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Abstract

While there is considerable interest in the relationship between narrative and ethics, the term “narrative ethics” is often used to mean different things by different authors. For some, narrative ethics means the use of literary narratives to inform ethical deliberations; for others it involves a close listening to patients’ stories. Such approaches are certainly narratively informed, but there is nothing inherently narratival about the ethical reasoning that the narratives are employed to support. Two other approaches may, more rightly, be called “narrative ethics.” The ﬁrst of these is a narratological approach that draws on concepts from literary theory – context, character, plot, voice, point of view, and resolution – seeking to understand the process of constructing a workable story and enable those involved to reﬂect upon the type of story they construct and how they construct it. The second form of narrative ethics is one that views narrative as foundational to ethical practice. Persons are viewed as narrative beings and narrative shapes self and identity, is a form of reasoning in itself, and is a collaborative process of coauthor ship. Several criticisms of narrative ethics are raised and the responses to these considered.

Introduction

The turn to narrative in medicine is perhaps well indicated by the publication of Howard Brody’s Stories of Sickness in 1987 and Arthur Kleinman’s The Illness Narratives in 1989. Since then narrative has moved from being a subject of study in medicine to the lens through which medicine might be studied. In ethics, this move also involved a move from studying literature as a means of enhancing ethical awareness and furthering moral education to understanding narrative as a means of doing ethics.

Around the turn of the century, a good deal of interest was being expressed in addressing the relationship between narrative and bioethics with two major collections of articles (Nelson 1997; Charon and Montello 2002) presenting multiple positions on the matter, and the inaugural issue of the American Journal of Bioethics (2001) publishing a range of responses to Chambers’ (1999) The Fiction of Bioethics. In 2014, a special issue of the Hastings Center Report carried a series of articles reporting on the state of the ﬁeld. In between, the development of the ﬁeld of narrative ethics seems to have proceeded somewhat unevenly, and there are multiple positions, not always clearly demarcated, that draw on narrative as informing or constituting ethical reﬂection. One way of locating these different positions is to draw a distinction between those that draw on narrative in order to enhance the trustworthiness of medical ethics (Charon 1994) and those that view narrative, either as story or as theory, as central to our ethical understandings, or as holding some epistemological status of its own (Hauerwas and Burrell 1977). The former can be seen as being “narratively informed” and the latter, more properly, as “narrative ethics.”

Narratively Informed Ethics

Two broad approaches to narratively informed ethics can be identiﬁed. The ﬁrst is the use of narrative – and this is usually taken as meaning literary ﬁction – which may enhance our ethical sensibilities through the inclusion of circumstantial detail that enriches our understandings of medical and health care situations, through helping us recognize problems as being ethical problems and by focusing on lived experience. In so doing, literary narratives prompt us to extend our ethical imaginations, enhance our ability to empathize, and contribute to our becoming “educated” rather than simply “trained” (Downie 1999). Examples of such an approach might be the use of novels such as Huxley’s Brave New World to promote discussion on genetic engineering, Tolstoy’s The Death of Ivan Ilyich to raise discussion on approaches to death and dying, or Solzhenitzyn’s Cancer Ward discussion on paternalism, doctor-patient relationships, and the personal qualities and motivations of doctors. In this, literature is seen as a resource on which to draw as a means of enhancing the reader’s ethical sensitivity and providing guidance as to leading a moral life, with the responsibilities, obligations, and challenges that involves (Nussbaum 1992). Literature allows for the exploration of complexity, multiplicity, and uncertainty in a way that challenges more precise and philosophical approaches to ethics that are often taught in medical school and thus supports and informs direct contact with patients in their suffering.

The second approach focuses on the personal narratives of patients and those around them. By listening to patients’ stories, we glean information that may help us work through the ethical issues and implications in any given situation. In this view, narratives may provide rich data that may help us work through the ethical issues and implications arising in any given situation, enabling us to provide a fuller moral response (Davis 1991) but do not contribute to the way of reasoning. In other words, narratives may inform ethical reasoning, but are, ultimately, to be placed in the service of some other ethical framework such as principlism or the ethics of care. This view shares some of the same arguments for the inclusion of narrativist skills, namely, the interpretation of stories, an appreciation of the uniqueness of such stories, the expression of lived experience, and so on, which may all contribute to our moral sensitivity. Thus, there have been attempts to reconcile narrative with both principlism and the ethics of care, but these, in the end, still place narrative in a supporting rather than primary or equal role.

The differing perspectives on the role of narrative in the practice of ethics reveal a tension – on the one hand, a patient’s story might provide insight into the uniqueness of that individual’s experience and thus should be accorded some sort of privilege; on the other, attention to patients’ stories does not necessitate that we privilege such stories as being authoritative. Indeed, we may want to approach autobiographical accounts with a degree of caution given the epistemic problems with autobiographies: patients may lack insight into their situation, may remember inaccurately or not at all, may self-deceive, or may even outright lie. Patient stories, then, need to be worked on, from outside of the stories themselves, if they are to be ethically useful. That is, while they may describe patients’ lives well, they require some nonnarrative interpretation if they are to inform our ethical decision-making.

In each of these approaches, narrative – whether literary or personal – is seen as an adjunct to the practice of bioethics with narrative serving to support ethical development or reasoning, as “narrative contributions to the trustworthiness of medical ethics” (Charon 1994). There are, however, other approaches that accord to narrative a more central position in ethical reﬂection and are more appropriately considered as “narrative ethics.”

Narrative Ethics

As with narratively informed approaches to ethics, narrative ethics can also be viewed as comprising two broad positions. The ﬁrst of these is the narratological one, characterized by an emphasis on narrative components – such as the context, storytelling triangle, character, plot, voice, point of view, and resolution (see Charon 1994; Chambers 1999) – that have a bearing on how we think about bioethics. In this position narrative is not simply an aid to decision-making but shapes decision-making along certain contours. Through attention to context, the focus is not on “what is to be done” but on “how did we arrive at this point.”. This involves a dual focus: ﬁrst, a focus on the events, interactions, thoughts, feelings, and decisions that brought those concerned to this point, that is, the story or stories of individuals; and, second, a focus on the stories of which those individuals are a part, the stories that have, until now, shaped them and which have acted, for good or ill, as their companions. Through understanding such stories, we come to understand the moral worlds of other people. Stories, after all, “teach people what to look for and what can be ignored; they teach what to value and what to hold in contempt” (Frank 2010, p. 186). Once we understand how people arrive in the predicament in which they ﬁnd themselves, we are able to explore with them the best way to move forward (Montello 2014).

All narratives exist within what is called the “storytelling triangle.” This triangle is formed by the relationships between the three parties to any story: the author(s), the reader(s), and the story itself. All stories are composed with at least the idea of an audience and are shaped accordingly. Thus, we have a relationship between the author (s) and the reader(s) that frames the emerging story. Then, there is the relationship between the author (s) and the story itself, for example, to what extent is authorship evident within the story and what does the text imply about the author(s). Finally, there is the relationship between the reader(s) and the story: to what extent do readers accept the shaping and interpretations of the story intended by the author, to what extent are readers transported into the story, and how do readers read (do they read to ﬁnd out what the author says, or read for the difference reading might make to their lives). These relationships affect both the construction and reception of the story, and because such relationships may change over time or with changes in the story, the storytelling triangle is at all times unstable and requires constant negotiation.

With regard to character, there are three aspects that this approach to narrative ethics requires us to consider. First, there are the characters or personae that appear in the story, that is, who populates the story and in what role. The central concern here is, “Whose story is it?” The central character is, or perhaps should be, the patient, with others playing supporting roles. Sometimes, however, the patient is displaced from the central role by the privileging of stories that focus on the physician or the patient’s family. How individuals are positioned and portrayed in the story of the protagonist is importantly ethical as they may help or hinder, progress, or retard the story or disrupt or smoothly enter the narrative environment. For many patients, doctors and other medical/health care staff are merely supporting players in a longer, more complex narrative that has its origins well before they entered the story and will continue long after they leave. This is not to suggest that doctors and other medical/health care staff are always unimportant; rather, whatever role they do play, we need to remember that it is not our story but that of the patient. In other words, the various characters in the story need to be given their due and not more.

Linked to this is the second question of character, “Who is missing from the story?” and consideration of the impact of these absences upon the story and the individuals concerned. In focusing on the individual, we might inadvertently exclude others whose participation might be important. For the Hmong, for example, it is important that the community be consulted in health-related decision-making as such decisions are not purely individual or family matters; for others, the inclusion of religious leaders might be important and for still others, their friends and other signiﬁcant ﬁgures. Who is included and who is missing from the story are important considerations when helping patients develop a workable story that emerges from the context of the situation.

The third question to be considered under character is, “How are individuals in the story characterized?” Characterization is sometimes overlooked in the literature on narrative ethics but can be found as a concern in the sociology of medicine where individuals are framed or categorized (or frame or characterize themselves) in terms of moral adequacy. Such characterization might allow for the possibility of change, perhaps through education or training, or not, in which case more forceful or even coercive measures might need to be taken. Whichever may be the case, because the stories we tell have consequences, how we choose to depict individuals has an impact on how we, and others, view them (and will view them in the future), Dorothy Smith’s work K is Mentally Ill being a case in point, and is, thus, an ethical issue in itself.

It is often said that stories are either characterdriven or plot-driven. Character-driven stories revolve around a central character and often emphasize the development of that character, for example, George Bailey in It’s a Wonderful Life. Plot-driven stories rely more on events and action to move the story forward and do not necessarily involve any change or particular tension in the protagonist(s). Action movies or murder mysteries tend to be more plot-driven rather than character-driven. The process of emplotment whereby contingent events are shaped into a narrative within which such events (e.g., falling ill) are related to each other and to larger wholes (such as one’s whole-life history to date) is ethically important as it provides a means to restore integrity and wholeness to a life story that may have been disrupted or dislocated by the onset of illness. Emplotment thus works both backwards into the past – helping to answer the question, “How did we get here?”– and forwards into the future by establishing expectations. For Frank (1997) there are three possible framings of illness narratives: the restitution narrative, the chaos narrative, and the quest narrative. The restitution narrative is that which creates the expectation that while one is currently sick, at some point health with be restored; the chaos narrative is often disjointed or fragmented and one which holds out little prospect of life improving; and the quest narrative is one in which the person faces suffering in the belief that that suffering holds a lesson to be learned. Because a story does not simply reﬂect some set of external events or report external verities, but is a performance, acting on individuals in ways that make real what the story is about, enabling a patient to construct a workable plot, may not only be comforting but also may be therapeutically positive, as in the process of narrative therapy.

The question of voice is related to, but not synonymous with, the question of character. While under the rubric of character, we might ask the question, “Whose story is this?”; consideration of voice raises the question of “how is this story told.” The narrative voice of medicine tends to be third person passive, a voice that implies uniformity between narrators and objectivity of narration. What this tendency does, however, is to mask in any story the multiple voices at work and the multiple levels on which they work. The acknowledgment that most, if not all stories, contain multiple voices (patient, family members, doctors, other health personnel, religious or spiritual advisors and so on) allows for the identiﬁcation of the values being established or reﬂected in the story being told, the expression of disagreement or difference in context, characterization, or plot, and the exploration of the ethical and emotional complexity involved in the situation.

In attending to matters of context, character, plot, and voice, we are also attending, at least implicitly, to the matter of resolution. All stories require some sort of movement toward closure or resolution, and it is this movement that is important in narrative ethics. The process of narrative ethics is the construction of a workable story that will help patients and their families move forward through the disruption that illness or emergency has caused in their lives. This is not necessarily, or even primarily, a matter of solving a problem but of constructing a story that is coherent and consonant with the wider and longer stories of which it is a part and one which provides meaning and purpose and thus generates commitment to seeing it through. In this, the story does not have to be a happy one – a tragic tale, accepted as the best tale in the circumstances, may serve just as well.

The second position within narrative ethics understands narrative as foundational to the ethical enterprise. In this view it is foundational to the ethical enterprise because narrative is viewed as having peculiar epistemological beneﬁts: it is through narrative we understand experience, construct our sense of self, generate meaning and purpose, experience time, communicate with others, and act in the world. Human beings are homo narrans.

One of the ongoing debates regarding the relationship between narrative and the individual is whether narrative is a means by which we interpret and make sense of experience which is itself pre-narrative or whether experience itself is inherently narrative in nature. Crites (1971) argues that without consciousness no coherent experience would be possible, and consciousness is itself narrative in form. In other words, there is no nonnarrative experience. This view has been taken up in a number of ways by authors who argue that life and/or the self are narrative constructs and we come to know who we are by knowing the stories of which we are a part. In so doing, we understand ourselves across time through navigating between constancy and change, ourselves in relation to others by navigating between sameness and difference, ourselves in relation to the world by navigating between person-to-world and world-to-person direction of ﬁt.

The next step in this argument is that as we strive for narrative coherence – the construction of a stable pattern of beliefs, desires, values, traits, actions, and emotions that connects past, present, and future – we become increasingly responsible for our actions. Moral agency and responsibility are thus a function of our narrative self-experience (Schechtman 1996).

We do not, of course, experience ourselves in isolation, but, as indicated above, in relation to others and in relation to the world. The construction of a narratively coherent self, therefore, is assisted or hindered by how our stories interact with the stories of others. The stories of others – be they stories of other individuals, our families and friends, or wider stories of community or society, or even stories we have heard or read (ﬁctional or nonﬁction) – form the narrative environment within which we come to understand ourselves. This narrative environment is, in turn, shaped by meta or master narratives, socially shared, dominant narratives that frame what stories can be told and how. Such master narratives are not neutral but serve to demarcate the morally adequate from the morally inadequate. These master narratives are not absolute in their power to shape experience and may be resisted through drawing on stories we already know or the development of counter-stories, stories that serve to repair the damage inﬂicted on the narratively coherent (and thus morally agentic and responsible) self.

The narrative self is thus a dialogical self, a self that is shaped in, and articulates itself through, interaction with multiple levels of other stories.

All of this holds ethical import for the practice of bioethics in two ways. First, it is through listening to and appreciating the stories of patients, and the narrative environment within which those stories are being articulated, that we learn about the moral world of our patients: the ethical issues they face, the ethically salient features of their story, and their standing in this moral world. Understanding this moral world and the patient’s place in it grants insight into the sort of stories in which the patient can sustain her identity in the face of vulnerability or threat – “hold her own” to use Frank’s (2010) terms. Second, it is in the stories that we choose to construct that any rules or principles that we want to realize gain intelligibility. In other words, principles such as autonomy, beneﬁcence, non-maleﬁcence, and justice (to take but the ones generally associated with the practice of bioethics) both arise from and gain their sense and meaning through the narratives we construct and on which we draw. For example, a narrative approach may integrate the decisional, executive, and informational dimensions of patient autonomy in the capacity to develop a shared story that emerges from the past, is recognizably “one’s own,” incorporates signiﬁcant others, and projects the story into the future.

If conceiving narrative and experience (of self or identity) as inseparable is the ﬁrst tenet of a foundational approach to narrative ethics, the second is that the process of narration both frames the issues to be resolved or decided upon and provides a means whereby so to do. As narrative beings we communicate and reason through the production of stories. Linking together characters and events through time, purpose, and causality, narratives produce good reasons for acting in particular ways. Narrative as a means of making sense of the past and present thus serves as the basis on which to construct, and justify, potential futures. Choices between potential futures – or preferred narrative trajectories – can be made based on the alignment of such futures with one’s values and preferences , and the chosen narrative then becomes the framework for a plan to realize that preferred future. The narrative construction of a coherent story linking together characters and events through time, purpose, and causality may thus become a decision-making tool for bioethics in that it can embed ethical reasoning and action in lived experience, embody values and preferences , accommodate multiple voices and perspectives, and generate commitment to the preferred way forward as being consistent with stories that we know to be true in our lives.

The third tenet of this form of narrative ethics is that to be ethically useful, narration needs to be collaborative. This is so in two ways. First, in that any narrative involves the incorporation of and interaction between multiple voices and perspectives if it is to become mutually acceptable. Patients come to the clinical encounter seeking a story that will help them make sense of what is happening to them. The encounter is, of course, already framed within a narrative that identiﬁes what is happening as requiring a medical contribution. In the medical encounter, the primary story remains that of the patient (or the patient and her/his family), but this story may change in response to doctor’s medical story of illness or disease which must be incorporated into the patient’s wider story. This requires mutual respect for the story that each participant tells and an openness to the importance of the values embedded in each. In this way, the medical encounter can be seen as the negotiation of a mutually acceptable story. More complex cases will require the incorporation of further voices and will have wider implications for the patient’s wider story. Narrative collaboration is thus a process of constructing a shared story that all participants are willing to subscribe to as a basis for moving forward. The second way in which narration is collaborative is that relationships are formed and maintained through the stories we tell. While individuals are the main characters in their own stories, they are also characters in the stories of others, and these stories shape and deﬁne the relationships between characters. In other words, narrative makes sense of relationships by placing them within meaningful frameworks. Doctorpatient relationships are no exception in that together the parties need to ﬁnd ways of speaking about the situation that has befallen the patient and how the parties will stay in relationship (or not) with each other.

Critique And Response

While the use of narrative to enhance ethical sensitivity and inform ethical reasoning is relatively uncontentious, narrative as an ethical framework – that is, narrative ethics – has prompted a great deal of debate and strenuously argued counter positions. One such position is that which argues against the notion of a narrative self or narrative identity, a position forcefully argued by Strawson (1994). This position may weave together arguments from a number of threads: ﬁrst, that life is not, and is not necessarily experienced as, a narrative and is thus an empirical and descriptive counterclaim to the position outlined above; second, that personhood or the good life does not, contra Schechtman, depend upon experiencing or conceiving one’s life as a narrative, and to insist on the necessity of narrative is oppressive and itself unethical; third, that even if narrative plays a part in understanding experience, life is not, essentially, a dramatic narrative but comprises of much that is trivial, irrelevant, messy, and distracting and thus any narrative imposes a false sense of order and thus misleading; and, fourth, that narrative is secondary to experience, and thus humans are not homo narrans in any ontological sense. This challenge would seem to undermine any claim to be made for narrative that it can act as a framework for ethical reasoning. The force of the challenge relies, however, on a somewhat narrow concept of narrative. While it is conceded by many advocates of narrative that life is, indeed, messier than any narrative that can be told about it and that lives do not always follow a neatly developed plot, this does not, necessarily, mean that we should abandon the narrative approach. One does not have to establish a lifelong narrative in order for narrative to be a meaningful and effective way of being in the world – shorter, more episodic narratives will serve just as well and, indeed, may be more suited to the episodic nature of illness and clinical encounters. What is needed in these encounters is an understanding of how the patient came to be in this situation (not a life history), a workable story that links individual experience with medical explanations of illness and suffering, and the projection of a livable story into the future so as to engage the commitment of those involved to seeing it through. None of these requires a Strawsonian view of narrative and are thus not undermined by the challenge he poses.

A second challenge posed to narrative ethics is that a narrative approach does not provide guidance as to how to decide between competing stories. It is a commonplace that it is possible to tell multiple stories about the same events, a possibility that becomes important to address when those stories will shape actions and have consequences beyond simply the telling of the tale, for example, in deciding whether or not to continue nutrition and hydration. In such circumstances it may be possible to tell a number of equally well-constructed stories about how the patient and her family arrived at this point but with each story proposing a different trajectory. Appeal to notions of narrative coherency, consistency, plot, characterization, voice, and resolution internal to the stories may not provide any basis on which to decide between the ethicality of the competing stories. Having arrived at such an impasse, how might it be possible to move forward? As an initial step, it may be worthwhile to explore how this situation emerged, that is, by constructing a narrative around the issue of incommensurable stories. This might help identify paths not taken and thus open up further possibilities for narrative development. Following this, because narrative ethics works comparatively – in the sense that we compose our stories in relation to our narrative environment which includes our own stock or library of stories – seeking out new stories to enrich that environment may help in the construction of new stories that do not result in such an impasse. Comparing stories may help see through the distortions of any individual story and thus move toward the construction of stories that make life livable by those affected. In focusing on the process – narrativization – narrative ethics does not provide a formula for resolving ethical dilemmas. It does, however, help those affected to recognize and learn to live with the indeterminacy that is inherent within experience, and a story may be preferred precisely because it allows those affected in any given situation to live in that indeterminate world. Further, it is possible to identify narrative features that do allow us to discern between better and less well-told stories. When stories compete this is often because such stories are characterized by the delegitimizing of alternate stories, simpliﬁed character roles, linear plots that fail to describe the interdependence between actions and characters, and polarized or binary moral values and principles. On the other hand, seeking to accommodate all perspectives in a positive way – allowing for nuanced characters, constructing plots that are recursively complex, and incorporating complex moral positions – may lead to the construction of stories that work for all parties, an important outcome especially if the relationship between parties is likely to continue.

A third challenge posed to narrative ethics is in regard to the claims that narrative is a universal phenomenon. Barthes’ (1975) statement that there has never, anywhere, been a people without narrative is often cited in this regard as supporting the view that narrative, and by extension narrative ethics, is cross-culturally applicable. The problem with this view, however, is that as currently presented the narratological form of narrative ethics does rely on peculiarly Western understandings of concepts such as plot, characterization, voice, resolution, and so forth, and to impose this narrative form as an ethical framework can be seen as a form of colonization. Two responses to this criticism can be evinced. The ﬁrst is to draw attention to the distinction between narrative and narratology. While Barthes may be correct in claiming that stories are present in all societies, places, and times – that is, that narrative is universal – narratology may vary according to time, place, and society. Japanese and East Asian literature, for example, differs from Western literature’s mimetic thrust in being dominated by affective-expressive narration and also in the sharp distinctions between narrators and authors; Indian literature is distinguished from its Western counterparts by particular conﬁgurations of interiorization, serialization, fantasization, cyclicalization, allegorization, elasticization of time, spatialization, stylization and improvisation; and Chinese literature by the permeable boundaries between fact and ﬁction, and between author, narrator, commentator, and reader, and by a more episodic, loosely connected plot. Thus, attention to differing narratologies allows narrative ethics to be culturally adaptable and thus universally applicable. The second response focuses on the narrative environment within which narrative ethics operates. If individuals, families, communities, and societies all have stocks of stories on which they draw, attention to these stories allows for new stories to be located within, and thus have an appropriate relationship to, that narrative environment, as with the relationship between story (aggadah) and law (halakhah) in Jewish bioethics (Crane 2013). Narrative ethics can, thus, shape itself accordingly. Currently, however, there is little written on how non-Western narratologies and non-Western narrative environments might shape the practice of narrative ethics, and this remains an area for narrative ethicists to develop.

Conclusion

At one level narrative ethics appears quite straightforward – listening to and appreciating stories, after all, is something of which everyone has experience. Narrative is so ingrained into human beings that it is difﬁcult to imagine a nonnarrative means of understanding and sharing experience – and perhaps even if we could so imagine, those imaginings would themselves require narrativization. However, while the practice of narrative ethics does necessitate listening to and appreciating stories, it goes far beyond this – a beyond that requires sophistication, effort, and commitment on the part of the practitioner.

It requires sophistication because narratives and the process of narrativization are often complex and nuanced. At any point there are at least three relationships that need to be attended to: that between the author(s) and the reader(s), the author(s) and the story, and the reader(s) and the story. This triangle is, of course, never completely stable and is one of constant negotiation. Further, it requires sophistication because of the nuances of voice, of characterization, and of narration that storytelling involves. Finally, it requires sophistication because attention must be given to the narrative environment (personal, familial, organizational, community and societal narratives, and metanarratives) that shapes the emerging narratives of clinical encounters. These requirements of narrative ethics can be captured in the term “narrative literacy,” the ability to recognize, understand, and work with narratives in all their manifestations.

The practice of narrative ethics also requires effort. It requires the effort of listening closely to multiple stories and weaving these together in conjunction with others into a mutually acceptable narrative that both explains how those involved have arrived at the situation in which they ﬁnd themselves and establishes a narrative for the future that will hold together those concerned. It also requires the effort of reﬂexivity, seeing oneself as participating in the story, having an effect on, and being affected by the story. Narrative ethics is not simply a means of making decisions (though, of course, it will involve decision-making) but locating those decisions within wider contexts and attending to how those decisions ﬁt with the past and help shape the future. This requires disciplined narrative (and moral) imagination.

Finally, the practice of narrative ethics requires commitment. From the outset it requires the commitment to openness to the story of the other, to collaboration and dialogue in the construction of both backward and forward-looking narratives, and to the desires, values, hopes, and expectations of the person whose story it is. This requires a commitment to equalizing, as far as possible, the power relations inherent in the clinical encounter so that the emergent story is coauthored rather than imposed upon the patient. These commitments then allow for all parties to commit themselves to the forward-looking story and their relationship within it.

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