Sophie Püchel

Thèse en cours sous la direction de Ralf. J. Jox, IHM, CHUV-Unil et Service de soins palliatifs du CHUV

Résumé

The ‘hospital discharge’ letter through the lens of cultural studies: ethics of an unknown genre of medical communication.

This project is part of a Swiss National Science Foundation (SNSF) project in which I will working on the medical ethics section as a doctoral student: The ’hospital discharge letter’ through the lens of cultural studies: on the narrativity, history and ethics of an unknown genre of medical communication (Nr. 10003969).
It examines the ‘hospital discharge letter’ as a standardised medical genre that is of central importance for patient care worldwide. So far, this genre has been little researched in the humanities and cultural sciences. Although thousands of these letters are issued every day, little is known about their structure, function and ethical significance. Linguists emphasise that these letters are often incomplete or difficult to understand, highlighting the need for interdisciplinary research.
As part of the SNSF project, discharge letters are examined from a literary, medical history and medical ethics perspective. From a literary perspective, it examines how hospitals discharge letters function as narrative media and structure clinical thinking. They are considered as small forms of knowledge in which knowledge about patients, bodies and illness is systematically recorded and communicated. Literary analyses show how deagentification and standardisation in the text refer to ethical questions of depersonalisation and the doctor-patient relationship. Historically, these letters emerged in the context of
standardised medicine and changing concepts of the body since the mid-20th century. The 1960s and 1970s are considered the pivotal period of modern medical ethics, in which palliative medicine, legal regulations and the modern euthanasia movement were developed as reactions to increasingly technocratic medicine. The discharge letter reflects these dynamics, influences them at the same time and raises central ethical questions about paternalism, patient autonomy, and dignity. I will working on this ethical perspective as part of the project.
Methodologically, the project is based on a historical, literary and empirical approach. Historically, a completely anonymised corpus of around 180 discharge letters and 160 patient files (1920–present) was compiled from the archives of Bern and Basel. Literarynarratological analyses examine the narrative structure, epistemic functions, deagentivisation and standardisation of the text. Ethically, the discharge letter is viewed as a medium that Sophie Püchel Summary of doctoral project increasingly addresses patients as secondary readers, creating ethical tensions between autonomy, dignity and care. The empirical component examines current writing practices of female doctors. Semi-structured interviews with 20–30 clinicians at two hospitals (Bern and Fribourg) record how hospital discharge letters are written, how doctors navigate complex patient files, combine automated data entry with narrative work, and reflect on the ethical dimension of the letters. The aim is to systematically record the narrative strategies, ethical sensitivity and writing practices of doctors.
The following five ethical dimensions are examined:

1. Fragmentation of the body in discharge letters: Discharge letters increasingly depict the body as a collection of organs, organ functions and molecular processes, which is often difficult for patients to understand.
2. Ethical consequences: Ethical consequences of this type of representation of thebody when patients read along as secondary readers and perceive themselves as a collection of difficult-to-understand findings.
3. Patient rights and discrimination: Analysis of how discharge letters can be designed in such a way that patients are neither discriminated against nor their right to knowledge and non-knowledge violated.
4. Autonomy and care: Analysis of the tension between autonomy and the principle of care in the development of the genre, especially for elderly or chronically ill patients.
5. Communication practice: Analysis of the current conditions of discharge lettercommunication, both historically and in the present, in order to developrecommendations for ethically appropriate design. Everyday clinical writing practice generates knowledge, structures patient communication and influences moral tensions.

Another focus of the project is the digitisation of hospital discharge letters and the possible use of artificial intelligence. The introduction of digital systems is fundamentally changing writing practices. Digitisation offers new opportunities in terms of automated data maintenance. At the same time, the risks, especially regarding autonomy, dignity and care, must be systematically investigated.
By combining literary studies, medical ethics and medical history, the project shows that discharge letters are both epistemically and ethically significant. They illustrate how everyday clinical writing practices generate knowledge, structure patient communication and influence moral tensions. The project contributes significantly to the further development of medical humanities and demonstrates the value of interdisciplinary research for understanding expert
prose and its impact on patients and clinical practice.