Silence and Oppression in Narrative Approaches to Healthcare

The “narrative turn” in healthcare urges that listening to patient stories is morally and medically important. I largely agree. However, not everyone has equal access to telling stories and to having them heard, and so not everyone equally benefits from a narrative turn. Importantly, injustice and oppression often manifest in silencings, and so uncritically focusing on available stories risks upholding existing disparities. My dissertation argues that we should be concerned not only with how to engage with patient stories, but also to more critically engage with silences. First, I argue that narrative approaches require a more critical account of silence and silencing than current literature admits. I propose an operating account of silences as disruptions in expected or valued modes of communication, and which considers patient silences neither as mere absences nor restricted to speech. Second, I argue that different varieties of silencing demand different responses, and that these cannot be uniformly reduced to the usual calls to share one’s story, to break the silences, or to become more virtuous listeners. Third, I elaborate on these arguments by examining varieties of silencing that are often neglected in existing literature: silencing as a strategy of resistance, silencing in suicide prevention research, and silencings maintained by built environments. Ultimately, I argue that narrative approaches to healthcare must critically attend to the variety and complexity of patient silences. By better understanding the complexities of silences and silencings, we are better positioned to identify and respond to silences as they appear. Where existing literature argues for developing competencies in listening and engaging with stories, my arguments call for more critical attention to the preconditions of stories and silences, to the presumed value of stories over silence, and to the potentials of choosing silence.

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