Narrative in medical ethicsBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7178.253 (Published 23 January 1999) Cite this as: BMJ 1999;318:253
- Anne Hudson Jones, professor ()
- Institute for the Medical Humanities, 2.210 Ashbel Smith Building, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1311, USA
This is the fourth in a series of five articles on narrative based medicine
The contributions of narrative to medical ethics come primarily in two ways: firstly, from the use of stories (narratives) for their mimetic content—that is, for what they say; and secondly, from the methods of literary criticism and narrative theory for their analysis of diegetic form—that is, for their understanding of how stories are told and why it matters. Although narrative and narrative theory, like the form and content of a literary work, are inextricably bound up with each other, I will discuss them separately to help chart the evolving appreciation for the importance of narrative in the work of medical ethics.
Narrative contributes to medical ethics through the content of stories (what they say) and through the analysis of their form (how they are told and why it matters)
The study of fictional and factual stories can be an important aid to understanding in medical ethics
The techniques of literary criticism can be applied to the analysis of ethical texts and practices and can inform the understanding of different perspectives in an ethical dilemma
To understand and accept a patient's moral choices, a practitioner must acknowledge that the illness narrative has many potential interpretations but that the patient is the ultimate author of his or her own text
The use of stories
During the past two decades, stories have been important to medical ethics in at least three major ways: firstly, as case examples for the teaching of principle based professional ethics, which has been the dominant form of medical ethics in the Western world; secondly, as moral guides to living a good life, not just in the practice of medicine but in all aspects of one's life; and thirdly, as narratives of witness that, with their experiential truth and passion, compel re-examination of accepted medical practices and ethical precepts.
Stories as cases for teaching principle based medical ethics
When medical humanities programmes were first established in American medical schools in the 1970s and ‘80s, historians, ethicists, and lawyers usually preceded scholars of literature on the faculty. In the early years, the presence of literature in medical humanities programmes was often justified by its service in the teaching of medical ethics.1 Literary stories were useful in “fleshing out” issues or dilemmas in medical ethics by showing them embedded in a particularised human context complicated by powerful emotions and complex interpersonal dynamics. Works by physician-writers have become staples of such teaching, and the short stories of Williams2 and Selzer3 have become especially well known and frequently taught.
Narrated retrospectively from the doctor's point of view, stories such as Williams's “The use of force”2 and Selzer's “Brute”3 offer insight into why a presumably good doctor with beneficent intentions none the less ends up harming his patient in an abuse of power. The first uses of these stories as cases for medical ethics may well have been limited to discussions of standard ethical principles such as autonomy or respect for persons, beneficence and non-maleficence, and social justice.4 In principle based ethics, or principlism, general ethical principles are applied in a deductive analysis of a case to determine logically the best ethical resolution of its issues or dilemmas.5 In both “The use of force” and “Brute,” a doctor physically assaults a patient in order to diagnose or treat. The ethical issue is whether such powerful medical paternalism can be justified by appealing to beneficence—that is, by claiming that what the doctor did was for the patient's own good. 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 rationalise unethical behaviour that is driven by sexual attraction, anger, or pride.6–8
Narratives as moral guides for living a good life
The second way in which literary narratives have been important to medical ethics is best articulated by Coles, who is concerned with moral inquiry of a far ranging kind that does not limit itself to the practice of medicine.12 He is concerned with what it means to live a good life and, coincidentally, to practise medicine. Not professional medical ethics but existential ethics or virtue ethics is what he seeks to develop in his medical students. For this purpose Coles believes that reading novels such as Eliot's Middlemarch, Lewis's Arrowsmith, Fitzgerald's Tender Is the Night, and Percy's Love in the Ruins works better than studying analytic ethics.
Although Coles chooses more complex literary texts than the short stories that are often used as cases for the teaching of medical ethics, he chooses novels whose main characters are doctors. Yet narratives that serve as moral guides for living a good life need not be topically about medicine, as Hawkins has argued in describing her use of Dante's The Divine Comedy with medical students.13 From this broader perspective, any narrative that might instigate moral reflection about what it means to be a good person, to live a good life, and to practise a profession in an ethical manner could be considered important for medical ethics.
Narratives of witness
Autobiographical accounts by patients or by their family members or friends can also be important for medical ethics.14 These works can have considerable value as narratives of witness. Some of these narratives offer commentary from the patient's point of view on such ethical issues as autonomy and respect for persons, truth telling and informed consent, beneficence and, sometimes, maleficence—doctors' negligence, incompetence, and errors. As these narratives have begun to appear on the internet, they have reached larger audiences and have had the potential for more influence on the practices of doctors and institutions.15
Patients and their family members and friends are not the only ones who write important narratives of witness. By writing narratives from their personal experiences, doctors and other healthcare professionals also can have a powerful effect on the public discussion of an ethical issue. In the United States, for example, it was doctors' narratives of assisting patients' suicides that broke through decades of professional silence and opened debate about this issue in American medical journals. In 1982,after Selzer published his fictional story “Mercy,”3 about a doctor's unsuccessful attempt to help a terminally ill patient die by giving him an overdose of morphine, he received hate mail. A few years later, when the journal of the American Medical Association (JAMA) published “It's over, Debbie,”16 an anonymous, presumably factual account by a doctor who had deliberately given a patient who was terminally ill with cancer an overdose of analgesics to speed her death, a Cook County state's attorney took the journal's editor to court to try to force him to reveal the author's identity. The effort was unsuccessful. And a few years later, after Quill published an eloquently written account of prescribing drugs for a patient who, he knew, intended to use them to commit suicide,17 he was brought before a grand jury but was not indicted. Despite the general legal prohibition against physician assisted suicide in the United States, exemplified by the legal action taken against JAMA and Quill, doctors' narratives have helped compel re-examination of this controversial ethical issue.
Methods of literary criticism and narrative theory
In the past decade, scholars have begun to use the methods of literary criticism and narrative theory to examine the texts and practices of traditional medical ethics. What are now referred to as narrative approaches to medical ethics, or narrative contributions to medical ethics, use techniques of literary analysis to enhance the practice of principle based medical ethics. In contrast, what has become known as narrative ethics has reconceptualised the practice of medical ethics, seeking to replace principlism with a paradigmatically different practice.
Narrative approaches to medical ethics
In those early years of medical humanities programmes in the United States, the presence of literature was justified either on the basis of its service to medical ethics1 or on the basis of claims that reading literature helps teach students “to read in the fullest sense,”18 a skill that helps prepare them for the clinical work of listening to and interpreting patients' stories19 as well as reconfiguring and retelling those stories as medical cases with plots and causality.20 To read in the fullest sense students must have mastered certain basic skills of literary analysis. The same questions that they learn to ask about a literary text—who is the narrator?; is the narrator reliable?; from which angle of vision does the narrator tell the story?; what has been left out of the narrative?; whose voice is not being heard and why?; what kind of language and images does the narrator use?; and what effect does that kind of language have in creating patterns of meaning that emerge from the text?—can also be used in the examination of ethical texts and practices.
One of the best examples of applying these methods to ethical texts is Chambers's work examining the inherent value biases in the ways that ethicists construct their cases.21 Chambers shows that from their very first choices—of point of view, diction, images, and other features of style—ethicists construct cases that lead readers to the conclusions that emanate from the author's ethical theories and preferences.
Charon is the best known advocate of using the methods of literary criticism and narrative theory to help doctors and ethicists examine their ethical practices. The title of her article, “Narrative contributions to medical ethics: recognition, formulation, interpretation, and validation in the practice of the ethicist,”22 is in itself almost an abstract of the article and a summary of her position. Making doctors and ethicists more aware of the narrative aspects of their medical and ethical practice will make them better doctors and ethicists, she argues.22 She hopes that narratively competent practitioners will be able to prevent ethical dilemmas from arising by having conversations about ethics and values with their patients before a medical crisis throws them into an unanticipated ethical dilemma.
Hunter's work on the narrative structure of medical knowledge has helped clarify some of the mental processes involved in medical education and practice.20 Unlike analytic philosophers who are trained to work deductively from general principles to the particular case, doctors are trained to work in the opposite direction, beginning with the particular case and then seeking general medical principles that might apply. Hunter argues that this practice is not inductive but abductive, as doctors tack back and forth between a particular case and the generalised realm of scientific knowledge. 20 23 24 This process is similar to the ethical practice of casuistry, which was revived and rehabilitated in an influential book by Jonsen and Toulmin.25 In casuistry, ethical examination begins with the features of a particular case, then seeks to recall similar paradigm cases that may shed enlightenment about the best resolution for the case at hand. Casuistry is, arguably, one form of narrative ethics.
But narrative ethics has underlying assumptions that casuistry does not share. Foremost among them is a focus on the patient as narrator of his or her own story, including the ethical choices that belong to that story. Brody has described a narrative ethics in which the doctor must work as coauthor with the patient to construct a joint narrative of illness and medical care.26 This coauthoring involves more than simply recognising the patient's autonomy as author. Brody calls it a relational ethic.26 Kleinman27 and Frank28 have written about it from differing perspectives, the doctor's and the patient's respectively, but both agree that such a narrative practice is relational and requires the doctor to be an empathic witness of the patient's suffering.
In an ideal form, narrative ethics recognises the primacy of the patient's story29 but encourages multiple voices to be heard and multiple stories to be brought forth by those whose lives will be involved in the resolution of a case. 30 31 Patient, doctor, family, nurse, friend, and social worker, for example, may all share their stories in a dialogical chorus32 that can offer the best chance of respecting all the persons involved in a case.33
To move narrative ethics into a next phase of development, proponents must determine how training for competence in narrative ethics might best be achieved. Reading and interpreting complex written narratives certainly helps, and that is part of what literature and medicine has been doing for 25years.34 But for those whose professional training has not included such experiences, continuing education that focuses on specific narrative skills may be helpful.35 Whether or not attaining greater narrative competence would make analytically trained ethicists more open to the possibilities of narrative ethics remains to be seen, but such training will do them no harm and it may lead to richer ethical discourse for us all.
Series editor: Trisha Greenhalgh