Microsoft Word - Moulesetal2013.docx 1 University of Calgary Corresponding Author: Dr. N.J. Moules Email: njmoules@ucalgary.ca Journal of Applied Hermeneutics March 21, 2013 The Author(s) 2013 “Isn’t All of Oncology Hermeneutic?” Nancy J. Moules1, David W. Jardine1, Graham P. McCaffrey1, & Christopher Brown1 Abstract In this paper, we describe an event during a pediatric oncology research meeting that prompted the discussion of the ways in which hermeneutics brings a different kind of understanding to both research and practice. We claim that oncology is the practical science of handling natural science research and as such practice in oncology is deeply hermeneutic in character in its recog- nition of the importance, vitality, and generativity of the “individual case” even in the face of amassed, verified, and aggregate knowledge that is given from the natural science research. On- cology is always contingent, next case handling, and is not identifiable simply as something de- termined and guided by natural sciences alone. In the face of this, we propose that there is an ob- vious, profound, and natural fit of hermeneutic research in understanding the lives, relationships, suffering, and experiences that are affected by cancer. Keywords childhood cancer, Gadamer, hermeneutics, pediatric oncology, Robert Buckman The impetus for this paper arose during an Alberta Children’s Hospital pediatric oncolo- gy research day in November 2012 in Calgary, Alberta where dedicated researchers present- ed the work they were currently conducting in efforts to cure, treat, and make sense of child- hood cancer. Most of the research presented was that of bench and natural science, under- standing the progression of tumours, the im- pact of radiation on mice, randomized control trials, or evidence of the potential of a new chemotherapeutic agent. Dr. Nancy Moules, Alberta Children’s Hospital Foundation and Research Institute Nursing Professorship in Child and Family Centred Cancer Care, pre- sented her research on understanding the im- pact of childhood cancer on lives and rela- tionships, and her research approach of her- meneutics. In this context with this audience, it is a shared understanding that there is a very human experience of cancer and an apprecia- tion that bench science offers one way of Moules et al. Journal of Applied Hermeneutics 2013 Article 3 2 knowing that must be translated in another kind of knowing that is handled in the day-to- day practical decisions, judgments about, and interactions with those undergoing such expe- riences. Cancer is readily understood as an affliction that can affect all aspects of a per- son’s life, a phenomenon replete with com- plex and often contradictory cultural, histori- cal, and personal/familial understandings, as- sumptions, hopes, fears, and expectations. There exists a whole world of lived experi- ence that precedes bench science and provides it with the contexts of its application and the conditions of its value. Moules, in her description of hermeneu- tics as a legitimate research method in under- standing cancer, moved past the very public cry for finding “cures” for cancer and into the lives of people who have cancer, who may or may not be treated successfully, who may die, who may suffer losses to their sense of self, their body image, or their peace of mind. There is something inherently difficult when we add this mention of suffering. Over and above the sought-for clarities of bench sci- ence, doctors, nurses, and other health profes- sionals must learn to live with what they know and to handle this knowledge well, with a sense of dignity and proportion that is acute- ly aware that this knowledge inevitably in- vokes a whole life-world of experience and faces medical practitioners and patients and families alike with the experience of suffering. In the valuation of research that seeks for cure, there is hope and fear, and an awed waiting upon the presumed inevitable triumph of sci- ence. Hermeneutics is a form of research into the effects of cancer on individuals and fami- lies, as well as the effects of cancer on those treating such individuals and families, a method that opens a way to inquiry into all of these considerations, in all their awkwardness and difficulty. Yet, in this context, as in many others, hermeneutics is again and again re- quired to account for itself, while all along addressing the suffering that is attendant upon childhood cancer. Hermeneutics is frequently asked to live up to the ways, means, and methods of the natural sciences. In addressing the issue of numbers and power in this kind of research, Moules briefly outlined some of the ideas in Dr. David Jardine's (1992) “The Fecundity of the Indi- vidual Case” which demonstrated the strengths that surround hermeneutic work and the vital importance of hermeneutics as a way to understand the living character of our liv- ing professions. It is in the power of the par- ticular - in the recognition of one voice, one experience, one diminishment of suffering, one experience of healing - that our profes- sions have always found their real power and their real, living knowledge. It is in the mo- ment of being present at the death of one child; or watching one patient walk for the first time on artificial limbs; or the privilege of being present while this family hears bad news or good news. It is in the richness of the power of these individual, particular moments of grace, kinship, and human relationship where the professions have always found their own graceful and powerful place - in the con- text of one human life, here and now, in this, and this, and this (Wallace, 1987). In this forum and in reaction to this sketching out of the nature of hermeneutic knowledge and its place in our profession, Dr. Peter Craighead, Professor and Head of the Department of Oncology at Tom Baker Can- cer Centre, rose and said, in response. “Yes, this makes sense to me. Isn’t all of oncology hermeneutic?” A part of this response was rooted in Dr. Craighead's respect for a recently deceased colleague. Dr. Robert Buckman died at 63 years of age on October 9, 2011. A renowned medical oncologist, author, and comedian, Dr. Buckman was known for his unorthodox ap- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 3 proach to illness and death. He was reported to have once commented that it was the indi- vidual person who changed his practice every time. In this regard, Dr. Buckman was argu- ing for something subtly hermeneutic about his practice and about the knowledge that arises only in practice. It was not simply that the individual patient was more important than his aggregate knowledge of oncology, but that the confrontation with the individual, the particular, always enlivened, challenged, and informed that very knowledge, keeping it awake, alert, and in proper perspective. He held his amassed professional knowledge with a certain readiness and “lightness,” as could always be seen from the often sheer delight with which he greeted “the next case.” The next case always seemed to arrive as an op- portunity to open up his vast knowledge and to let it be susceptible to what enlivening dif- ference this new arrival might make. He em- bodied this openness with his patients, with the general public, and in relation to his own suffering. Dr. Buckman provided us with a strong confirmation of the vitality and im- portance of hermeneutics to professional life and practice, as demonstrated in the title of one of his books, Cancer is a Word, Not a Sentence (2006). For the experienced practitioner, the arri- val of “the next case” involves its arrival into a territory of knowledge and experience for which that case provides a live and rich occa- sioning of our attention. The experienced practitioner is one who must remain open to such arrivals and the differences that can be made to them, to us and to the life and well- being of the living discipline(s) we are inhab- iting with our patients and their families. The word “case,” long since incorporated into medical, legal, and other professional speech, has this sense of arrival in its origin. Case de- rives from the Latin casus, meaning a chance, occasion, opportunity; accident, mishap. Lit- erally, it means “a falling.” In the 13th century, it had the meaning of “what befalls one” and in the 18th century began to be adopted by medicine (Online Etymology Dictionary, 2012). A case is something that has befallen one. Despite the professional control implied in the “case history” or the “case study,” when a doctor or nurse meets a person with cancer, something “befalls” the professional too. The next case of a patient is not simply an “existential” matter of it being this person and no one else, and therefore a matter of the irreplaceable life of this individual who is not replaceable in their suffering with anyone else. All this is certainly true. The issue is what difference it makes to those of us who already know much about such suffering, who have already witnessed a long line of symptoms and presentations and varieties of heartache or fear or bold readiness to do “battle” with the invader. The issue is how our knowledge is not simply “amassed verified knowledge” (Gad- amer, 1989, p. xxi) anonymously held in some figurative storehouse, so that this new arrival simply gets slotted into the right locale of that store. Our knowledge is also a form of readiness for new experience it opens towards this new arrival in anticipation of being called to account, of being summoned and needing to respond professionally, “properly,” in ways that Gadamer (1989) described as “relations of responding and summoning” (p. 458). This describes the profound vulnerability of our professional bearing that we deliberately make ourselves and what we know suscepti- ble to the subtleties of what is arriving. More than this, it is because we are experienced that we are able to find this carrying of our- selves practicable, day-to-day. This suscepti- bility is a matter of how we experience our experience; whether we can see ourselves not only out of the authority of our expertise, but also as being experienced by the other. Expe- rience in this sense includes humility; it is permeable and reciprocal, and inevitably at- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 4 tendant upon that which it does not produce from itself and its own storehouse of knowledge. As Gadamer (1996) noted in his essay Hermeneutics and Psychiatry, “…the doctor needs more than just scientific and technical knowledge and professional experience” (p. 172). The doctor or the nurse also needs a well-honed sense of practical knowledge and practical judgment, wherein individual cases are treated with a sense of proper proportion borne of practice itself (what Aristotle called phronesis rather than techne). These two forms of knowledge are not in a battle with one another for the same territory or voice, but neither is one simply replaceable for the other or able to do the work of the other. “Although the expertise of a technical knowledge...has a proximity to phronesis, technical knowledge does not ask the question of the good or the just comprehensively, or it does not allow us to act comprehensively in each situation” (Gadamer, 2007b, p. 232). An experienced hematologist/oncologist col- league offered this view: I deal with very nasty malignant diseas- es. Fatal if our therapies don’t work. Each of these diseases can be categorized under broad headings and, as our knowledge advances, increasingly narrow sub- headings. Such a degree of organization implies that a process of inquiry about this disease has revealed enough to form the basis of a broadly accepted approach to the disease, a therapeutic plan, a man- agement strategy. For many disease enti- ties we have such an approach. “You have disease X and the book says do this.” It doesn’t always work as well as is hoped but at least we have a plan. This makes medicine sound quite formulaic and from a biomedical perspective this is what we strive for - - the magic formula. A moment of reflection will reveal that these formu- lae provide strategies for managing dis- eases. But diseases exist in people and our magic formulae rarely take that into ac- count. Hermeneutics provides a form of research geared to precisely such difficult accounting. It does so by reformulating what it means to “apply” what one knows in a specific case. It is not that those who practice within the natu- ral sciences and help to develop such knowledge that provide formulae do not care about individual cases; they do this work be- cause they care deeply. Hermeneutics, how- ever, maintains that the difficulty of these cases and the complexity of the human expe- rience of them can be understood and known. Science might question the study of such things as perhaps only subjective, private, and even indemonstrable, or that if they are to be studied, they must be subjected to the particu- lar rigour of the scientific method. Hermeneu- tics provides a way to study human experi- ence that does not subject it to the demands of the natural sciences, but still provides dynam- ic, rich, compelling, and detailed understand- ing and description that leaves all of their dif- ficulty and ambiguity in place and makes it available to thinking, communication, sharing, and a deeper understanding of, and sensitivity to, the subtleties of lived experience. Hermeneutics also provides ways to im- prove practice through studies of lived expe- rience by pointing to the layers of ambiguous entailment in which live with our patients – the coming of the death of a child is trouble- some, terrible, surrounded by myriad tales, images, and fears. Understanding this in detail improves the practice of oncology, not by “nailing down” something more securely but by honing and shaping our ability to be aware of and articulate our lived surroundings. In Truth and Method, Gadamer (1989) demonstrated how understanding, in this her- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 5 meneutic sense, is “more a passion than an action” (p. 366). It is not the application of a rule to a case but more like the application of a case to a rule. Our already established “magic formulae” must befall and respond to the demands that the new case brings and ex- pects of such knowledge. This knowledge is something we must therefore “undergo,” something we must “suffer.” In choosing to work in an area such as oncology, one agrees to this hermeneutic wager, to a willingness to not only suffer but to “suffer together” in the way that Moules (1999) wrote of compassion as a hermeneutic endeavor that is willful and deliberate. This is why Gadamer suggested that at the heart of this living knowledge is an old Greek adage: pathei mathos: “learning through suf- fering” (Gadamer, 1989, p. 356), an idea itself inherited from the Greek tragedies of Aeschy- lus (c. 525 BCE). The hermeneutic tradition recognizes that there is something inherently difficult and transformative in the act of be- coming experienced in the ways of the world, and from such a process “no one can be ex- empt” (Gadamer, 1989, p. 355). This claim about experience extends across the whole gamut of human life, from small, exhilarating interruptions of one’s expectations (moments of inquiry, learning, engagement, investiga- tion, questioning) to traumatic experiences of mortality, impermanence, and illness (mo- ments considered “life changing”). In all these cases, the learning and teaching that ensues is understood as “an adventure and, like any ad- venture, it always involves some risk” (Gad- amer, 1983, p. 141), including, of necessity, “moments of loss of self” (Gadamer, 1977, p. 51) wherein who I understand myself to be and what I understand of the world might have to endure suffering change. This is why, as professionals, we are drawn towards the suffering of others because it is there that we experience a deep insight into our shared hu- man lot. This, again, recalls the example of Dr. Buckman and his willingness to step into the suffering of others and to use his own suffer- ing as way to help others. Application is neither a subsequent nor merely an occasional part of the phenom- enon of [hermeneutic] understanding, but codetermines it as a whole form the be- ginning. This does not mean that…he first understands [some pregiven universal] per se, and then afterward uses it for particu- lar applications. Rather, the interpreter seeks no more than to understand this uni- versal -- i.e., to understand what it says, what constitutes [its] meaning and signifi- cance. In order to understand that, he must not try to disregard himself and his partic- ular hermeneutical situation. He must re- late [it] to this situation if he wants to un- derstand at all. (Gadamer, 1989, p. 324) This next patient, this next presentation of symptoms, these next uttered words of con- cern, do not simply “fall under” general prin- ciples or established knowledge, but ask something of this knowledge. They ask of the general principle that it proves itself “in this case” to be adequate to such a case. This abil- ity to deftly judge the relationship between established knowledge and the arrival of a new case is itself a type of practical knowledge that does not operate in the same way as the establishment of that natural scien- tific knowledge itself. It is, rather, a cluster of contingent practical judgments. One can be- come practiced in such judgments, but one cannot give a set of rules for how to make such judgments because those rules, in turn, would require cultivating, in practice, an un- derstanding of their application. Each patient is embarking on a difficult journey on a road that is unknown to them. A part of our responsibility as phy- sicians is to prepare our patients for the journey and then walk with them. That Moules et al. Journal of Applied Hermeneutics 2013 Article 3 6 comes partly by providing them with in- sight about what may lie ahead and the likelihood of having to change plans ac- cording to what happens on the jour- ney. The conversation needs to be ongoing and open-ended. Things change. I start such a conversation by asking the patient and family to explain to me what they know about their disease and what is be- ing offered. For me, it defines the starting point and strategy of our ongoing conver- sation and it is often a unique starting point and always a unique strategy. The hermeneutic object of interest is the abil- ity, in practice, to recognize a case as a case of some general principle, as a case that ex- emplifies it, modifies it, defies it, or “nearly fits” or demands that our established knowledge gain more subtlety, differentiation, and acuity. This judgment is not a matter of simply applying the general principle to the case, but allowing the case to “speak back” to that already-established knowledge in such a way that the case puts the principle into ques- tion and demands that the knowledge already established gives an account of its applicabil- ity in the face of the demands made by the case: The ordering of life by rules of law…is incomplete and needs productive supple- mentation. At issue is always something more than the correct application of gen- eral principles. Our knowledge…is always supplemented by the individual case, even productively determined by it. The judge not only applies the law in concreto, but contributes through his very judgment to developing the law. [Our knowledge] is constantly developed through the fecundi- ty of the individual case. (Gadamer, 1989, p. 38) The individual case on which judgment works is never simply a case; it is not ex- hausted by being a particular example of a universal law or concept. Rather, it is al- ways an “individual case,” and it is signif- icant that we call it a special case, because the rule does not [and cannot] compre- hend [this individuality]. Every judgment about something intended in its concrete individuality (e.g., the judgment required in a situation that calls for action) is -- strictly speaking -- a judgment about a special case. That means nothing less than that judging the case involves not merely applying the universal principle according to which it is judged, by co-determining, supplement, and correcting that principle. (Gadamer, 1989, p. 39) Negotiating this susceptibility of estab- lished knowledge to the arrival of the next case is the work of hermeneutics and it is the work of oncology. “The true locus of herme- neutics is this in-between” (Gadamer, 1989, p. 295). This is how professions, of necessity, are not simply the impervious and imperial wielding of “amassed verified knowledge.” Professionals seek out instances of suffering or undergoing, instances of susceptibility where the locale of meeting a challenge to our knowledge is at once a locale of meeting our patient “in” this suffering, “in” the locale of taking seriously their arrival as requiring us, with all our aggregate knowledge of, and fa- miliarity with, such matters, to engage this arrival. We, like them, must allow what we know to come into play with the person that has arrived with questions, knowledge, fears, concerns, evidence, foibles, resolve, and all the particularities of presentation. This is the negotiation that is at the heart of diagnosis, that our aggregate knowledge is not simply a slot into which the new patient fits, but is, ra- ther, something that must, with great subtlety, respond well to that arrival and let that arrival do the work proper to its particularity. We know, as professionals, that we can, with those new to our profession, lay out the crite- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 7 ria of a particular pathology, but we cannot outrun the difficulty of recognizing this case as an example of that pathology. I met with the patient and family to dis- cuss what we had to offer to treat the leu- kemia and our chances of success. They asked insightful questions. I was told, “if my number is up there is nothing I can do about it but let’s try our best.” There was a peace in the room. The treatment went well at the beginning but then went off the rails. Each challenge was faced with de- termination and a calmness as “the num- ber” came up. Our conversations had re- mained easy despite the increasing gravity of what we were discussing and often we had shared a laugh. After many weeks of struggle, the patient passed away with the family at their side. This is a practical form of knowledge that cannot be amassed theoretically, nor can it be simply handed over to another professional without that person having to now cultivate this knowledge for him or herself. A common adage in the work of oncology is the “experienced” practitioner. Hermeneu- tics identifies how “becoming experienced” is not a matter of simply an increased expertise in “amassed verified [bench science] knowledge” (Gadamer 1989, p. xxi) but an increased deftness in how one “handles” such knowledge in practice. Being experienced does not culminate in knowing more and bet- ter than anyone else (the sort of required ex- pertise in the “amassed verified knowledge” of one’s field requisite of being “knowledge- able in the field”). Hermeneutics points to an- other vital and essential form of knowledge and experience that are not of the same kind of knowledge as this expertise. “Experience has its proper fulfillment not in definitive [amassed] knowledge but in the openness to [new] experience[s] that is made possible by experience itself” (Gadamer 1989, p. 355). An experienced doctor or nurse, therefore, is not simply someone who as been in such a pro- fession for many years. Being experienced, in hermeneutics, is connected with an old con- cept from the Humanist tradition: Bildung (Bruford, 2010; Gadamer, 1989; Pinar, 2011; von Humbolt 2000), a German term meaning self-formation, that is, the endured process of becoming someone in the act of coming to know about oneself and the world. This site of becoming someone is the site of pathei mathos because it requires a type of “under- going” or “suffering” in which one risks be- coming changed and having to live with the consequences. I met with the patient and family to dis- cuss what we had to offer to treat the leu- kemia and our chances of success. They asked insightful questions. I was told, “if my number is up there is nothing I can do about it but let’s try our best.” There was palpable fear in the room and the patient looked truly terrified. The next questions were, “what will happen to me?” and “what are my chances?” I started over again and tried a different approach. The treatment went badly from an early stage. Each challenge was faced with de- termination but the terror never left the patient’s eyes. I was never sure if my con- versations were answering their questions or addressing their needs. After many weeks of struggle, the patient passed away with the family at their side. This situation started and ended the same as the one described before it, but in the middle of it something changed, something that called the oncologist to realize that no amount of amassed and aggregate knowledge or mas- tery of such knowledge, no “magic formulae,” could save the oncologist from the “delibera- tion and decision” to move and act differently in this case (Gadamer, 1983, p. 113). Gada- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 8 mer advanced the idea of hermeneutics as a condition of being human, an inescapable immersion in making sense of the world, but always finitely, always open to re- interpretation. This does not mean, however, that hermeneutic reflection is automatic. Bild- ung demands effort and practice; hermeneutic experience has an ethical dimension of choos- ing to make oneself available to the difficulty of life, the pathei mathos. In this encounter, the oncologist persevered in the face of the disease, in facing the terror in the patient’s eyes, and in facing the fact that he could nev- er be sure. Concluding Reflections When a diagnosis is confirmed for a patient, or particular symptoms are described as such, the oncologist is able to “hear” a wide range of possibilities and probabilities. There is an ability to know, from long experience, some- thing of a patient's possible future(s) and pos- sible future suffering in ways that someone without this expertise simply could not. This is not exactly the same as simply “having the facts” but rather knowing that the facts alone will not save you or address the situation. There is that wonderful/terrible weight of then having to decide what might be best to say or not say, to indicate, or clothe, or to be straightforward about. This sort of judgment and its soundness and trustworthiness is an amazing thing. As professionals knowledgea- ble in our fields, we sometimes hold back in having a patients bear all the weight of what could be said, not to be dishonest, but to be measured and to try to act properly, in proper proportion to the best reading that can given of the full breadth of the circumstances. This is something of why and how we are profes- sionals and not only technicians in possession of amassed scientific knowledge: The way of life of human beings is not fixed by nature like other living beings. Knowingly preferring one thing to another and consciously choosing among possible alternatives is the unique and specific characteristic of human being. The knowledge that gives direction to action is essentially called for by concrete situa- tions in which we are required to choose the thing to be done and no learned and mastered technique can spare us the task of deliberation and decision. (Gadamer, 2007b, pp. 230-231) Even though we slowly, through practice and experience, become more receptive to the arrival of the next case and the difference it will bring, it always also feels like the first time as well; it feels brand new - - this family, that child, those odd descriptions of symp- toms, real, imagined, dreamt, feared, or seen with terrible clarity. As Buckman reminded us, walking into the room of the next patient will forever change our practices, but this requires an awareness that something has changed as well as an opening not to just find what fits with what we already know but what informs us anew. Gadamer (2007a) suggested that “[the world] compels over and over, and the better one knows it, the more compelling it is. This is not a matter of mastering an area of study” (p. 115). This is the practical knowledge or “being experienced” that is the object of research in hermeneutic work and it: does have a certain proximity to the expert knowledge that is proper to technique, but what separates it fundamentally from technical expertise is that it expressly asks the question of the good--for example, about the best way of life [or about what course of action would be better than oth- ers]. It does not merely master an ability, like technical expertise, whose task is set by an outside authority [e.g., the methods of natural science in producing experi- Moules et al. Journal of Applied Hermeneutics 2013 Article 3 9 mental results, or the simple rote follow- ing of procedures in a hospital unit] or by the purpose to be served by what is being produced [e.g., given we have to reduce wait times, do this instead of that]. (Gad- amer, 2007b, p. 232) Robert Buckman knew something of suf- fering, but perhaps his greatest wisdom was that he did not claim to know it with certainty and finality, because he understood that that is not our lot, as humans, to know once and for all. Even knowledge that has been pinned down with great precision by natural scien- tific methodology does not help us avoid hav- ing to decide, contingently and carefully, as to whether this is a case of that, and if it is, what we might now best do with those whose suf- fering is in our hands. Buckman saw suffering as the thing that could only be approached through a hermeneutic wager that the next “case” would indeed change the face of un- derstanding the minute the door was opened. Oncology is world of discovery, of devout care and intense search for cure. The natural and biological sciences are responsible for significant decreases in cancer morbidity, long-term cure, and longevity of life. This world of science and discovery is vital but there is another world inherent in oncology - - a world of the individual case, the n=1. This is a particular world of suffering that is not dis- embodied or detached from the rest of the world of scientific discovery, for it is fecund with its own kind of discovery, where fear shows or it does not, and even if the outcomes are the same, the process of getting there nev- er is. It is the argument for the innate fit of hermeneutic inquiry and research into the worlds of particulars, worlds that do not stand alone but have always something to say to the next door. Authors Nancy J. Moules, RN, PhD is a Professor in the Faculty of Nursing at the University of Calgary. She also holds an Alberta Children’s Hospital Foundation/Alberta Children’s Hos- pital Research Institute Nursing Professorship in Child and Family Centred Cancer Care. David W. Jardine, PhD is a Professor in the Faculty of Education at the University of Cal- gary. Graham P. 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