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Thematic Coherence Within Narratives: A Feature or a Bug?

Bioethics stresses that patients’ autonomy be respected, even when they make decisions contrary to their medical caregiver’s advice. However, bioethics also requires that patients show a degree of capacity, such that their decisions are perceived as rational. Without this rationality, the principle of non-maleficence comes into play, and we would be faced with a competing compelling interest to ignore a patient’s request when it would result in selfharm, or worse. When a patient’s life is at stake, arguably it is especially imperative that we employ caution when we are assessing the patient’s mental state. Goldberg (2020), in describing a method to assess this mental state of the patient regarding treatment decisions, elected to put substantial reliance in the patient’s narrative to assess their ability to make decisions to knowingly put themselves in harm’s way. Goldberg further suggests that it is the coherence of this narrative—especially thematic coherence—that is an important and useful indicator of rationality required for respecting patient autonomy. As Goldberg describes it, thematic coherence is displayed by “particular themes that are implied or explicitly affirmed by the narrator. His example: a “patient who begins her explanation about why she’s come to the doctor by stating, “Bad things always come in threes” (12). Goldberg’s focus on casual and thematic coherence within a narrative are not necessarily novel. They have long been pertinent in the context of patientresearcher relationships, where patients have inherent “bounded rationality:” while most patients are conscious and capable of making decisions for themselves, not all are consistently rational. Patients subconsciously fill in gaps in memory when relaying their narrative to their physician (Lee 2011). In the field of psychiatry and psychotherapy, clinicians have adopted the method of narrative therapy where they rely heavily on patients’ ‘testimony’ in order to reach diagnoses and treatment decisions. This model assumes that people use stories to form identity, derive meaning, and ultimately make sense of their own lives. Most significantly, these self-defining stories often involve reconstructing the past into a coherent narrative. Thus, many patients subconsciously prioritize coherence over accuracy (McAdams and Cox 2010). However, due to a combination of cognitive miserliness and easily manipulatable perceptions of reality, our personal narrative may be one of the least trustworthy criteria in deciding on treatment options. This has recently come to fore in politics where the law currently struggles with how to deal with the emerging reality that much of our personal narratives may lack accuracy and trustworthiness. In particular, narrative coherence has become an important component within the scourge of fake news, i.e., the transmission of non-fact based misinformation in the guise of truth, typically via social media channels, often for either malicious purposes or political gain. Fake news is not new, but in the not-to-distant past it was mostly limited to supermarket check-out aisle tabloids and doctored photos. However, the unfortunate confluence of the rise of citizen reporting, the decimation of professional newsrooms, and the increasingly political polarization of society, has resulted in a breeding ground of misinformation. Moreover, within the echo chamber of social media, fake news has staying power, not necessarily because we trust the source of the information, but rather because it conforms to our political sensibilities; fake news gets accepted because it kowtows to our weltanschauung and gives us coherence within our narratives, especially when those narratives rest on a profound distrust of our political opposites. For example, research has shown that implausible statements that are initially rated as untrustworthy are subsequently perceived to be more reliable upon hearing the statement for a second time. Pennycook and