J7ournal ofMedical Ethics 1997; 23: 45-50

Imagination in practiceP Anne Scott University of Stirling, Stirling, Scotland

AbstractCurrent focus in the health care ethics literature on thecharacter of the practitioner has a reputable pedigree.Rather than offer a staple diet ofAristotelian ethics inthe undergraduate curricula, perhaps instead one shouldfollow Murdoch 's suggestion and help the practitioner todevelop vision and moral imagination, because this hasa practical rather than a theoretical aim. '

The imaginative capacity of the practitioner plays animportant part in both the quality of the nurse's roleenactment and the moral strategies which the nurse uses.It also plays a central part in the practitioner's ability tocommunicate with a patient and in the type ofpersonwhich the practitioner becomes.Can the moral imagination be stimulated and

nurtured? Some philosophers and literary critics arguethat not only is this possible, but that literature is themeans of doing so. If this is the case then a place shouldbe made for literature in already crowded health carecurricula.

IntroductionA current interest in both nursing and medical liter-ature is the character of the health care practitionerand its influence on the type of care which the prac-titioner provides for patients or clients.2 Con-siderations of character move one into the domain ofmoral discourse. In speaking about the moral dimen-sions ofboth nursing and medical practice one needsto consider issues of role enactment and moralstrategy.3 The importance of these concepts wasarticulated by Downie in the 1960s within the widersocial context.4 These issues are also directly relatedto the type of care which the practitioner provides forpatients or clients, and to the character of the practi-tioner. Moral strategy refers to when and how we goabout doing something of moral relevance; forexample when and how a patient is asked to partici-pate in a clinical trial. Role enactment refers to thosequalities which an individual brings to his or herfunctioning in a role. These qualities are elements ofthe character and are thus not reducible to aspects ofthe role.

Key wordsMoral imagination; moral strategy; role enactment.

When one wishes to consider characteristics of thepractitioner, particularly those related to the issuesof role enactment and moral strategy, one is talkingof virtue in the Aristotelian sense of the word.5 Afurther element which is needed when one considersrole enactment and moral strategy is that of an activemoral imagination. This is because the type of"agent-attention"6 which is needed for high-qualityrole enactment and sensitive moral strategy presup-poses activity of the moral imagination.

It is difficult to describe adequately what themoral imagination is. For our present purposes, Isuggest that moral imagination is that aspect of theimagination which potentially becomes active in themoral agent's attempt to consider what moral deci-sions to make: that human faculty which allows"gut-reaction" to be used and moderated into theperceptual schema and which enables the moralagent to build up a multi-dimensional understandingof a situation - including a reasonably complexunderstanding of the situation of the actors involved.This faculty comprises three elemental influences:reason, gut-response and something akin to Humeanfancy.

I suggest that it is at least partially activity of themoral imagination which allows the sensitive nurseor doctor, for example, to perceive the non-verbalcues and attend to patients sufficiently to know whenthe patient is capable of coping with bad news, ratherthan merely stating such news in a cold, factual way,without any attempt to consider if the time is ripe.Respecting patient autonomy is important.However, given the vulnerability which illnessbrings, so also is a consideration of the particular sit-uation of the individual patient. This process of con-sideration of the particular situation is facilitated byan active moral imagination.23

I am suggesting, therefore, that the developmentof an active moral imagination is necessary in thepreparation of the health care practitioner. Howmight this development of the moral imagination besupported within the educational preparation whichnovice practitioners undergo?

Murdoch's idea, that by paying attention (inWeil's sense of a just and loving gaze directed upona person or object) properly, selflessly, one comes tosee what must be done,7 has at least a strong intuitiveappeal. However as Murdoch points out:

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from

46 Imagination in practice

"I can only choose within the world I can see, in themoral sense of 'see' which implies that clear vision isa result of moral imagination and moral effort."8

She also suggests that:

".... where virtue is concerned we often apprehendmore than we clearly understand and grow bylooking."9

It is a noteworthy point that in medicine, and innursing, students are being educated in whatclinical features - which signs and symptoms -should be noted as likely to be of relevance. It is alsonoteworthy that one of the results of this is that thestudent, perhaps unconsciously, is becoming awareof what can be ignored. The student is activelytrained to filter out large chunks of informationwhile being encouraged to focus on, usually (quitereasonably) physical complaints. (The problem isthat sometimes the physical complaint is sympto-matic of the only partially physical or the non-physical; and sometimes problems which can have asignificant effect on the patient's treatment are notof a physical nature. Current developments inmedical and nursing curricula are suggesting achange in focus).'0

Awareness of the psychosocial dimension ofillness sensitises one to the idea that a patient maynot overtly show the effects of hospitalisation, or ofbeing socialised into the patient mode of operation.The dehumanising effects of being ignored or deper-sonalised by health care staff may not be readilyevident to staff whose encounters with a patient arerelatively brief. However, such encounters may harmthe patient (and the staff involved for that matter);and they do carry moral evaluation. Is the healthcare practitioner morally responsible for interactionswith patients, (or other professionals) the effects ofwhich the practitioner does not see, or is not con-sciously aware of?

It seems that the answer to the above questionmust contain the phrase "it depends". It depends onwhether it is reasonable to expect that the practi-tioner should be aware of her impact on the patient,or the impact of the institution, or a certain diag-nosis, or a certain treatment, on the patient.

If certain actions or attitudes would be objectedto, found wanting, or found to cause harm to aperson in ordinary social interactions there is at leasta good case to be made for suggesting that they willcause the same effect in a patient - professional inter-action, unless they take place in a clearly defined sit-uation in which both parties are aware of their ownneeds and desires, and of the effect which these haveon the other participating party. For example, tostick a glass tube in another person's mouth in themiddle of a public bar or a shop could be describedas assault. In a doctor's surgery the person isprobably having her temperature taken. However, to

strip a person naked in a public ward (or indeed in asingle room), leaving the person totally exposed issurely not acceptable; any more than it would beacceptable to demand that a customer strip in adepartment store.

It would appear that many incidents similar (inthe metaphorical sense) to stripping a patient nakedin a public ward become equivalent, in the mind ofmany health care practitioners, to taking a patient'stemperature. Failure, on the part of the health careprofessional, to listen when a patient tries to com-municate that which she feels is information relevantto her condition, failure to respect a person's(patient's) rights or human dignity, failure to see thepatient as a person, all fit into this category.

This type of failure results from a problem withthe quality of role enactment of particular practition-ers. It seems likely that this problem may arise froma lack of sympathy and/or empathy with the patient.One cannot sympathise or empathise with a person ifone cannot imaginatively enter the world of that par-ticular person. To sympathise means to have anaffinity with or to share another's interests and/oremotions. To have an affinity with or to share theinterests or emotions of another presupposes acommon understanding or the ability to identifywith the perspective of the other person. In a similarway, to empathise with another person, by defini-tion, means the ability to understand and imagina-tively enter into another person's feelings.Therefore, one cannot sympathise or empathise witha patient if one cannot imaginatively enter into theworld of the particular patient with whom one is incontact. The problem would thus seem to be one oflack of imagination.

Nurses (and other health care practitioners) canreasonably be expected to have the imaginative sen-sitivities which would allow and/or encouragefeelings and attitudes of sympathy and empathybetween the practitioner and the patient. These arenecessary qualities in practitioners who describethemselves as belonging to the caring professions. Italso seems that practitioners can and should be heldresponsible for lacking these qualities or characteris-tics when it causes harm to patients (or indeed them-selves as persons).

Imagination, what is its relevance?An analysis of the concept of imagination is beyondthe remit of this paper. Some clarification of thataspect of imagination which is of concern in this papermay be achieved by stating that it is not the grosserperceptual aspects of imagination which are ofinterest in this instance, but a fine tuning of the imag-ination. The former aspects of imagination are dis-cussed in depth by Hume," Kant 12 and Wamock 13for example. Imagination, in Wamock's words,"bridges the gap between sensory data and intelligiblethought". ' 3

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from

PAnne Scott 47

Evidently it is not this type of survival imagina-tion which appears to be lacking in the health care

practitioner who strips a patient naked in public or

who carries on a teaching round while an old ladytries to use a bed pan.'4 It is possible to argue thatin this sort of situation the fine tuning of the imagi-nation may be missing. By "fine tuning" is meantthat aspect of the imagination which allows thenurse to perceive, in this particular patient, person-

hood; that aspect of the imagination which allowsthe practitioner to believe not only in the con-

tinuous existence of this particular patient, butwhich allows her to believe that here exists a humanbeing: "a person such as I". This is the aspect of theimagination which in the words of Henry Jamesallows one to be "finely aware and richly respon-

sible".'5 It seems that it is something like this typeof imagination which Murdoch refers to as the"moral imagination". 16

Moral paralysisOne may ask at this point why this type of imagina-tion appears to be important for the health care prac-

titioner. Are practitioners not too busy trying to geton with their jobs to have time to worry about being"finely aware and richly responsible"? Inherent inthis kind of criticism may be the very real fear expe-

rienced by some teachers of health care ethics thattoo much concentration on imagination and imagi-natively identifying with patients may induce a moraland professional paralysis.My reply is as follows: if health care professionals

are willing to take upon themselves ultimate respon-

sibility for decisions that can have a profound impacton the lives of their patients, then it is vital that thesesame practitioners clearly understand the possible or

likely implications of their decisions from within thepsychosocial context of the patient, rather thansimply consider the medical implications. Thereforepractitioners have a duty actively to engage withtheir patients at a level which will allow the practi-tioners to gain insight into the patients' lives in orderto get a clearer perception of the likely implicationsof decision A or treatment B.

I suggest that this engagement only comes

through activity of the moral imagination. Thisactivity of the moral imagination is not a flounderingat the level of uneducated emotion; which can

indeed lead to paralysis, or perhaps the many inci-dences of burnout which one sees referenced in theliterature. It is instead the activity of a faculty whichhas been nurtured and developed in the practitioner.A faculty akin, I suggest, to an intellectual virtue inAristotle's sense of the term5; or more particularly a

faculty directly relevant to the Aristotelian virtue ofphronesis. It is this close connection with phronesiswhich leads to my suggestion above that the facultyof the moral imagination is in fact a compositefaculty.

I would wish to argue that activity of the moralimagination is central to issues of moral strategy,role enactment and the personal characteristic ofcompassion. It is therefore at least indirectly relatedto the quality of health care which members of thegeneral public receive. 2 3 If this is so then educatingthe moral imagination is an important function ofthe education of a health care practitioner.

It is impossible to achieve much of the under-standing which compassion requires without, tosome extent, entering imaginatively into the world ofthe person who is the patient. For example it is notpossible to understand the meaning or impact whichbreast cancer has for this thirty-six-year-old womanunless the practitioner also learns of and takes intoconsideration the fact that this young woman hasfive small children and an alcoholic husband. Thisallows the practitioner imaginatively to identify withthis woman from within the context provided by thisextra information.

Again a major coronary is a serious condition forany patient to face; the implications of this conditionfor Mr Jones cannot be more than glimpsed at unlessit is also known that he is a widower who is respon-sible for the welfare of a son with uncontrolledepilepsy and Korsakoff s amnesia.

It may be suggested that though these extra bits ofa patient's social history may be useful to know theyare not vital. I suggest that possibly the only time ina patient's treatment that such information is notdirectly relevant to his treatment programme is insituations of life or death. For example duringcardiac resuscitation the only really relevant infor-mation is "is the heart beating?" and "is the patientbreathing?" If a patient is not responding to treat-ment, or is not responding as well as expected, or ifhe is refusing to take any treatment, apparently irrel-evant bits of his social history may provide theanswer to the problem. (Kleinman discusses suchcases, for example that of Mrs Melissa Flower).'7 Itmay also provide sufficient context, sufficient story,for the practitioner to begin imaginatively to identifywith the particular patient.

Non-compliancePatients are unlikely (unless desperate) even to try tocommunicate adequately with practitioners who areunable to establish a rapport with them or evincesympathy/empathy or compassion. This failure canpotentially cause the patient harm through inappro-priate treatments or through non-compliance withtreatment regimes. These factors alone seem toprovide good reasons to try to help nurses anddoctors develop the capacities necessary to enablethem to provide adequate humane care for theirpatients. But there is another relevant consideration.

If the practitioner continually fails to reachcommon ground with her patients in terms of devel-oping an appreciation of what sickness means for

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from

48 Imagination in practice

them in their lives and world, then it would appearthat not only the patient may be damaged. Murdochsuggests that we "grow by looking".7 If one does notlook, one does not learn to see. At the very least thiscauses one to stagnate or at worst one is diminishedby the experience.To fail to see or to understand is to be oblivious of

the reality of a situation. To be oblivious to a realitymeans that this reality has failed to enter one'sworld. One may stagnate behind a self-protectivewall or one may be forced to channel one's energiesinto strengthening the wall, resulting in a shrinkingof one's own humanity. Murdoch7 and Griffin'8suggest that such stagnation and shrinking is theresult of self-protective selfishness. A pertinentquestion here is: "is it selfishness or is it that thepainfulness of what one sometimes witnesses,prevents one from being able to 'see"'?'9One may certainly witnesses events so painful that

the desire in one not to look, not to see, is over-whelming. It is this lack of insight into the humancondition that makes the completely virtuous state agreat deal more difficult to attain than eitherAristotle or Murdoch suggest.5" It is also preciselybecause health care practitioners are almost dailyfaced with this reality in an unadulterated, undis-guised way, that their ability to look, to see, to livewith and grow from such experiences is all the morenecessary. For if such abilities are not fostered, des-iccation of the personality, burnout, attrition fromthe professions and poor patient care are almostinevitable scenarios.The potential for this type of scenario to befall the

practitioner should be recognised more widely thanit would appear to be at present. This problem hascertainly been identified in sociological literature. Itis occasionally described as an undesirable aspect ofthe process of professional socialisation for a numberof practitioners. This potential for the desiccation ofpersonality to occur seems to provide another reasonfor supporting the development of the practitioner'smoral imagination. If the practitioner can imagina-tively identify with a particular patient during certaintrying situations the focus of the practitioner's atten-tion is on the patient rather than on himself and hisown particular needs (conscious or unconscious).Therefore, the practitioner's practice is patient-centred and in that sense patient-directed or patient-focused, rather than practitioner-centred orpractitioner-focused. This can result in an enrichingand an enlarging of the perspective of the practi-tioner.

It seems that the imaginative capacity of thepractitioner plays a very important role in thequality both of the practitioner's role enactmentand the moral strategies which the practitioneruses. It may also play a central role in the practi-tioner's ability to communicate with a patient andin the type of person which the practitionerbecomes. In a useful analysis of the concept of

caring in clinical practice Griffin'8 makes somerelevant remarks:

"To be able to care what must a nurse first be like? Ifshe or he is an active participant in an importanthuman experience, it is necessary that she is able andwilling to understand the features of this situationand that the nurse is 'a mind in possession of itsown experience', (not everyone understands muchof what happens to them) receptive too, to painfulemotional questions. Part of this understanding maybe built up by reflection. . . Its essential value isrelated to the maturity of the individual in being ableto clear his mind of self-oriented concerns andobsessions. It requires some liberation from self-centeredness towards awareness of another's needs.(To achieve this is one of the major aims of a moraleducation such as many nurses and others may wellnot have had)."

Griffin's suggestion that many nurses may notreceive the relevant type of education (moral educa-tion) to allow them to perceive accurately andunderstand the needs of their patients shouldprovide food for thought for those of us who try toteach ethics to nurses (and other health care practi-tioners). This seems to raise the following questions:"what are educators attempting to do, when they tryto teach ethics to health care practitioners?" "Whatis the goal?" "Why is the teaching of ethics seen as agood idea, or in more and more instances a neces-sary part of the curriculum?" The answer which Ioffer is that ethics is taught in an attempt to help thestudent become a better practitioner; better in thesense of more humane, more compassionate, morecaring towards the persons who are the practitioner'spatients.

Can the moral imagination be stimulatedand nurtured?"The claim seems to be that if you really vividlyexperience a concrete human life, imagine what it'slike to live that life, and at the same time permityourself the full range of emotional responses to thatconcrete life, you will (ifyou have at all a good moralstart) be unable to do certain things to that person.Vividness leads to tenderness, imagination to com-passion. The patient effort to see moderates thecoarseness of which political horror is made." 20The notion of "a good moral start", bracketed in

the above quote from Nussbaum, is of course crucialhere. It is an Aristotelian idea and is supportive ofmy idea of activity of the moral imagination being anintellectual virtue. The intellectual virtues, in anAristotelian framework, are built upon a foundationof moral virtues, the existence of which depends on"a good moral start".5 This suggests that attempts toeducate the moral imagination come secondary tothe need to consider the character of entrants to thehealth care professions. This is perhaps an idea that

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from

PAnne Scott 49

has been highlighted by the Allitt Inquiry.2' Thepoint being that attempts to stimulate, develop andeducate the moral imagination will "fall on stonyground" unless it is viewed as an element in thedeveloping character of the practitioner.

In the literature there is a growing school ofthought which suggests that the answer to thequestion "can the moral imagination be stimulatedand nurtured?" is a resounding "yes". The theory isthat the moral imagination can be stimulated andnurtured through the use of the humanities, perhapsparticularly the serious reading of literature; espe-cially certain types of novels. Nussbaum, quotedabove, is a persuasive contemporary supporter ofthis theory. Further support for the theory comesfrom the field of literary criticism. For examplePrice:

"Our capacity to enter imaginatively into the lives ofothers is a process of irreversible growth. It providesus with knowledge we can never resign and must actupon."

He goes on later to argue:

"What we in turn recognise as readers is the need -if we are to read with any sense at all - to feelourselves into the moral imagination of the charac-ters. We may shift back and forth, from inside tooutside ... but we cannot begin to understand theexperience the novel presents without some par-ticipation in the moral realities within which itscharacters live."22

Further support for this view is found in medicalhumanities literature, for example, Trautmann,23Brody,24 Downie.25The notion that literature can affect people's

behaviour is certainly not new. Plato in The Republicbans poets and artists because of the potentiallydetrimental effects of their work on the generalpopulation.26 Censorship laws are based on thesame premise. If some forms of literature or art canbe deemed to have bad influences on people then itseems quite reasonable to suggest that other formsof literature and art can influence people to thegood.

Nussbaum, following the Aristotelian tradition,suggests that one of the more effective ways of devel-oping and nurturing this element, which recognisesthe importance of perception and emotion as well asparticularity in ethics, is through the use of thenovel.20 Attentive reading of certain types of novel(such as those of Henry James and Charles Dickens,according to Nussbaum) helps develop moral sensi-tivity and moral imagination by inviting the reader togo beyond her immediate experience, to see theimportance of the specific context and yet also toperceive the links of common humanity which bindthe reader to characters in stories. It is perhapsnot too difficult a step from here to developing

sympathetic identification with the patients onemeets in clinical practice.

This notion of course raises two further issues.Firstly if literature can stimulate the moral imagina-tion how can it be ensured that this is a positiverather than a detrimental influence on practitionercharacter and patient care? And secondly the litera-ture which scholars such as Nussbaum suggest maynot be immediately accessible to the average medicalor nursing student, therefore how does one decidewhat literature to use?An answer to the first concern is not easy, but

must be rooted in an acceptance of certain ideals ofclinical practice which are based on explicit articula-tion of the core concepts of practice: such as "care"and "treatment". The answer is also directly relatedto an identification of dispositions of character whichare seen to be desirable in the practitioner.

In answer to the second problem Nussbaumconcentrates on the novel as a means of moraleducation. Many educators in the medical humani-ties use also, or exclusively, contemporary shortstories, drama, poetry (Coles,27 Trautmann,23 andDownie.25 I suggest there are advantages in using amixture of texts, and a mixture of media - bothprinted and visual. Use of novels and film has theadvantage of historical perspective, and lengthydescriptions of context and character. They are alsogood sources for developing history-taking skills instudents - an idea which exercised Kleinman.'7However, within the realities of a crowded curricu-lum one must be realistic in one's expectations ofstudents. Poetry and short stories can often focus themind sharply and effectively on an issue of concern.The development of a syllabus is not my inten-

tion here. However, there is a growing variety ofhelp in the literature, for teachers of health careethics who wish seriously to consider the sugges-tions in this paper and to attempt to act upon them(for example'7 20 23 24 25 27) A point that is worthmaking, I think, is that it is useful to becomereasonably familiar with the second level curriculumin that it will give the teacher of medical or nursinghumanities some insight into which texts ourstudents will, initially, find accessible.Murdoch advises focusing on certain works of art,

and there is evidence of this being considered inmedical and nursing education.25 This may be veryuseful for those who find art accessible. However,literature has two advantages in this area: firstly mostof our students will have been exposed to literatureuntil midway through their secondary education, ifnot afterwards. Therefore one is not working fromscratch in this area. Secondly literature will providefirst-order and also second-order concepts withwhich to enrich the language and thought processesof our students. In a context where there is growingsubsumption of the language of the market placeinto the thinking, writing and policy-making abouthealth care practice, I suggest that this is not an

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from

50 Imagination in practice

unimportant consideration. Language influencesthought28 29 7) and it is difficult to see how verbalthought does not affect the boundaries of imagina-tive activity

ConclusionFrom what is being argued above it seems to be thecase that moral imagination is important to thequality of a practitioner's role enactment, the moralstrategies which the practitioner uses and the prac-titioner's ability to communicate with patients. Thequality of care which a patient receives from a prac-titioner is not only to do with technical, clinical skillsbut also with the practitioner's ability to listen andcommunicate, as well as with the quality of the prac-titioner's role enactment and moral strategy. There-fore, it seems that an active moral imagination isimportant to the type of care which patients receivefrom health care practitioners.

It is further being suggested by many theoriststhat the moral imagination can be stimulated andnurtured through the humanities, particularly litera-ture. If this is the case, a place should be made forthe use of literature in the already crowded curricu-lum of medical and nursing students. This, ofcourse, is not a new idea. However, I think that anattempt to link activity of the moral imaginationdirectly to certain aspects of patient care is a signifi-cant factor in giving weight to the demand.

PAnne Scott, BA, MSc, PhD, RGN, is Senior Lecturerin the Department ofNursing and Midwifery, Universityof Stirling, Stirling FK9 4LA.

References1 Murdoch I. Vision and choice in morality. Proceedings

ofthe Aristotelian Society [supplementary] 1956; 30:32-58.

2 Scott PA . Virtue, imaginative identification and the healthcare practitioner. Unpublished PhD thesis, University ofGlasgow, 1993.

3 Scott PA. Care, attention and imaginative identificationin nursing practice. 3rournal ofAdvanced Nursing 1995;21: 1196-1200.

4 Downie RS. Government action and morality. London:MacMillan & Co, Ltd, 1964.

5 Aristotle. The nicomachean ethics. Translated by SirDavid Ross, revised by JL Ackrill and JO Urmson.Oxford: Oxford University Press, World ClassicsSeries, 1980.

6 White AR. Attention. Oxford: Basil Blackwell, 1964.7 Murdoch I. Sovereignty ofgood. London: Routledge andKegan Paul, 1970.

8 See reference 7: 37.9 See reference 7: 31.10 General Medical Council. Tomorrow's doctors: recom-

mendations on undergraduate medical education. London:General Medical Council, 1993.

11 Hume D. A treatise on human nature [2nd ed]. Textrevised by P. Nidditch. Oxford: Clarendon Press, 1978.Hume D. An enquiry concerning the human understandingand an enquiry concerning the principles of morals. Oxford:Clarendon Press, 1902.

12 Kant E. A critique of judgment. New York: Hefner,1951.

13 Warnock M. Imagination. London: Faber and Faber,1976.

14 Caplan AL. Can applied ethics be effective in healthcare practice and should it strive to be? Ethics 1983; 93:311-9.

15 James H. The art of the novel. New York: CharlesScribner and Sons, 1907.

16 Murdoch I. See reference 1 and also Murdoch I.Metaphysics as a guide to morals. London: Chatto andWindus, 1992.

17 Kleinman A. The illness narratives: suffering, healing andthe human condition. New York: Basic Books Inc, 1988.

18 Griffin AP. A philosophical analysis of caring innursing. Jtournal of Advanced Nursing 1983; 8:289-295.

19 This very relevant question was raised by an anony-mous referee of an earlier draft of this paper.

20 Nussbaum MC. Love's knowledge. Oxford: OxfordUniversity Press, 1990.

21 Clothier C, chairman. The Allitt inquiry: independentinquiry relating to deaths and injunres on the children's wardat Grantham and Kesteven General Hospital during theperiod February to April 1991. London: HMSO, 1994.

22 Price M. Forms of life: character and moral imagination inthe novel. New Haven: Yale University Press, 1983.

23 Trautman J. Healing arts and dialogue - medicine andliterature. Illinois: Southern Illinois University Press,1981.

24 Brody H. Stories of sickness. New Haven: YaleUniversity Press, 1987.

25 Downie RS, ed. The healing arts: an Oxford illustratedanthology. Oxford: Oxford University Press, 1994.

26 Plato. The Republic. Translated by D Lee.Harmondsworth: Penguin, 1974.

27 Coles R. The call of stories: teaching and the moral imagi-nation. Boston: A Peter Davidson Book, HoughtonMiffin, 1989.

28 Vygotsky L. Thought and language. Revised and editedby Alex Kozulin. Massachusetts: MIT Press, 1986.

29 Diamond C. Losing your concepts. Ethics 1988; 98:255-277.

copyright. on F

ebruary 12, 2021 by guest. Protected by

http://jme.bm

j.com/

J Med E

thics: first published as 10.1136/jme.23.1.45 on 1 F

ebruary 1997. Dow

nloaded from