Issue link: https://www.massageandbodyworkdigital.com/i/1417136
a professional and informed guess at the relative risk. For most, the harm generated by missing a massage (even for a chronic pain patient) seems minimal compared to the risk of contracting COVID-19, infecting several others, and possibly, indirectly causing the death of one or more people. Again, it seems obvious. Or does it? Currently, the answer depends on what you believe. People still unconvinced about the dangers of the virus—and that includes many practitioners—might disagree. Others may accept the dangers of the virus, but consider they have taken all necessary safety precautions, thus reducing the relative risk to a minimum. Then there's the elephant in the room: Is this really more about losing one's livelihood and professional identity, and less about the ethical predicament? Where does risk cross the line into "harm," and whose "harm" matters more? Is the inconvenience and difficulty of having to pivot professionally actually "harm"? (What if my family starves?) Is the sense of "abandoning" a patient in need unethical? (What if they run for the opioids? What if they lose the will to carry on?) I'm using this current and very thorny issue of COVID exposure as an example, but the truth is that in manual therapy there are many similar ethical dilemmas raised, and sometimes, they're weaponized as arguments for and against particular modalities (Is there evidence?) or preferred approaches (manual therapy sucks!), 2 and these usually end up as vicious debates that go absolutely nowhere. These are difficult questions and they cannot, with the best will in the world, be reduced to memes, social media slogans, or a list of "rules" generated by people supporting either ideology. We can shout all we like on the internet, call people out, shut down conversations, and wave around terms like ethical and unethical, follow the science, evidence, and so on, but that doesn't make us right. It just destroys any possibility of actual communication or learning. So, how can they be answered? Is it even possible to cut through this noise? And if this isn't what applied ethics looks like, what does it look like? The good news is that narrative medicine gives us a way to cut through the noise. Warning: it involves openness, listening, and humility. Here's how it works. NARRATIVE ETHICS (AGAIN) Narrate means to tell a story. Narrative ethics is checking out an individual story and weighing how the main principles of bioethics apply to the clinical decision- making in response to that story. In Part 1 of this series ("Listen, My Body Electric," Massage & Bodywork, March/ April 2021, page 42), I wrote that narrative ethics starts "with the individual patient and adapts how the medical knowledge base could be appropriately applied to their particular situation." It developed precisely to deal with situations where there are no clear-cut answers, but where ethical decisions must be made. If we go back to our example looking at the relative risk of stroke versus blood thinners and relative risk of bleeding, you might note the only thing we factored in was the patient's health profile and the algorithm based on all known evidence. We did not factor in the patient's (true) story: L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 47 Summary of Bioethical Principles 3 Respect for Patient Autonomy: The final decision must be theirs and made freely Nonmaleficence: Do no deliberate harm Beneficence: Have the patient's best interests as a priority Justice: Eliminate discrimination in health-care provision on the basis of sex, race, age, beliefs, sexual orientation, or any additional factors An elderly patient had suffered from mostly controlled ulcerative colitis since early adulthood. They also had partially controlled atrial fibrillation—a heart arrhythmia increasing the risk of stroke. They had recently received an unexpected cancer diagnosis, which caused the arrhythmia to flare, and days later, they experienced two transient ischemic attacks (often considered a forewarning of a major stroke to come). The hospital cardiologist and neurologist both recommended beginning the use of aspirin or a stronger blood thinner, warning the stroke risk was severe, but the patient was fearful of the bleed risk due to the colitis, which had been flaring for some months. On refusing the medication, the patient was dismissed by both specialists as "difficult" and "stubborn." Both refused the patient's requests to discuss the relative risks and alternative options. The patient discharged themselves, expressing suicidal ideations. Within a week, they were rushed to the ER with uncontrollable gastric (gut) bleeding and only just survived emergency surgery after massive blood loss. Postsurgery, the patient was sent home with no medication to control their heart arrhythmia and were not consulted about follow-up care. A week later, they had a major stroke. On arrival back in the ER, the resident physician said to the family, "What, atrial fibrillation and no blood thinner? Of course they had a stroke; what, were they stupid?" Following a brain scan, the neurologist recommended permanent, palliative sedation citing—without a patient interview—the patient was not capable of making informed