Stories Matter: The Role of Narrative in Medical Ethics (Reflective Bioethics)
You will search medical textbooks in vain for the differential diagnosis distinguishing modern illness from postmodern illness. But if this dichotomy and the evolution of the former condition into the latter were established, the project of narrative ethics would follow logically. According to David Morris, a contributor to Stories Matter, the modern perspective is "biomedical": we are our genes, our organs, our laboratory measurements. The postmodern perspective is "biocultural": we are made of stories -- cultural, familial, interpersonal, psychological, emotional, and biologic narratives. "Reading" these stories from the perspective of the main characters is the job of physicians and medical ethicists. The notion that we are narratively constructed (related to the belief that reality consists of many local truths rather than one universal Truth) is called "constructionism"; it contrasts with "essentialism," the belief in a deep, permanent self. But it is unclear what ethics would entail in a world peopled by constructs -- or why any construct would concern itself with ethical behavior toward another construct. Thus, narrative ethicists embrace a modified postmodernism, in which narratives do not constitute persons but rather provide the best access to them. Although, as Charon notes, "the self cannot be created -- or even found -- independent of narrative activities," there is, according to various contributors, an "authentic" or "true" self. Despite the different perspectives of physicians and patients, they are "of the same substance at the deepest levels of human experience and value." Physicians must connect with patients at that level and flesh out their stories -- preferably escaping the realm of the "objective" professional to enter those stories as interactive, three-dimensional characters (not archetypal heroes) -- in order to make ethical decisions about patients' care. This requirement demands an involved process: one cannot simply hear a traditional case presentation, apply abstract principles (most famously, autonomy, beneficence, nonmaleficence, and justice), and rest assured of ethical rectitude. Many pertinent persons must have a voice, including those usually marginalized, for narrative ethics is allegedly democratic where "principlist" ethics is elitist. Unlike "principlism," which sees the world in black and white, narrative ethics purports to accommodate real-life grays and therefore to be more humane. This revolution in medical ethics is part of a larger transformation in the sciences -- the "narrative turn," based on the belief that much human knowledge takes narrative form. A corollary is that methods used by literary scholars in interpreting fictional narratives are valuable for those reading life stories. So for 30 years, literature has been infiltrating medical school curriculums, and for about 20 years, ethicists have drawn on methods of literary interpretation. Many of the contributors to Stories Matter are major players in this narrative movement. Here, they practice what they preach, building their essays on stories of patients who want to conceal their medical conditions from their families, 60-year-old women who want to use assisted reproductive technology, parents of infants born with neurologic injuries who want to let them die -- stories on whose proper endings reasonable people might disagree. The authors do agree on certain concepts -- the emphasis on particulars, multiple perspectives, context, and emotional as well as rational understanding. Many stress the obligation incurred by hearing a story of suffering. But because the narrative approach comprises an evolving variety of practices rather than a unified theory, these authors do not establish new rules. As a result, there is inevitably a fair amount of variation in the procedures followed, the elements of literary narrative that are deemed central (character development, plot, symbolism, closure, and voice, among others), the tools of literary interpretation that are considered useful, and the applications considered appropriate in the medical domain (deliberations of ethics committees, but also daily relations between doctors and patients and the obtaining of informed consent from study participants). Such variation is generally promising, but in some instances, dispersion highlights the theoretical danger of stretching the concept of "narrative" to the point of meaninglessness. Despite intriguing questions raised by a chapter on consent forms, for instance, I wonder whether such forms can really be considered narratives. Moreover, at times, the divergence seems similar to the conflicting perspectives valorized by the narrative approach, which hints at a practical danger: a narrative-ethical deliberation might, as it embraces ambiguity and open-endedness, "undermin[ing] the false confidence . . . that an ethical dilemma necessarily calls for or accommodates a single right action," prove to be interminable. When all the evolving stories have been told and heard, what then? How does one proceed in an environment in which there is no accessible objective truth and no rules? In this sense, narrative ethics might work better as an approach to ongoing relationships than for momentous decisions in which only one path may be chosen. Some of the contributors to this book simply delineate conflicting perspectives on a given case and leave the matter unresolved -- perhaps implying that the best course of action will become evident once the physician is transformed from detached "author" to engaged "character." Others finally return to principles, suggesting that decisions must be made on the basis of rules but will be better informed after the narrative process. Contributor Howard Brody voices the hope that principlism will turn out to have "irreducibly narrative roots" -- in which case, perhaps, it can be rehabilitated without hypocrisy. This collection provides a fascinating introduction to the field of narrative ethics. It points readers in myriad directions, offering, in endnotes to each essay, a fruitful, multidisciplinary bibliography. It should prove useful to ethicists, health care professionals, patients' advocates, and patients themselves, as they collaboratively write a new story of ethical behavior.Debra Malina, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.--This text refers to an out of print or unavailable edition of this title.