narrative device that judges stories to be acceptable only ifthey do not name what they ultimately fear-mortality-and only ifthey speak of what they immediately fear-pain-in a language dissociated from emotions like grief. The recognition of mortality and theaffect appropriate to that recognition would require a completely different storytelling scene.
The other G twin, the Holy Grail, represents some lost object that,if found by the right person, has the power to heal and to redeem. InGrail stories, some crisis animates the hero's quest to find the lost objectthat is the sale means to remedy the trouble. Grails take multiple forms,giving plots different shapes. A variation relevant to Kramer's story isthe plot of The Lord of the Rings. The ring is an inverse Grail: life is goodas long as the ring remains lost; as soon as it is found, it corrupts anddestroys. The quest is not to find the ring but to destroy it, and thatdestruction will heal and redeem. In Kramer's story people invest atechno-object with powers to set things right; when their faith in thisobject proves misplaced, they are left vulnerable in their resourcclessness.
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Both The Lord of the Rings and the medication-machine story can becalled false-Grail stories, and they can be traced back to stories of falsegods and idols. The medical staff's attention to the medication machineis a form of idolatry, with Kramer as a modern Moses, coming downfrom the mountain to smash it.
One of the first Grail stories is the quest of Parzival, the youngprince whose mother fears that if he becomes a knight, he, like hisfather, will be killed in battle.l" So she raises him in perfect ignoranceof who he is and of what the world is. Since parental intentions alwayshave the opposite effect, Parzival becomes a knight, and his naiveteleads him to do things that other knights either fear to do or have themature judgment not to do. These actions have both good and pernicious effects, and as Parzival becomes more self-reflective, he learns torecognize these effects and take responsibility for them. It is entirely tooeasy to imagine a contemporary retelling of Parzival as a youngphysician.
The best-known part of Parzival's story occurs when he arrives atthe enchanted castle of the wounded king, Anfortas. Anfortas has beenwounded by a boar, and the wound festers, causing him great pain. Thefestering wound causes a stench which the poet, Wolfram VonEschenbach, describes in graphic terms. Everyone breathes better whenAnfortas is outdoors fishing; hence he is known as the Fisher King. Thepresence of the Holy Grail keeps Anfortas alive, but the effect of theCrail is not benign, at least not for the king who wants most of all tobe allowed to die and therefore released from pain. The Grail is notunlike the contemporary intensive care unit (JeU), in which people aresometimes kept alive, suffering, for purposes that are unclear. Unlikethe leU, the Grail's purpose is pedagogical and redemptive, andAnfortas's suffering has a narrative coherence that will ultimately berevealed.
Anfortas's wound will heal only when someone comes to thecastle and asks him the right question, quite simply, "What ails you?"It is an utterly naive question, blessed in its naivete, and Parzival seemsto be the ideal candidate to ask it. But he fails to do so. He does notask the question because in the education he has picked up in thecourse of his travels, he has been taught that the many questions he hasbeen accustomed to asking make him seem simple and are often rude.On this occasion, Parzival takes this well-intentioned, civilizing lessontoo much to heart and does not ask the question that must be asked.His inability to apply what he has been taught-his lack of sensitivityto context-is a symptom of Parzival not yet being the person who is
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capable of asking the right question. The enchanted castle then disappears, and Parzival has to go through his own sufferings before he canreturn to the castle, ask what he should have asked, and release theking. One of the healthier Christian tropes that the story presents is theidea that getting it wrong the first time is par for the course. Whatcounts is learning from initial failure.
Here, finally, we begin to think with stories. Hearing VanessaKramer's story with Parzival in our imaginations, we see her auntplaying the role of the wounded king and all the health-care professionals in the room as candidates for the role of Parzival, When a nursefinally does ask the question of what is wrong, she asks the questionwrong. Kramer reacts by asking, "How could the nurse not see?"Thinking about stories suggested one response: the nurse is caught ina restitution narrative that renders her blind to what Kramer sees asobvious. Thinking with stories suggests that the nurse, like the immature Parzival, can see perfectly well, but she cannot act on what shesees. She sees but cannot speak in a manner that is congruent withwhat she sees; both the wording of the question and her mannerconstrain what can be answered. The way she asks the question is notconsequentially different-not different in its effect on the patient-fromParzival's not asking. Both the nurse and Parzival act as if they cannotsee the monster in the room, and both leave the suffering person to dealwith this monster alone. The nurse's problem, in the story she believesshe must be part of, is that the patient's room will not magicallydisappear, leaving her in a dark wood to wander and to learn. It isunclear how the nurse will learn unless she hears Kramer's story andunless she is the kind of person who can hear Kramer's story.
Proximity, Distance, and Empathy
Parzival asks the right question (and asks the question right) oncehe takes the reality of Anfortas's suffering as a starting point. To sharea common humanity means to be able to see that something is wrongbut not to presume that what the observer and the suffering personperceive to be wrong are the same. A delicate balance of proximity anddistance operates here: you have to ask, but how you ask depends onknowledge that is incomplete without the asking. This balance-beingclose enough to know but recognizing the distance that always remains-seems crucial to the practice called empathy.
The need for proximity requires the clinician to approach Kramer'saunt as another human being who is a living body. The clinician's
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experience of being a body allows him or her to know that , as Kram ersays, of course there is pa in after such a surgery, and of course thereis suffering after such news. Kramer 's "of course " sig na ls th is need forproximity, the aspect of em pa thy typically emphasized .
Proximi ty dem ands recognizing that yes, the monster is in theroom and that the clinician take a stand with the pati ent in facing thatmon ster. The first and crucial clinical move is to express the commitment to stay with the patient, to be there to do wha tever can be done.H is an eno rmo us defect of health-care organiza tions that professionalsoften cannot express th is commitmen t because there are cons tant terr itorial d isruptions ove r who stays how long an d does wha t. Thisstructured disruption of con tinui ty of relational care is more than anorganization problem; it is a moral failure of health care, defor mingwh o pa tien ts and clinicians can be to and for each oth er.
Th is mora] failure genera tes stor ies that work to keep the mons terun mentionable, but no less present. It blocks the telling of s tories thatname the mon ster and that enab le the suffering person to feel tha t sheor he does not face this monster alo ne . The beginning of no t feel inga lo ne is hearing someone e lse exp ress, o ut loud, h is o r her recognition
of the mon ster 's presen ce.But proximity can become unbalan ced an d turn to presumption if
empa thy fai ls to sus tain dis tan ce. Distance is necessar y to avoi d projecting one' s own feelings onto the other. The mature Parziva l ma y seelittle more of Anfortas's sufferin g than he saw the first tim e, but he haslearned not to presume to know that suffering without asking. Howdifferent might the reaction of Kramer 's au nt have been if the nursehad first offered the grea t gift of recog ni tion? She needed first torecognize her patient's pain and suffe ring and mak e that recogni tionher starting po in t- no t to appea r to be interrogating th is pain. Afteracknow ledging the limi tations of what she cou ld recogni ze, she couldthen say that in order to treat the pain, she needed Kramer 's aun t todescribe it in her own term s. The element of su spicion wou ld have beenavoi ded and space cleared for a story in which the nurse couldparticipate. The difference between wh at happens and what might havehap pen ed is less about phrasin g than about attitude-how the nursepresented her own body to the body of her patient. The phrasing ofwords counts less tha n the sens e of relati on ship within which the wordsare spoken.
I shou ld add one cavea t, learned from wa tching difficult clin icalscenes . If a pa tien t is alrea dy in chaos-deep in chaos- then theprofessional's self-prese n tation risks being interpreted th rou gh the len s
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of that chaos. People who are experiencing multiple sorts of violenceagainst themselves learn to see what they fear they will see. If medicalcommunications often fail people living in chaos, it is equally true thatliving in chaos makes it difficult to communicate.
Because one story leads to another, our understanding of the storywe are presently part of is always influenced by stories in the background. Maybe I hear an element of suspicion in the way that the nurseasks the question because of another story I have heard which comesfrom Bernie Carter's research on nursing care. Carter quotes from thediary of a child being treated for pain. We can hear this child as acontemporary, wounded king, captured in a system that inhibits askingthe question that would begin to relieve suffering. The child describeshis experience:
I've had pain in my stomach for nearly 2 years. It seems muchlonger. I found most of the doctors very helpful, however, a coupleof the doctors treated me like I was faking. One doctor told me thatwhat she was seeing on examination and what she was being toldwere two different things. I was 11 and knew that I was beingaccused of lying. This made me really angry, because it didn't helpthe pain (it actually got worse) and it really hurt me to be called aliar when the pain was very real. 11
With this story in my imagination, I hear Kramer's aunt being set upfor the same kind of accusation. If the answer she gives to the nurse'squestion does not fit the medical staff's expectation, she could havetrouble getting the care she needs. People who care for other people donot test them, and too often I hear stories about patients being testedby clinicians. As the boy in Carter's story says, this makes the painworse.
Empathy is not so much an attitude toward another person; it isprimarily a response that is, in turn, responded to, and that cycle ofresponse is dialogue. Parzival's empathy depends not on how he feelsas he sees and smells Anfortas's wound. What count are Parzival'sactions in relation to Anfortas: asking the right question, which requiresreturning to the enchanted castle, which requires becoming the personwho is entitled to return. In this sequence of actions, Parzival does notact for himself alone.
Parzival's quest is interdependent with the fate of Anfortas. Anyperson's story depends on others who become less other as the enmeshment of stories teaches interdependence. I confess to believing that in
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learning this interdependence patients have a qualified advantage overclinicians. This advantage may have less to do with physical sufferingand the feelings that generates (though these can count) and more todo with not having a particular institutional face that must be sustainedbefore one's colleagues. Being suspicious is one technique of sustainingthat professional face; it shows the professional's ability to judge.
The interdependence of witness is stated clearly by another childwhom Carter interviews: "I know what my pain is like, but he [thephysician] never wants to hear. He might be a doctor but I've got thepain. if I can't tell him, who can J tell?"12 That dependence of thesuffering person on the clinician embodies the Parzival aspect of anymedical encounter. The dependence is really interdependence becauseuntil the clinician becomes someone willing to hear the other's pain, sheor he, like Parzival when he fails to ask the question, is incomplete asa person. Whenever a clinician walks into a patient's room, Parzivalencounters the wounded king all over again. If this secular yet stillspiritual Grail of medicine is to bring healing and not prolong thesuffering, the right question has to be asked.
I emphasize that the dialogical approach to clinical conununication
is neither original nor is it difficult to practice. Parzival has to unlearnthe manners he has learned well but without discrimination. Asking theright clinical question often involves more unlearning than learning,and unlearning-simplifying-is difficult to write up for continuingmedical education (CME) credits. The professional education systemassumes that anything worth learning must be new and technicallycomplex. Communication is turned into another procedure, practicedaccording to a prescribed regime. No professional credit is given forsaying or learning that something is obvious, but in the story ofParzival, redemption depends on doing the obvious. The CME system,as one representative of institutional medicine, accords no value togiving people permission to act on their best instincts. We need analternative, and this alternative needs a name.
Phronetic Practice
If what counts about any story is what those who hear it chooseto do with it, and if people need to reduce the gap between sufferingthat seems an unavoidable part of the human condition and sufferingthat is compounded by the social treatment of the ill, then the finalquestions concern whether one can learn to ask the right question, and
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if so, what the appropriate pedagogy would be. Parzival apparentlylearns. His ordeals endow him with the quality that Aristotle callsphronesis, conventionally translated as practical wisdom.F'
Phronesis is one of the three branches of knowledge that Aristotledescribes, the other two being episteme and iechne. Episteme is concernedwith universal laws; it aspires to be context invariant. Episteme sets theideal for scientific knowledge-including evidence-based medicine-andfor those branches of philosophy and social science that are concernedwith rules, principles, and laws. If episteme is of the head, iechne is ofthe hand. Techne invokes making; it produces objects, originally artworks and what we now call technology. Surgery, as a craftwork ofhands, is a form of iechne. Techne teaches how to craft, and epistemeteaches the laws that govern what is crafted, but neither form ofknowledge takes us very far in deciding what we ought to craft. For thatwe need phronests. Phronesis is what Parzival needs to acquire if he isto make good use of the warrior skills (tedme) that he picks up, perhapstoo quickly. Acquiring phronesis takes far longer. Thinking about phronesisafter Pascal, I am inclined, perhaps with violence to Aristotle, to thinkof it as being of the heart, in the sense of that which exceeds reason.Phronesis is the type of knowledge for which we lack any contemporaryEnglish term, which may be a bigger part of our problem than werealize: contemporary society has lost the understanding that phronesisis necessary to becoming a complete human. Thus, we fail to trainpeople for it.
From the philosophical perspective of the present, phronesis seemsto anticipate pragmatism in its interdependence of action and values. Toact is to act on the basis of some value, and any value achieves specificmeaning only in the unfolding of an action; actions alone enable us toknow what the value means.l" In order to learn to act in ways thatexemplify our values, we need to pay attention to how different actionsdevelop, with what consequences, and for whom. In seeing how valuebased action plays out, we discover the goodness or the failure of ouraction. Phronesis thus depends not on rules or laws but on experience.A person develops phronesis by taking his or her values through thetrials of multiple actions and by reflecting on the outcomes. Experienceenables a person to know where certain courses of action are likely tolead. Phronesis is the opposite of acting on the basis of scripts andprotocols; those are for beginners, and continuing reliance on them candoom actors to remain beginners.P
Because phronesis requires experience and is expressed in action, itcannot be specified in the abstract. Is it more than a tautology (with a
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Gree k nam e) to say that the w ise person knows to act w isely becau seshe or he is wise? We save phronesis from tau tology w he n we under stand th at a story unfolds ov er time, with time human izin g the hero .In all qu est stories, th e hero spe nds years wandering. Parzival kn owshow to as k the right qu est ion only after h is adven tures an d trials givehim time and expe rience to reflect on his initial failure.
There are tw o other condi tions that mu st be met in order forParz ival to become the kind of person w ho knows how to ask the rightqu estion. As well as requiring time, becoming a wise hero requireshaving a bod y tha t can suffer, in part be cause this bo d y also kn ows th epossibility of joy. Finally, becoming wise req uires inter acting with otherpeop le on whom the hero has effects that have moral cons eque nces;recip roca lly, these people affect the hero. While these three cond itionscould be cons idered essential to all stor ies, in the quest sto ries more isinvolved than the sum of the characters, their experien ces, and theirintera ctions. At the center of Parzival' s stor y is the Grail, in all itspower and mystery. Here I need to return to my G twins as the basisof understand ing people's stories .
I regret the un generous observa tion that the idea of the Grail inman y stories di ffer s from Parzival 's Gra il, and thi s difference is onereason w hy his story con tinues to be sign ificant for our con tem porarymora l development. Th e kind of Grail that many people imagine ismore like a Goose tha t Lays the Golden Egg. Man y peo ple have theidea that if they cou ld ge t thei r hands on some thing, like a wi nninglottery ticket, or the perfect medicati on, or a new surg ical proced ure,then thei r lives would be healed and rcdeemed.!" Anfortas, the wounde dking , has the C rail in the sense that it is there for h im, bu t it d oes notheal him . More accurately, the Gra il has the kin g, and there lies theproblem of both pain and med icine: too often they have us.
The Grail can provide, bu t first it demands. Th e C rai l's demandthat Parziv al become the person who can ask the righ t question is ademand for phronesis. Par zival m us t learn to discriminate what actionfits the con text. One aspect of his you thful na ivete is hi s ignorance ofthe dema nds of different con tex ts. Initially this lack of awareness hasa comic quality, but then it turns serious: first, when Parzival failsAnfortas; and later as he learn s the consequences of so me of h is ea rl ieractions . Par zival must learn to kn ow what a given context as ks of himand how to choose the appropriate skills w ith w hich to mee t the needsof the si tua tion, including but not lim ited to his formid able skills as awarrior. Parzival , like man y young physicians, is prem aturely potent intoha! he can do. He need s to learn tohen and hotu to do.
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Parziva l can and does learn, althoug h the course of learning doesnot run smoothly; it requires fai th, which migh t be described assustaining focus on an ideal. The Grail can be int erpreted as what it isworth having faith in; it d raws people into pro cesses that requ ire andultimately produce faith. Parzival's story gives the res t of us faith thatno matt er how badly we bungle things ini tially, we can get it right ifwe sus tain a belief in the mor al significance of the qu est to ge t it right.The Grail is that promise.
Thinki ng with stor ies is one kind of phronetic inq uiry. The studyof narrat ives can be used to gene ra te epis tcmic know ledge, a ndnarratology can be a form of tee/me, concerne d with the making ofstor ies . Those uses have their va lue , but I want to claim that the uniquepossibility of stories is to teach phronesis.t? Let me offer a fina l yetalw ays partial definition of phronesis. To practice phronesis is to tra inonese lf to cons tant self-awareness as a moral actor. One form of thattrain ing is the tell ing of stor ies, like Vanessa Kramer 's stor y, tha thighl ight how people are constantly affecting each othe r's capa city tobe car ried off by some Grendel or to be rede emed by a Grail. I ima ginethe epic Parzioal as a story tha t Par zival tells to himself, becoming ablein the cour se of that telling to see himself at his best an d his wo rst andin all the effects he has had on people during his life and to see howthe y have affected him. After telling himself th is story, Parzival is ab leto ask the question- the right question about pain-that ends one stor yand begins another. This provisional ending may be as close to goo dness as we are able to ge t.
NOTES
Ear lier ve rsions of this essay were p rese nted at the " Narrative, Pain, andSuffering " conference a t the Rockefeller Found ation's Bcllagio Study and Co n ferenceCenter in Ita ly; in the Med ical Class ics lectur e series a t the University of Ca lifo rn ia,Los Angeles (a lso sponso red by the UCLA Interd iscip linary Croup for the Study an dTreatment of Pain); and at Deaki n Uni versity, Melbourne , Au stra lia. My th an ks to myhosts on th ose occasions and to colleagues wh o contrib uted to this essay 's progre ss.My par ticipation in Bellagio was funded in par t by a tra vel grant from the Uni versit yof Calgary and in part by the Rockefeller Foundation . Thanks to thi s jou rnal 'sano nym ous rev iewers for their very help ful suggestions.
1. I d iscuss thinking witlt stor ies in The wounded Storyteller, 23-5, 158- 63. I tookthe idea fro m perso na l com muni cation wi th Ju lie Cru ikshan k, subsequently publishedin her book , The Social Life of Stories. Da vid Morris expa nds the concept in " Narra tive,Ethics, and Pain."
2. The social scient ific recog ni tion of the ethnog rapher as a storyteller w ho ispa rt of the s to ry is developed in a la rge bod y of literature. See, fo r example, VanMaanen , Tales of the Field. In the ph ilosophical litera ture, see Maci ntyre, Aft er Virtue:
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" Each of us be ing a main cha racter in his own d ra ma plays subord ina te part s in thedramas of ot he rs, and each drama cons tra ins the others" (213). I would ad d thai eachd rama also enables th e others.
3. Kramer, "Case Story ," I. I should note that I w as the ed itor of the seriesof ar ticles in w hich th is story ap peared . J disc uss Kram er's w hole story in TheRcncuml of Ccnerosits].
4. lbid ., 1,4.5. Law rence M. Fisher , "The Race to Cash in on the Genetic Co de," New York
Times, Aug us t 29, 1999, C l , quoted in Callaha n, What Price Beller Health", 67.6. Kermode, The Sense of nil Ending, 45. See also Cham bers, The Fiction oj
Biocihics, 81.7. On ho w stor ies emplo t a fu ture, see Matt ingly, Healing Dramas and Clinical
Plots. For examples that show how people use in terna lized s tories to rehea rse fu turecourses of ac tion, see Mead, Mind, Self, and Society.
8. Sontag, ll lncss as Mclaphor, 3.9. See Hea ney's int rodu ction to Beowulf for a brillian t evoca tion of what I am
calling th e Grendel for ce.10. See Von Eschenbach, l'arzival. Amon g the numerous contemp orar y reteJling s
of Pa rz ival, I rely especially on Pat erso n' s Parzioa! and Cla rke's Parzioal and the Stonef rom Heaven.
'II . Ca rte r, " Pa in Narra tives and Narrative Practiti oners," 210.12. lbid ., 214 (m y italics).13. See Aristo tle, Nicomachcan Ethics. My di scussion of phroncsis is ins tiga ted
and gu ided by Plyvb jcrg, Making Social Science Matter; my usage of " phronetic" asan ~l djl'c t i v e is ta ke n fro rn Plyv bjc rg. My fa vo ri te di scussi on o f pltroncsi« as a n l,thi calva lue is Vanier's Made for Happi/less.
14. A contempora ry summation of p ragmat ist e thics is found in Va rela , EthicalKnow-lIoH' .
15. See Flyv bjcrg 's d iscussion of the ed uca tiona l research of Stua rt and Hu ber tDrey fus in Making Social Science Matter, which concludes: " If peop le arc exclusivelytrained in context-ind ependen t know ledg e an d r ules, th at is, the kind of kn owl edgew hich form s the basi s of textbooks and com pu ters, the y will remain at the first levelsof the learn ing process " (71).
16. One examp le is cosmetic surgery; for a psychoan alyt ic inte rpreta tion ofcosmet ic sur ge ry as the search for a lost w ho leness , see Blum, Flesh vvounds.
17. Th is cla im simp ly a rrives by a di fferen t rou te at the sa me point othe rs havemade; see, for example, Cha ron, "The Nar ra tive Road to Empat hy."
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