From "Customary Morality" to "Reflective Morality": a physician's personalized competence development facilitated by narrative medicine.

Background: Contemporary medicine faces ethical complexity arising from biotechnological advances, the growth of patients' needs, and the occurrence of cross-cultural value conflicts. These challenges expose the limits of customary morality, an unreflective and habit-driven moral framework prevalent in traditional medical training. This situation demands a more dynamic, context-sensitive, and humanistic form of moral commitment from physicians, while also requiring the development of professional competence. Narrative medicine provides a potential solution to this problem, yet its theoretical foundation remains insufficiently articulated. Method: In this paper, we propose that John Dewey's moral growth model of "reflective morality" provides a coherent and generative foundation for narrative medicine and links this process to competence development within competency-based medical education (CBME). Results: The core tools of narrative medicine, close reading and reflective writing, are grounded in Dewey's moral development model, which encompasses habit, impulse, and deliberative intelligence. Reflection on habitual behavior during narrative practice works as a corrective to clinical habits, affective responses are examined and integrated through affiliation and reflection, and contextual deliberative intelligence is cultivated through reflective practice. These practices facilitate physicians' moral development, enable them to develop moral perceptiveness, decision-making capabilities, and initiative, and help them progress from passive moral conformity to active ethical agency, thereby enacting the transition from Dewey's philosophical "customary morality" to "reflective morality". This framework further facilitates the cultivation of personalized competency, a dimension of professional competence essential to patient-centered care yet resistant to conventional training. Conclusion: This paper provides a Deweyan theoretical foundation for narrative medicine by interpreting its reflective practices through Dewey's distinction between customary and reflective morality. It proposes a habit-impulse-intelligence framework to explain the moral developmental mechanisms through which narrative medicine may influence physicians' professional formation, connecting this process to the cultivation of personalized competence.