ethics
The work of narrative in medical ethics is done in two ways first, through the application of stories and narratives for their mimetic content that is, for what they say, and second, through the tools of literary criticism and narrative theory for their analysis of diegetic form that is, for their knowledge of how stories are told and why it matters. While narrative and narrative theory, like the form and content of a literary text, are inevitably intertwined, I shall treat them separately to assist in mapping the changing appreciation for the significance of narrative in the work of medical ethics.
In the last two decades, medical ethics has been engaged with stories in at least three significant ways first, as examples for case teaching of principle-based professional ethics, which has been the hegemonic version of medical ethics in the West secondly, as ethical instructions for a virtuous life, not merely for the practice of medicine but in every facet of one’s life, and thirdly, as witness narratives which, through their experiential truthfulness and passion, require re-consideration of habitual medical practice and ethical dictums.
Teaching principle-based medical ethics
When the medical humanities programs were initially formed in American medical schools during the 1970s and ’80s, historians, ethics, and lawyers typically led scholars of literature on the staff. During the initial years, the inclusion of literature in medicine humanities courses was most frequently defended by its work in the education of medical ethics. Stories from the literature helped flesh out problems or conflicts in medical ethics by depicting them set within a specified human context complicated by intense emotions and complicated interpersonal relations. Literature written by physicians has become classics of such education, and Williams’ and Selzer’s short stories have become widely known and commonly taught.
Told in retrospect by the doctor himself, tales like Williams’s The Use of Force and Selzer’s Brute provide an understanding of how a presumably well-meaning doctor who has good intentions still manages to harm his patient in an abuse of power. The earliest applications of these cases to medical ethics may have been confined to the application of standard ethical principles like autonomy or respect for persons, beneficence and non-maleficence, ethics, ethics and practice, medical ethics, education, social justice.
In principle-based ethics or principles, broad ethical principles are used in deductive reasoning through a case to conclude logically the optimal ethical solution to its dilemmas or issues. Both in The Use of Force and in Brute, a physician violently attacks a patient to diagnose or treat. The ethical question is whether such vigorous medical paternalism can be supported by appealing to beneficence, i.e., by insisting that what the physician did was good for the patient.
But by attending to the richly evocative language used by the doctor-narrators of these stories, readers have the opportunity to learn about more than patients’ autonomy and doctors’ paternalism. They can learn how ethical principles and arguments may sometimes be used to rationalize unethical behavior that is driven by sexual attraction and anger, or pride.
Narratives of witness
Autobiographical stories written by patients or by their relatives or friends can also be valuable to medical ethics. Such books may be of significant value as witness narratives. These stories provide commentary from the patient’s perspective on such ethical matters as autonomy and respect for persons, truth-telling and informed consent, beneficence and, at times, maleficence, and physicians’ negligence, incompetence, and mistakes.
Since these stories have now been published on the web, they have reached greater numbers and have greater potential for impacting doctors and institutions practices. Patients’ family members and friends and patients themselves are not the only ones to compose significant witness narratives.
By publishing accounts based on their own experience, physicians and other medical professionals are also able to have a strong impact on public debate about an ethical question.
In the United States, for instance, it was physicians’ accounts of helping patients to commit suicide that breached decades of professional silence and led to debate in American medical ethics journals on this question. In 1982, following Selzer’s publication of his fictional account Mercy, wherein a physician’s failed effort to assist the dying patient in causing his death by administering an overdose of morphine is described, he was subjected to hate mail.
Narrative methods of medical ethics
During those initial years of medical humanities programs in the United States, the inclusion of literature was defended either on the grounds of its contribution to medical ethics or because reading literature educates students to read in the richest sense, a skill that prepares them for the clinical work of listening to and interpreting patients’ stories and reconfiguring and retelling those stories as medical cases with plots and causality. To read in the fullest sense, students need to have mastered certain minimal skills of literary analysis.
The same questions that they learn to ask about a literary text are: Who is the narrator? Is the narrator trustworthy? From whose point of view is the story being told? What has been omitted from the story? Whose voice is silenced and why? What sort of language and imagery is used by the narrator? And what impact does that type of language have in forming patterns of meaning that arise from the text? It can be applied as well in the analysis of ethical texts and practices.
Perhaps the greatest example of applying these techniques to ethical texts is Chamber’s study of the value biases inherent in the manner in which ethicists build their cases. Chambers demonstrates how, health ethics, insurance ethics, medical philosophy, ama ethics, clinical ethics in their very first selection of point of view, vocabulary, pictures, and other stylistic elements, ethicists build arguments that direct readers towards conclusions that stem from the writer’s ethical positions and tastes.
Narrative ethics
Hunter’s research on the narrative form of medical ethics knowledge has assisted in demystifying some of the cognitive processes behind medical education and practice. In contrast to analytic philosophers, who are educated to labor deductively from general principles to the particular case, physicians are educated to labor in the reverse direction, starting with the particular case and then looking for general medical principles that may apply.
Hunter contends that this is not an inductive but an abductive practice, in which physicians toggle back and forth between a specific case and the general domain of scientific knowledge. This is like the ethical practice of casuistry, which was rehabilitated and restored to favor in a seminal book by Jensen and Toulmin. In casuistry, ethical analysis starts with the characteristics of a specific case and then attempts to remember comparable paradigm cases that can serve to illuminate the best solution for the given case. Casuistry is, perhaps, one narrative type Ethician.
But there are underlying assumptions in narrative ethics that casuistry lacks. Most prominent among them is an emphasis on the patient as the author of his or her tale, including the ethical decisions that are part of that tale. Brody has spoken of narrative ethics in which the physician must collaborate as coauthors with the patient to create a shared narrative of illness and medical treatment.
This coauthor ship entails more than the acknowledgment of the patient’s autonomy as an author. Brody refers to it as a relational ethic. Kleinman and Frank have each described it from the doctor’s and patient’s points of view, respectively, but both authors concur that such a practice of narrative is relational and involves the doctor becoming an empathic witness to the patient’s suffering.
Conclusion
In its ideal form, narrative ethics acknowledges the patient’s story as primary. Nevertheless, it invites several voices to be heard and several stories to be told by individuals whose lives will be engaged in the resolution of a case. To propel narrative ethics to the next stage of development, advocates need to figure out how training in the competence of narrative ethics can most effectively be acquired.
Reading and interpreting richly written narratives assists, and that is exactly what literature and medicine have been doing for 25 years. Patient, physician, family, nurses, friends, social workers, for instance, can all tell their stories in a dialogical chorus that can provide the best opportunity to honor all the individuals who are part of a case. However, for individuals whose professional training has not yet involved such an experience, continued education aimed at particular narrative capabilities may prove beneficial.
Whether or not increased narrative competence would make analytically trained ethicists more receptive to the potential of narrative ethics is yet to be determined, but such training will do them no harm, and it could result in more fertile ethical discussion for all of us.
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