4. An (Incomplete) Bibliography on Attention
"The development of the faculty of attention forms the real object and almost the sole interest of studies." - Simone Weil
Kestrel, Alexis Lours, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons
Much of my current thinking on attention was primed by the way it was introduced during my training in Narrative Medicine. My mentor Rita Charon would often quote the line from Henry James’ The Wings of the Dove where the protagonist Milly Theale meets with a physician:
“So crystal clean the great empty cup of attention that he set between them on the table…it was like an absolute possession, a new resource altogether, something done up in the softest silk and tucked away under the arm of memory.” (Book 5, Chapter 3)
In the practice of narrative medicine, attention makes a space or opening, that leads to representation (the rendering of experience in listening, interpretation, or writing) and affiliation (aligning and with a patient in the shared experience of the clinical encounter). Furthermore, acts of representation and affiliation hone the attention of the clinician, creating a cycle of deepening engagement. Within this approach, attention is crucial (see Narrative Medicine[1], The Principles and Practice of Narrative Medicine[2] and Close Reading and Creative Writing in Clinical Education[3]): possibly “the most pivotal skill with which to endow a health professional who wants to be a healer.”[4] Seeking out ways and spaces to better understand and incorporate into practice this “great empty cup” of attention became a catalyst in clinical work and reflection.
In list form, here are several other sources that inform our approach:
Emmanuel Levinas’ Totality and Infinity,[5] Otherwise than Being,[6] and the interview transcript Ethics and Infinity,[7] in which the French philosopher develops his concepts of the Face and the Saying and Said, both of which contribute elements to understanding of the immediacy of the interpersonal encounter and its role in ethics and communication.
Philosopher and cultural critic Matthew Crawford’s books Shop Class as Soulcraft,[8] a mediation on the nature of technical work, and The World Beyond Your Head: On Becoming an Individual in an Age of Distraction,[9] a detailed study of attention in the contemporary landscape.
Crawford is a reader of Iris Murdoch, whose essay The Sovereignty of Good[10] outlines several connections between the intellectual, ethical, and attentive modes of being. In one section, she writes about learning Russian, and the way that a discipline of instruction can lead to a moral/ethical awakening:
“My work is a progressive revelation of something which exists independently of me. Attention is rewarded by a knowledge of reality. Love of Russian leads me away from myself toward something alien to me, something which my consciousness cannot take over, swallow up, deny or make unreal.” (87)
It is possible to see how the study of medicine, both in its technical aspects and rigor, and also in the opportunities for what Murdoch calls “unselfing” that come about when witnessing the phenomenon of disease and affliction, can serve a similar role.
Murdoch, in turn, was a close reader of Simone Weil. In particular, Weil’s essays Reflections on the Right Use of School Studies[11] and Human Personality,[12] the essay Forms of the Implicit Love of God,[13] and sections from her notebooks reproduced in Gravity and Grace,[14] build up a nuanced characterization of the ethical and interpersonal implications of attention. In School Studies, Weil writes:
“[T]he development of the faculty of attention forms the real object and almost the sole interest of studies” (57).
And in Human Personality, in a gloss on the Biblical story of the Good Samaritan, that
“Only one stops and turns his attention toward [the suffering other]. The actions that follow are just the automatic effect of this moment of attention” (90).
A recent paper exploring these ideas can be found here.[15]
Thinking about ways to operationalize these ideas in the material conditions of the hospital or clinic, we began to become interested in ways that attention is characterized from the lens of cognitive science, diagnostic accuracy, and work measurement and design. Philosopher Wayne Wu’s book Attention[16] includes a comprehensive catalog of different ways of thinking about attention and different areas of tangency between philosophy and neuroscience. It helped us to develop some of the initial categories that grew into this scoping review[17] identifying various methods for measuring aspects of attention (such as vigilance, task switching, and cognitive load).
There is a body of literature on cognitive load in the healthcare environment that is relevant to many of these concerns.[18-22]
The scoping review led to the discovery of a delightful series of articles by social scientists Klaartje Klaver and Andries Baart, which are grounded in the kind of broad interdisciplinary thinking that motivates our work.[23-25]
In Attentiveness in Care, the authors write:
“We argue [that] attentiveness is not only the first step in care, but also a good in itself. Attentiveness makes people flourish, it makes them do well.”
The authors distinguish between “instrumental attentiveness” that takes a dominant role in contemporary healthcare, emphasizing the concrete ends such as patient compliance that might be reached through greater attention, and instead elevated “beneficent attentiveness,” a broader and more deeply transformative attentiveness that “creates a space in which a relationship may arise.”
There are many more on our list, some of which we have just begun to explore, including writing by Martha Nussbaum, William James, Michael Polanyi, and Maurice Merleau-Ponty. As we branch into conversations about emerging technologies and their role in the clinical environment, it doesn’t escape us that the foundational article that paved the way for large language models involved a technological innovation that enabled a different method for training and was titled Attention Is All You Need. And we continue to be interested in the locus between these philosophical ideas and the everyday encounters of the hospital and clinic.
Reference list
1. Charon, R., Narrative medicine: Honoring the stories of illness. 2008: Oxford University Press.
2. Charon, R., The principles and practice of narrative medicine. 2017: Oxford University Press.
3. Charon, R., N. Hermann, and M.J. Devlin, Close reading and creative writing in clinical education: teaching attention, representation, and affiliation. Academic Medicine, 2016. 91(3): p. 345-350.
4. Charon, R., Narrative medicine: attention, representation, affiliation. Narrative, 2005. 13(3): p. 261-270.
5. Levinas, E., Totality and infinity: An essay on exteriority. Vol. 1. 1979: Springer Science & Business Media.
6. Levinas, E., Otherwise than being or beyond essence. 1981: Springer Science & Business Media.
7. Levinas, E. and P. Nemo, Ethics and infinity. 1985.
8. Crawford, M.B., Shop class as soulcraft: An inquiry into the value of work. 2009: Penguin.
9. Crawford, M.B., The world beyond your head: On becoming an individual in an age of distraction. 2015: Farrar, Straus and Giroux.
10. Murdoch, I. and M. Midgley, The sovereignty of good. 2013: Routledge.
11. Weil, S. and J. Soskice, Reflections on the Right Use of School Studies with a View to the Love of God. In: Waiting for God. 2021: Harper Collins.
12. Weil, S., ed. Human Personality. In Simone Weil: An Anthology. ed. S. Miles. 1986, Weidenfeld & Nicolson: New York.
13. Weil, S., Forms of the Implicit Love of God. In: Waiting for God. 2009: Harper Collins.
14. Weil, S., Gravity and Grace. 2002: Routledge.
15. Kissler, M., The Rarest and Purest Form of Generosity: Simone Weil’s Attention and Medical Practice. Journal of Medical Humanities, 2024. 45(4): p. 391-402.
16. Wu, W., Attention. Second ed. 2024: Routledge.
17. Kissler, M.J., et al., Attention Among Health Care Professionals: A Scoping Review. Annals of Internal Medicine, 2024.
18. Harry, E., et al., Cognitive load and its implications for health care. NEJM Catalyst, 2018. 4(2).
19. Szulewski, A., et al., From Theory to Practice: The Application of Cognitive Load Theory to the Practice of Medicine. Academic Medicine, 2021. 96(1): p. 24-30.
20. Douglas, H.E., et al., Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature. Applied ergonomics, 2017. 59: p. 45-55.
21. Burden, M., L. McBeth, and A. Keniston, Salient Measures of Hospitalist Workload. JAMA Network Open, 2023. 6(8): p. e2328165-e2328165.
22. Coiera, E., The cognitive health system. The Lancet, 2020. 395(10222): p. 463-466.
23. Klaver, K. and A. Baart, Attentiveness in care: Towards a theoretical framework. Nursing ethics, 2011. 18(5): p. 686-693.
24. Klaver, K. and A. Baart, How can attending physicians be more attentive? On being attentive versus producing attentiveness. Medicine, Health Care and Philosophy, 2016. 19: p. 351-359.
25. Klaver, K. and A. Baart, Managing socio-institutional enclosure: A grounded theory of caregivers' attentiveness in hospital care. European journal of oncology nursing, 2016. 22: p. 95-102.