“ Narrative Ethics as Dialogical Story-Telling By a rthur w. f ra nk
N
arrative ethics ought to begin—and often end— with a story, but first, five briefest points of reorientation. Narrative ethics asks first what the problem might be for patients and their families, not for health care professionals and institutions. This shift in perspective does not devalue professional or institutional problems, but it does mark the need for a complementary form of ethics, proceeding from a different point of view. Second, narrative ethics takes seriously that people not only live their lives, but also imagine the lives they are living, and stories express those imaginations. We humans act on what we have imagined even as actions shape our imaginations. Acting and telling stories about actions are thus iterative, not sequential; each builds on the other. What stories people tell themselves about their lives is crucial to their sense of what is ethical because whatever responsibility people feel for their actions depends on their imagined lives. Any proposals that people live and act differently must make sense to those people in terms of the stories in which they imagine their lives, or else resistance is predictable. Third, most people, most of the time, want to do the right thing, and an ethics case begins when something is getting in their way. A workable sense of what is right has gotten lost, either in the sheer rush of unexpected events or in having to choose between options that all have risks and entail sadness. Finding a workable next story is a work of practical ethical thinking that proceeds according to a narrative logic. How characters realize themselves
Arthur W. Frank, “Narrative Ethics as Dialogical Storytelling,” Narrative Ethics: The Role of Stories in Bioethics, special report, Hastings Center Report 44, no. 1 (2014): S16-S20. DOI: 10.1002/hast.263
S16
through actions that fit a plot is a form of logic, albeit a logic that assumes there will be false starts and retractions, internal contradictions, and ongoing ambivalence about whether the ending was a good one or whether the story actually has ended.1 Fourth, and overarching the other points, narrative ethics seeks not to formulate its own preferred solutions, but rather to help people tell stories that imagine the best possible ways to act. Fifth, not finally but sufficiently, narrative ethics is more interested in preventing breakdowns in mutual understanding from happening in the first place than in adjudicating conflicts over preferred courses of action. The primary focus is to prevent situations from turning into cases. Thus narrative ethics necessarily morphs into narrative medicine, including in its purview how everyday clinical practice proceeds and how well such practice honors people’s stories of suffering. Narrative ethics focuses on pedagogy—teaching people how to recognize the best versions of themselves in whatever circumstances they find themselves. In adjudication, by contrast, an expert prescribes a preferred solution that participants were unable either to think of or to agree upon. Pedagogy is slower, helping people become capable of new imaginations of themselves and, crucially, of others and their imaginations about what they must do. But pedagogy has more lasting effects. All five of these points imply how narrative ethics is dialogical.2 The narrative ethicist imagines life as multiple points of view, each reflecting a distinct imagination and each more or less capable of comprehending other points of view and how they imagine. Each point of view is constantly being acted out and then modified in response to how others respond. Again, people generJanuary-February 2014/ H A S T I N G S CE NTE R RE P O RT
What matters first in narrative ethics is giving people an opportunity to hear themselves tell their own stories, and probably to tell stories repeatedly, until they find a version they can live with, at best a version worth living with. ally have good intentions, but they get stuck realizing those intentions. Stories stall when dialogue breaks down. People stop hearing others’ stories, maybe because those others have quit telling their stories. The narrative ethicist’s job is to help people generate new imaginations that can restart dialogues. Now, finally, a story that illustrates the need for narrative ethics and how such ethics is already being practiced, often intuitively, by the best clinicians. Dialogue, Not Autonomy
I
n a recent issue of the Hastings Center Report, the physician April Dworetz published a story about the hospitalization of her father-in-law, Saba.3 Saba was eighty-nine, a retired professor and clinical psychologist. Dworetz describes him as wanting to die. He was hospitalized against his wishes, initially for depression but subsequently for urinary problems requiring bladder catheterizations. Given how his hospitalization story started, his refusals of even basic blood work and medication were not surprising. Moreover, Dworetz tells us that these refusals were entirely consistent with Saba’s lifelong attitudes toward medicine. The antagonist in Dworetz’s story is Saba’s physician, Dr. Briggs, a psychiatrist who then directed treatment for urinary problems when those developed. At least there was continuity of care between Dr. Briggs’s outpatient treatment of Saba and his role when Saba was hospitalized. The problem was the quality of that care. Dworetz began to have doubts when Dr. Briggs asked her to leave the room while he talked to her father-in-law. “I sensed that Dr. Briggs was hiding something from me,” she writes. Whether or not Dr. Briggs was hiding something matters less than the illusion of concealment that he created. By asking his patient’s daughter-in-law to leave the room, Dr. Briggs missed an opportunity to find out her story of Saba’s needs, and he generated suspicion about his interventions. For narrative ethics, as for narrative medicine, everyone involved in a patient’s care needs to know what story everyone else is telling about what is happening. If some participants do not want others to know what story they are telling, that impediment to mutual understanding becomes the prerequisite ethical issue requiring consultation. Until all those directly involved in care and having claims to ethics participation can tell each other versions of
their respective stories that contain all significant details— if not every detail—then only misunderstanding can follow. Everyone needs to find everyone else’s stories at least plausible; approval of others’ stories is not necessary, but plausibility and respect are essential.4 Dr. Briggs, playing the antagonist part to the hilt, then acted like the isolated figure he had set himself up to be. When Saba wanted to leave the hospital, Dr. Briggs threatened him with the misinformation that his insurance would not pay his hospital costs if he left against medical advice. He then failed to take Dworetz’s calls or answer messages. Finally, he invoked the catch-22 that can render patient autonomy meaningless: when Saba refused surgery to treat his urinary obstruction, Dr. Briggs told him that “if he refused another catheter, he would be sent to the emergency department with certification that he lacked decision-making capacity.” Saba refused and was sent to the ER. Dworetz asks retrospectively, “Why didn’t I think of requesting an ethics consultation?” A good question, but the prior question is what kind of clinical practice could have avoided needing such consultation. Dworetz is clear that while her father-in-law was being a very difficult patient and making decisions that many people would consider irrational, he “was being himself, his decisions were in keeping with his beliefs.” Saba was acting consistently with the character he was in stories he told about himself. For narrative ethics, the issue is not autonomy; Saba might have been entitled to exercise autonomy by refusing treatment, but few would consider that a happy ending. The issue is whether either Saba or Dr. Briggs was open to examining whether the stories guiding his actions were good ones. Is the ending implied by those stories the kind of ending a human ought to want for his or her life? Saba’s story then brightens. Ethics conflict—autonomy being set in opposition to beneficence—can be avoided by a physician who practices narrative medicine, whether or not he knows that term.5 “Dr. Carey [the ER physician who attended Saba] kneeled and looked Saba in the eye when he spoke to him. He took that time to discuss both Saba’s problems and his options, and he listened to Saba’s fears and calmed them.” Saba agreed to the recommended procedures, was transferred back to the psychiatric unit, and in the moment that readers were waiting for, fired Dr. Briggs.
SPECIAL REP ORT: N a r r a t ive E t h ic s: T h e Ro le of S tori e s i n B i oe th i c s
S17
If Dworetz had asked for an ethics consultation, what might have happened? An approach that sought to adjudicate an outcome from a principle—autonomy or beneficence—would probably have intensified mutual suspicion. Court orders eventually trump. Dr. Carey presented himself first as one who listens and secondarily as an expert performing procedures. He avoided ethical conflict by practicing basic narrative medicine: he made eye contact, heard especially his patient’s fears, and calmed these fears rather than dismissing them. When a patient can believe that a physician truly is being beneficent, then not always but often that patient will agree with the physician. And reciprocally, when a physician truly grasps the grounds for a patient’s insistence on autonomy, that physician’s sense of what is beneficent often shifts. Dworetz’s story is almost too perfect a parable of narrative ethics and its allied practice, narrative medicine. A narratologist notices that the roles of antagonist and protagonist, Drs. Briggs and Carey, respectively, seem too clear-cut. The stories people tell are accurate reflections of how they feel about events and how they perceive events, but narrative structure shapes how the story is told, which shapes perceptions.6 Many narratives are structured by an opposition between antagonist and protagonist. That structure then generates interpretations of behavior. The point is not to attempt to adjudicate which came first, the actor’s actions or the casting of actors in character types whose actions are interpreted according to type. All concerned—patients, families, and health care workers— should realize that they are being cast to play parts in others’ stories and that how they are cast will affect subsequent interpretations of how they act. As storytellers, people are rarely capricious about what parts they cast others to be in their stories, although when capriciousness does happen, it is notable. But stories need certain types of characters, and so those being cast are rarely wholly responsible for what parts they end up playing. Reflectively or intuitively, Dr. Carey realized that Saba and his family would cast him in the stories they would tell about the hospitalization, and he worked to affect what kind of character they cast him to be. That work was his practical ethic. The way he played his part enabled subtle but significant changes in his patient’s response to hospitalization. Saba became a slightly but significantly different character in the co-constructed story. Practicing Post-Autonomy Ethics
I
f autonomy has been the dominant argument and practical contribution of bioethics, narrative ethics can be thought of as post-autonomy. The distinctive work of narrative ethics begins only after the battles to get autonomy recognized have been fought and—despite some remaining catch-22s—generally won.7 Once we move from Dr. Briggs
S18
to Dr. Carey, the question is about what Saba will do with his autonomy and what kind of companion his physician will be in that moral work of best using autonomy. For Saba to “go home, let his bladder burst, and die” might be autonomous, and might be consistent with how he had lived his life, but it would be a sad, even wasteful end to a life. Narrative ethics is post-autonomy in its recognition that autonomy as an isolated principle is hollow, a necessary beginning but rarely a stopping point.8 How, then, does such a post-autonomy ethics consultation proceed? Again, Dworetz’s description of Dr. Carey’s clinical practice provides a useful template. The ethics consultant first positions him- or herself as a listener. That positioning begins as a physical relation between bodies: sitting at eye level, looking at the face of the other person with the care of an artist about to sketch that face; then finding a point of stillness within oneself; and above all, being genuinely curious what story is about to be told. As this story is being told, and for some time after it is finished, there is no need to respond. The story can just sit there, being or trying to be complete in itself. The longer it sits uncommented upon, the more any cracks within it may make themselves visible. The pragmatist social-psychologist George Herbert Mead had the insight to notice the significance of the fact that people hear themselves speaking.9 In Mead’s idiom, a speaker’s words call out the same response in him- or herself that they call out in the listener. What matters first, and often most, in narrative ethics is giving people an opportunity to hear themselves tell their own stories, and probably to tell stories repeatedly, with minor variations, until they find a version they can live with, at best a version worth living with. The experienced narrative ethicist, in my view, enables people to get to a decision by themselves.10 Or, if different participants are telling stories that seem in conflict, to let them decide how their stories will change in response to others, which parts of the story do not change but can be set aside, and what kind of shared story all participants can find good enough as a basis of future action. That work of people finding their own best way does, however, often need guidance; there is a professional role to be played. People get stuck, especially in what the narrative therapists Michael White and David Epston usefully call “problem-saturated stories.”11 The stories that patients, families, and health care professionals bring to ethicists are problem saturated. Dworetz’s story of Saba is a prime example. In my interpretation of White and Epston’s work, they hear the problem-saturated story itself as a significant part of the family’s problem. They give the story their fullest attention and respect, but they refuse to treat it as a final, definitive version. The story is a contingent visitor that January-February 2014/ H A S T I N G S CE NTE R RE P O RT
families can allow to stay (which has not been working out well) or that they can change (by “restorying”). This intimation of narrative therapy—the possibility of changing a story—is sufficient to propose that narrative ethics can make too much of whether someone’s story is consistent with the life that person has led. Dworetz’s recognition that Saba’s refusals of treatment were consistent with how he had told the story of his life was a necessary beginning. But to allow narrative consistency to be a master principle guiding future acts seems to leave narrative ethics with its own thin version of autonomy. People’s lives often come to the attention of ethicists—situations become cases—when someone is upset about where narrative consistency is leading events, and very often that upset is well justified. Being consistent with my life story as I have previously told it hardly guarantees good future decisions. Dr. Carey recognized the consistency of Saba’s story, but then he liberated Saba from at least some implications of having to live a problem-saturated story. Dr. Carey heard the story through, respected it, but treated it as only one option that Saba might act upon and not one to which he had to remain bound. In White’s phrase, Saba was freed to move beyond “the negative identity conclusions . . . associated with [his story].”12 Saba became capable of receiving immediate treatment rather than going home to die. Three Concluding Questions
N
arrative ethics presupposes that people want to tell a good story of their lives, in the sense of a story that imagines life being lived well for oneself and for others.13 For narrative ethics, people’s sense of what is good depends on their interpretations of what prior stories show about what is good. People need help from ethics consultants when prior stories offer insufficient guidance in present situations, when how one wants to act is blocked, or when actions are not leading to expected consequences. Saba had all these problems—as did Dr. Briggs, if he let himself think about it. For a new story to emerge, people’s sense of how present circumstances fit old stories needs to change, and interpretations of how those old stories show what is good may also need to shift. As a narrative ethicist views a case, multiple storytellers are mutually dependent. Narrative ethics treats everyone— patients, families, health care workers, and the ethicist him- or herself—as needing to reorient their stories toward what each can accept as best for all, which often means good enough for any individual participant. Among all those who have an interest in what happens, the desires of the ill person should not automatically trump others’ needs, as in a strict autonomy model of ethics. But the ill person’s needs
and perspective do receive a preferential option. His or her suffering is most immediate. I conclude with three clusters of questions that orient the practices and goals of narrative ethics, as I imagine it. First is a question about mutual plausibility. Does each participant in the extended clinical relationships—patients, their families and caregivers, health care professionals, and possibly administrators—know what stories each of the others is telling and how those stories make others’ actions plausible? Does each regard the others’ stories as plausible, in at least a minimal sense of being worthy of respect because they have a history in that person’s life? Second, the shared trajectory question. Despite differences between the stories that participants bring to clinical relationships, do they share sufficiently similar narrative trajectories that it is possible to co-construct a future story in which all can participate? The issue here goes beyond what are often glossed as “treatment goals.” It extends to conditions that make treatments acceptable or unacceptable to patients like Saba, including dignity, companionship, and recognition.14 Third, the question of monological blocks to dialogue. Are anyone’s actions conducted by an overriding sense of narrative imperative that renders that person near insensible to others’ fears, needs, and desires? Within what larger narrative might this sense of necessity make sense? Can the person shift to understanding that theirs is only one plausible narrative among several that are at play, rather than the narrative that necessarily trumps all others? If not, this sense of narrative imperative can mark a limit for the effectiveness of narrative ethics. Narrative ethics is already being well practiced by people like Dr. Carey. This practice is contingent, adaptive, and tactful. It seeks not to assert preferred solutions but instead accepts that the “good enough” may be as much as the situation admits and as far as an ethicist should go. The pedagogical objective is to enable people to participate more fully in the dialogues in which they co-construct each others’ life stories. Those dialogues are practices of care. 1. See T. Chambers and K. Montgomery, “Plot: Framing Contingency and Choice in Bioethics,” in Stories Matter: The Role of Narrative in Medical Ethics, ed. R. Charon and M. Montello (New York: Routledge, 2002), 77-84. 2. On conditions of dialogue, see A. W. Frank, The Renewal of Generosity: Illness, Medicine, and How to Live (Chicago: University of Chicago Press, 2004). 3. A. R. Dworetz, “Reality Checks,” Hastings Center Report 42, no. 4 (2012), 7-8. 4. My usage of plausibility is derived from the oeuvre of Jurgen Habermas, especially The Theory of Communicative Action, vol. 2, Lifeworld and System (Cambridge, MA: Beacon, 1987). My imagination of narrative ethics owes much to Habermas’s “ideal speech situation,” without following his attempts at specifying linguistic conditions.
SPECIAL REP ORT: N a r r a t ive E t h ic s: T h e Ro le of S tori e s i n B i oe th i c s
S19
5. R. Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford, 2006). 6. See, among multiple sources, D. P. Spence, Narrative Truth and Historical Truth (New York: Norton, 1982) and A. W. Frank, Letting Stories Breathe: A Socio-narratology (Chicago: University of Chicago Press, 2010). 7. On autonomy battles, see R. P. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, ed. R. DeVries and J. Subedi (Upper Saddle River, NJ: Prentice Hall, 1998), 38-59. 8. Different developments of this argument are found in A. Mol, The Logic of Care: Health and the Problem of Patient Choice (London: Routledge, 2008), and C. Schneider, The Practice of Autonomy: Patients, Doctors, and Medical Decisions (New York: Oxford, 1998). 9. G. H. Mead, Mind, Self, and Society (Chicago: University of Chicago Press, 1970 [1934]). 10. For case examples, see R. Zaner, Troubled Voices: Stories of Ethics and Illness (Cleveland, OH: Pilgrim, 1993), and Conversations on the Edge: Narratives of Ethics and Illness (Washington, DC: Georgetown University Press, 2004). See also A. W. Frank, “The Philosopher as
S20
Ethicist, the Ethicist as Storyteller,” in Clinical Ethics and the Necessity of Stories: Essays in Honor of Richard M. Zaner (Philosophy & Medicine) (Dordrecht, The Netherlands: Springer, 2011), 153-63. 11. M. White and D. Epston, Narrative Means to Therapeutic Ends (New York: Norton, 1990). See also S. Madigan, Narrative Therapy (Washington, DC: American Psychological Association, 2010). 12. M. White, Narrative Practice: Continuing the Conversations (New York: Norton, 2011), 5. 13. My neo-Aristotelianism owes much to J. Lear, Radical Hope: Ethics in the Face of Cultural Devastation (Cambridge, MA: Harvard University Press, 2006). See also A. W. Frank, “Afterword,” in The Wounded Storyteller: Body, Illness, and Ethics, 2nd ed. (Chicago: University of Chicago Press, 2013). 14. Two different but complementary sources of clinical examples of such care are C. Mattingly, The Paradox of Hope: Journeys Through a Clinical Borderland (Berkeley, CA: University of California Press, 2010), and V. Sweet, God’s Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine (New York: Riverhead Books, 2012).
January-February 2014/ H A S T I N G S CE NTE R RE P O RT
N
arrative ethics ought to begin—and often end— with a story, but first, five briefest points of reorientation. Narrative ethics asks first what the problem might be for patients and their families, not for health care professionals and institutions. This shift in perspective does not devalue professional or institutional problems, but it does mark the need for a complementary form of ethics, proceeding from a different point of view. Second, narrative ethics takes seriously that people not only live their lives, but also imagine the lives they are living, and stories express those imaginations. We humans act on what we have imagined even as actions shape our imaginations. Acting and telling stories about actions are thus iterative, not sequential; each builds on the other. What stories people tell themselves about their lives is crucial to their sense of what is ethical because whatever responsibility people feel for their actions depends on their imagined lives. Any proposals that people live and act differently must make sense to those people in terms of the stories in which they imagine their lives, or else resistance is predictable. Third, most people, most of the time, want to do the right thing, and an ethics case begins when something is getting in their way. A workable sense of what is right has gotten lost, either in the sheer rush of unexpected events or in having to choose between options that all have risks and entail sadness. Finding a workable next story is a work of practical ethical thinking that proceeds according to a narrative logic. How characters realize themselves
Arthur W. Frank, “Narrative Ethics as Dialogical Storytelling,” Narrative Ethics: The Role of Stories in Bioethics, special report, Hastings Center Report 44, no. 1 (2014): S16-S20. DOI: 10.1002/hast.263
S16
through actions that fit a plot is a form of logic, albeit a logic that assumes there will be false starts and retractions, internal contradictions, and ongoing ambivalence about whether the ending was a good one or whether the story actually has ended.1 Fourth, and overarching the other points, narrative ethics seeks not to formulate its own preferred solutions, but rather to help people tell stories that imagine the best possible ways to act. Fifth, not finally but sufficiently, narrative ethics is more interested in preventing breakdowns in mutual understanding from happening in the first place than in adjudicating conflicts over preferred courses of action. The primary focus is to prevent situations from turning into cases. Thus narrative ethics necessarily morphs into narrative medicine, including in its purview how everyday clinical practice proceeds and how well such practice honors people’s stories of suffering. Narrative ethics focuses on pedagogy—teaching people how to recognize the best versions of themselves in whatever circumstances they find themselves. In adjudication, by contrast, an expert prescribes a preferred solution that participants were unable either to think of or to agree upon. Pedagogy is slower, helping people become capable of new imaginations of themselves and, crucially, of others and their imaginations about what they must do. But pedagogy has more lasting effects. All five of these points imply how narrative ethics is dialogical.2 The narrative ethicist imagines life as multiple points of view, each reflecting a distinct imagination and each more or less capable of comprehending other points of view and how they imagine. Each point of view is constantly being acted out and then modified in response to how others respond. Again, people generJanuary-February 2014/ H A S T I N G S CE NTE R RE P O RT
What matters first in narrative ethics is giving people an opportunity to hear themselves tell their own stories, and probably to tell stories repeatedly, until they find a version they can live with, at best a version worth living with. ally have good intentions, but they get stuck realizing those intentions. Stories stall when dialogue breaks down. People stop hearing others’ stories, maybe because those others have quit telling their stories. The narrative ethicist’s job is to help people generate new imaginations that can restart dialogues. Now, finally, a story that illustrates the need for narrative ethics and how such ethics is already being practiced, often intuitively, by the best clinicians. Dialogue, Not Autonomy
I
n a recent issue of the Hastings Center Report, the physician April Dworetz published a story about the hospitalization of her father-in-law, Saba.3 Saba was eighty-nine, a retired professor and clinical psychologist. Dworetz describes him as wanting to die. He was hospitalized against his wishes, initially for depression but subsequently for urinary problems requiring bladder catheterizations. Given how his hospitalization story started, his refusals of even basic blood work and medication were not surprising. Moreover, Dworetz tells us that these refusals were entirely consistent with Saba’s lifelong attitudes toward medicine. The antagonist in Dworetz’s story is Saba’s physician, Dr. Briggs, a psychiatrist who then directed treatment for urinary problems when those developed. At least there was continuity of care between Dr. Briggs’s outpatient treatment of Saba and his role when Saba was hospitalized. The problem was the quality of that care. Dworetz began to have doubts when Dr. Briggs asked her to leave the room while he talked to her father-in-law. “I sensed that Dr. Briggs was hiding something from me,” she writes. Whether or not Dr. Briggs was hiding something matters less than the illusion of concealment that he created. By asking his patient’s daughter-in-law to leave the room, Dr. Briggs missed an opportunity to find out her story of Saba’s needs, and he generated suspicion about his interventions. For narrative ethics, as for narrative medicine, everyone involved in a patient’s care needs to know what story everyone else is telling about what is happening. If some participants do not want others to know what story they are telling, that impediment to mutual understanding becomes the prerequisite ethical issue requiring consultation. Until all those directly involved in care and having claims to ethics participation can tell each other versions of
their respective stories that contain all significant details— if not every detail—then only misunderstanding can follow. Everyone needs to find everyone else’s stories at least plausible; approval of others’ stories is not necessary, but plausibility and respect are essential.4 Dr. Briggs, playing the antagonist part to the hilt, then acted like the isolated figure he had set himself up to be. When Saba wanted to leave the hospital, Dr. Briggs threatened him with the misinformation that his insurance would not pay his hospital costs if he left against medical advice. He then failed to take Dworetz’s calls or answer messages. Finally, he invoked the catch-22 that can render patient autonomy meaningless: when Saba refused surgery to treat his urinary obstruction, Dr. Briggs told him that “if he refused another catheter, he would be sent to the emergency department with certification that he lacked decision-making capacity.” Saba refused and was sent to the ER. Dworetz asks retrospectively, “Why didn’t I think of requesting an ethics consultation?” A good question, but the prior question is what kind of clinical practice could have avoided needing such consultation. Dworetz is clear that while her father-in-law was being a very difficult patient and making decisions that many people would consider irrational, he “was being himself, his decisions were in keeping with his beliefs.” Saba was acting consistently with the character he was in stories he told about himself. For narrative ethics, the issue is not autonomy; Saba might have been entitled to exercise autonomy by refusing treatment, but few would consider that a happy ending. The issue is whether either Saba or Dr. Briggs was open to examining whether the stories guiding his actions were good ones. Is the ending implied by those stories the kind of ending a human ought to want for his or her life? Saba’s story then brightens. Ethics conflict—autonomy being set in opposition to beneficence—can be avoided by a physician who practices narrative medicine, whether or not he knows that term.5 “Dr. Carey [the ER physician who attended Saba] kneeled and looked Saba in the eye when he spoke to him. He took that time to discuss both Saba’s problems and his options, and he listened to Saba’s fears and calmed them.” Saba agreed to the recommended procedures, was transferred back to the psychiatric unit, and in the moment that readers were waiting for, fired Dr. Briggs.
SPECIAL REP ORT: N a r r a t ive E t h ic s: T h e Ro le of S tori e s i n B i oe th i c s
S17
If Dworetz had asked for an ethics consultation, what might have happened? An approach that sought to adjudicate an outcome from a principle—autonomy or beneficence—would probably have intensified mutual suspicion. Court orders eventually trump. Dr. Carey presented himself first as one who listens and secondarily as an expert performing procedures. He avoided ethical conflict by practicing basic narrative medicine: he made eye contact, heard especially his patient’s fears, and calmed these fears rather than dismissing them. When a patient can believe that a physician truly is being beneficent, then not always but often that patient will agree with the physician. And reciprocally, when a physician truly grasps the grounds for a patient’s insistence on autonomy, that physician’s sense of what is beneficent often shifts. Dworetz’s story is almost too perfect a parable of narrative ethics and its allied practice, narrative medicine. A narratologist notices that the roles of antagonist and protagonist, Drs. Briggs and Carey, respectively, seem too clear-cut. The stories people tell are accurate reflections of how they feel about events and how they perceive events, but narrative structure shapes how the story is told, which shapes perceptions.6 Many narratives are structured by an opposition between antagonist and protagonist. That structure then generates interpretations of behavior. The point is not to attempt to adjudicate which came first, the actor’s actions or the casting of actors in character types whose actions are interpreted according to type. All concerned—patients, families, and health care workers— should realize that they are being cast to play parts in others’ stories and that how they are cast will affect subsequent interpretations of how they act. As storytellers, people are rarely capricious about what parts they cast others to be in their stories, although when capriciousness does happen, it is notable. But stories need certain types of characters, and so those being cast are rarely wholly responsible for what parts they end up playing. Reflectively or intuitively, Dr. Carey realized that Saba and his family would cast him in the stories they would tell about the hospitalization, and he worked to affect what kind of character they cast him to be. That work was his practical ethic. The way he played his part enabled subtle but significant changes in his patient’s response to hospitalization. Saba became a slightly but significantly different character in the co-constructed story. Practicing Post-Autonomy Ethics
I
f autonomy has been the dominant argument and practical contribution of bioethics, narrative ethics can be thought of as post-autonomy. The distinctive work of narrative ethics begins only after the battles to get autonomy recognized have been fought and—despite some remaining catch-22s—generally won.7 Once we move from Dr. Briggs
S18
to Dr. Carey, the question is about what Saba will do with his autonomy and what kind of companion his physician will be in that moral work of best using autonomy. For Saba to “go home, let his bladder burst, and die” might be autonomous, and might be consistent with how he had lived his life, but it would be a sad, even wasteful end to a life. Narrative ethics is post-autonomy in its recognition that autonomy as an isolated principle is hollow, a necessary beginning but rarely a stopping point.8 How, then, does such a post-autonomy ethics consultation proceed? Again, Dworetz’s description of Dr. Carey’s clinical practice provides a useful template. The ethics consultant first positions him- or herself as a listener. That positioning begins as a physical relation between bodies: sitting at eye level, looking at the face of the other person with the care of an artist about to sketch that face; then finding a point of stillness within oneself; and above all, being genuinely curious what story is about to be told. As this story is being told, and for some time after it is finished, there is no need to respond. The story can just sit there, being or trying to be complete in itself. The longer it sits uncommented upon, the more any cracks within it may make themselves visible. The pragmatist social-psychologist George Herbert Mead had the insight to notice the significance of the fact that people hear themselves speaking.9 In Mead’s idiom, a speaker’s words call out the same response in him- or herself that they call out in the listener. What matters first, and often most, in narrative ethics is giving people an opportunity to hear themselves tell their own stories, and probably to tell stories repeatedly, with minor variations, until they find a version they can live with, at best a version worth living with. The experienced narrative ethicist, in my view, enables people to get to a decision by themselves.10 Or, if different participants are telling stories that seem in conflict, to let them decide how their stories will change in response to others, which parts of the story do not change but can be set aside, and what kind of shared story all participants can find good enough as a basis of future action. That work of people finding their own best way does, however, often need guidance; there is a professional role to be played. People get stuck, especially in what the narrative therapists Michael White and David Epston usefully call “problem-saturated stories.”11 The stories that patients, families, and health care professionals bring to ethicists are problem saturated. Dworetz’s story of Saba is a prime example. In my interpretation of White and Epston’s work, they hear the problem-saturated story itself as a significant part of the family’s problem. They give the story their fullest attention and respect, but they refuse to treat it as a final, definitive version. The story is a contingent visitor that January-February 2014/ H A S T I N G S CE NTE R RE P O RT
families can allow to stay (which has not been working out well) or that they can change (by “restorying”). This intimation of narrative therapy—the possibility of changing a story—is sufficient to propose that narrative ethics can make too much of whether someone’s story is consistent with the life that person has led. Dworetz’s recognition that Saba’s refusals of treatment were consistent with how he had told the story of his life was a necessary beginning. But to allow narrative consistency to be a master principle guiding future acts seems to leave narrative ethics with its own thin version of autonomy. People’s lives often come to the attention of ethicists—situations become cases—when someone is upset about where narrative consistency is leading events, and very often that upset is well justified. Being consistent with my life story as I have previously told it hardly guarantees good future decisions. Dr. Carey recognized the consistency of Saba’s story, but then he liberated Saba from at least some implications of having to live a problem-saturated story. Dr. Carey heard the story through, respected it, but treated it as only one option that Saba might act upon and not one to which he had to remain bound. In White’s phrase, Saba was freed to move beyond “the negative identity conclusions . . . associated with [his story].”12 Saba became capable of receiving immediate treatment rather than going home to die. Three Concluding Questions
N
arrative ethics presupposes that people want to tell a good story of their lives, in the sense of a story that imagines life being lived well for oneself and for others.13 For narrative ethics, people’s sense of what is good depends on their interpretations of what prior stories show about what is good. People need help from ethics consultants when prior stories offer insufficient guidance in present situations, when how one wants to act is blocked, or when actions are not leading to expected consequences. Saba had all these problems—as did Dr. Briggs, if he let himself think about it. For a new story to emerge, people’s sense of how present circumstances fit old stories needs to change, and interpretations of how those old stories show what is good may also need to shift. As a narrative ethicist views a case, multiple storytellers are mutually dependent. Narrative ethics treats everyone— patients, families, health care workers, and the ethicist him- or herself—as needing to reorient their stories toward what each can accept as best for all, which often means good enough for any individual participant. Among all those who have an interest in what happens, the desires of the ill person should not automatically trump others’ needs, as in a strict autonomy model of ethics. But the ill person’s needs
and perspective do receive a preferential option. His or her suffering is most immediate. I conclude with three clusters of questions that orient the practices and goals of narrative ethics, as I imagine it. First is a question about mutual plausibility. Does each participant in the extended clinical relationships—patients, their families and caregivers, health care professionals, and possibly administrators—know what stories each of the others is telling and how those stories make others’ actions plausible? Does each regard the others’ stories as plausible, in at least a minimal sense of being worthy of respect because they have a history in that person’s life? Second, the shared trajectory question. Despite differences between the stories that participants bring to clinical relationships, do they share sufficiently similar narrative trajectories that it is possible to co-construct a future story in which all can participate? The issue here goes beyond what are often glossed as “treatment goals.” It extends to conditions that make treatments acceptable or unacceptable to patients like Saba, including dignity, companionship, and recognition.14 Third, the question of monological blocks to dialogue. Are anyone’s actions conducted by an overriding sense of narrative imperative that renders that person near insensible to others’ fears, needs, and desires? Within what larger narrative might this sense of necessity make sense? Can the person shift to understanding that theirs is only one plausible narrative among several that are at play, rather than the narrative that necessarily trumps all others? If not, this sense of narrative imperative can mark a limit for the effectiveness of narrative ethics. Narrative ethics is already being well practiced by people like Dr. Carey. This practice is contingent, adaptive, and tactful. It seeks not to assert preferred solutions but instead accepts that the “good enough” may be as much as the situation admits and as far as an ethicist should go. The pedagogical objective is to enable people to participate more fully in the dialogues in which they co-construct each others’ life stories. Those dialogues are practices of care. 1. See T. Chambers and K. Montgomery, “Plot: Framing Contingency and Choice in Bioethics,” in Stories Matter: The Role of Narrative in Medical Ethics, ed. R. Charon and M. Montello (New York: Routledge, 2002), 77-84. 2. On conditions of dialogue, see A. W. Frank, The Renewal of Generosity: Illness, Medicine, and How to Live (Chicago: University of Chicago Press, 2004). 3. A. R. Dworetz, “Reality Checks,” Hastings Center Report 42, no. 4 (2012), 7-8. 4. My usage of plausibility is derived from the oeuvre of Jurgen Habermas, especially The Theory of Communicative Action, vol. 2, Lifeworld and System (Cambridge, MA: Beacon, 1987). My imagination of narrative ethics owes much to Habermas’s “ideal speech situation,” without following his attempts at specifying linguistic conditions.
SPECIAL REP ORT: N a r r a t ive E t h ic s: T h e Ro le of S tori e s i n B i oe th i c s
S19
5. R. Charon, Narrative Medicine: Honoring the Stories of Illness (New York: Oxford, 2006). 6. See, among multiple sources, D. P. Spence, Narrative Truth and Historical Truth (New York: Norton, 1982) and A. W. Frank, Letting Stories Breathe: A Socio-narratology (Chicago: University of Chicago Press, 2010). 7. On autonomy battles, see R. P. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, ed. R. DeVries and J. Subedi (Upper Saddle River, NJ: Prentice Hall, 1998), 38-59. 8. Different developments of this argument are found in A. Mol, The Logic of Care: Health and the Problem of Patient Choice (London: Routledge, 2008), and C. Schneider, The Practice of Autonomy: Patients, Doctors, and Medical Decisions (New York: Oxford, 1998). 9. G. H. Mead, Mind, Self, and Society (Chicago: University of Chicago Press, 1970 [1934]). 10. For case examples, see R. Zaner, Troubled Voices: Stories of Ethics and Illness (Cleveland, OH: Pilgrim, 1993), and Conversations on the Edge: Narratives of Ethics and Illness (Washington, DC: Georgetown University Press, 2004). See also A. W. Frank, “The Philosopher as
S20
Ethicist, the Ethicist as Storyteller,” in Clinical Ethics and the Necessity of Stories: Essays in Honor of Richard M. Zaner (Philosophy & Medicine) (Dordrecht, The Netherlands: Springer, 2011), 153-63. 11. M. White and D. Epston, Narrative Means to Therapeutic Ends (New York: Norton, 1990). See also S. Madigan, Narrative Therapy (Washington, DC: American Psychological Association, 2010). 12. M. White, Narrative Practice: Continuing the Conversations (New York: Norton, 2011), 5. 13. My neo-Aristotelianism owes much to J. Lear, Radical Hope: Ethics in the Face of Cultural Devastation (Cambridge, MA: Harvard University Press, 2006). See also A. W. Frank, “Afterword,” in The Wounded Storyteller: Body, Illness, and Ethics, 2nd ed. (Chicago: University of Chicago Press, 2013). 14. Two different but complementary sources of clinical examples of such care are C. Mattingly, The Paradox of Hope: Journeys Through a Clinical Borderland (Berkeley, CA: University of California Press, 2010), and V. Sweet, God’s Hotel: A Doctor, A Hospital, and a Pilgrimage to the Heart of Medicine (New York: Riverhead Books, 2012).
January-February 2014/ H A S T I N G S CE NTE R RE P O RT
