Dr Zen's first words* capture the context perfectly. She and Mr Unger have a fixed time of five minutes available for their consultation, with penalties for Dr Zen if they run over. Dr Zen inquires how "we", not "I", can help. Chillingly, it quickly becomes apparent that "we" includes not just Corporation Enterprise but also their industrial sponsor of clinical guidelines and the manufacturer of Ease.

Of course, five minutes is never going to give Dr Zen the opportunity to explore the wealth of possible meanings behind Mr Unger's words "I don't feel well". Like many doctors under pressure, Dr Zen takes the patient's first complaint as the principal one, and limits her attention to that.1 Even using this strategy, it is unlikely that there will be time for much in the way of health promotion during this consultation. This is a pity, as Mr Unger probably consults a doctor rarely, and is at particular risk following his bereavement. And yet Dr Zen, who likes talking with her customers on her taxi shift, tries to encounter Mr Unger as a person.

All good doctors struggle continually to reconcile what have been called the biomechanical and the interpretive aspects of medical practice.2 Who would not wish to be offered care based on the best available scientific evidence? Symptom checklists, diagnostic algorithms and evidence-based guidelines provide the basis for optimising health outcomes. Furthermore, we cannot ignore the pressures of time. Even in private practice, every extra minute spent with one particular patient is a minute lost for others in the waiting room.

There is more to care, however, than the efficient optimisation of outcomes. As doctors, by listening to the patient's story we help to clarify and define their distress. By responding empathically we validate it. By exploring and discussing their symptoms we help elaborate their understanding of their bodies, and hence of themselves. Through diagnosis we provide the patient and their family with a vocabulary for their suffering, helping to integrate the illness story into their life narrative. And when we offer a prognosis and treatment, we provide elements of the plot for the patient's story of their future. Doctors who work in primary care, like Dr Zen, have an additional function, that of working with the patient to define what is to be classified as illness — and hence treated as a health problem — and what is to be regarded as one of the vicissitudes of life.3 Much mischief can arise when patients and their doctors get this distinction wrong.

Although the scenario is fictional, it is an extrapolation, if extreme, of recognisable current trends. The influence of Corporation Enterprise and its industry partners on the process of the consultation is so pervasive that they seem personified in the room.4 Dr Zen's agenda is determined almost entirely by the technologies of biomechanical medicine, even though the evidence base she mentions for Ease is quite irrelevant to a bereaved person consulting in a primary care setting. Mr Unger's agenda is crowded out; he is a case to be managed rather than a person to be cared for. The human interaction is constrained and reduced to the minimum needed to define the problem in a form recognised by a third party, and then to provide the matching treatment. And Dr Zen has little opportunity to display the qualities of sensitivity, empathy and compassion that we all need from our carers when we feel anxious and perplexed by illness.

With more time at their disposal, Mr Unger and Dr Zen would have the opportunity to discuss Mr Unger's story of illness in more depth and to consider other issues that might be troubling him. The shared understanding constructed in this conversation might still lead to the illness being labelled as depression, but other, more creative, possibilities might emerge. Perhaps Mr Unger just needs to be heard and reassured, or perhaps he is seeking a new story for his life following the death of his wife. Perhaps, too, Mr Unger has troubling physical symptoms that he is reluctant to disclose until he comes to trust Dr Zen. A richer conversation would provide Dr Zen with health promotion opportunities and a context in which to propose age- and sex-appropriate screening. And Corporation Enterprise might find that Dr Zen prescribes less, while Mr Unger reports greater satisfaction with his care.5

Medicine is fundamentally an ethical activity, concerned with right action towards others; doing the right things in addition to doing things right. While diseases can be classified, albeit imperfectly, illnesses cannot; every ill person has their own fears and concerns, hopes and needs, values and preferences. Bioscience provides the tools, but it is in the conversation between persons that the proper use of those tools is defined.