Journal of Aging Studies 34 (2015) 183–189

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Narrative ethics for narrative care Clive Baldwin ⁎ School of Social Work, St Thomas University, 51 Dineen Drive, Fredericton, NB E3B 5G3, Canada

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Article history: Received 18 September 2014 Accepted 24 February 2015 Available online 26 March 2015 Keywords: Narrative ethics Narrative care Personhood

a b s t r a c t Narrative permeates health care—from patients' stories taken as medical histories to the development of health policy. The narrative approach to health care has involved the move from narratives in health care as objects of study to the lens through which health care is studied and, more recently, to narrative as a form of care. In this paper, I argue that narrative care requires a move in the field of ethics—from a position where narratives are used to inform ethical decision making to one in which narrative is the form and process of ethical decision making. In other words, I argue for a narrative ethics for narrative care. The argument is relatively straightforward. If, as I argue, humans are narrative beings who make sense of themselves, others, and the world in and through narrative, we need to see our actions as both narratively based and narratively contextual and thus understanding the nature, form, and content of the narratives of which we are a part, and the process of narrativity, provides an intersubjective basis for ethical action. © 2015 Elsevier Inc. All rights reserved.

Narrative permeates health care—from the use of literature in medical education to patients' stories informing clinical decision making. More recently, narrative has taken up a more therapeutic role in the form of “narrative care,” an approach that relies on storytelling to promote health and well-being. This approach focuses on the uniqueness of individual lives and roots care in the stories that people tell, in all their messiness, ambiguity, and indeterminacy. This move in the role of narrative gives us pause to reappraise current ethical frameworks that are dominant in health care, such as principlism with its abstractions and claims to universalism. In this paper, I argue that narrative care requires a narrative ethics and attempt to outline some of the broad contours of that ethics. Narrative care The concept of narrative care is only just starting to coalesce as a field of study and practice. While some narrative practices have been around for a while (e.g., narrative therapy, developed by White and Epston in the early 1990s), others are more ⁎ Tel.: +1 506 452 9596; fax: +1 506 452 0611. E-mail address: [email protected].

http://dx.doi.org/10.1016/j.jaging.2015.02.014 0890-4065/© 2015 Elsevier Inc. All rights reserved.

recently formulated (see Bohlmeijer, Kenyon, & Randall, 2011), and while there is a sense that these approaches have something in common, it is probably too early to conduct a systematic concept analysis of the term “narrative care.” Having said that, I will attempt to draw out some of what I see as the underlying similarities of different narrative approaches as the background to my argument that narrative care (whatever it turns out to be) requires a narrative ethics. At root, narrative care entails an understanding that the stories people tell about their lives, the stories that are told about their lives by others, and the wider community, social, and discoursal stories that shape human life are central to, or at least very significant in, the well-being of individuals and groups. This understanding is reflected in the following examples of such care: biographical interviews with residents of long-term care settings celebrating residents' lives (Noonan, 2011); reminiscence groups with returning veterans (Westwood, McLean, Cave, Borgen, & Slakov, 2010); lifestory telling with survivors of the Holocaust (Greenwald, Ben-Ari, Strous, & Laub, 2006); life-review therapy with depressed older adults (Korte, Bohlmeijer, Cappeliez, Smit, & Westerhof, 2012); work with male perpetrators of domestic violence (AugustaScott & Dankwort, 2002); reminiscence activity with people

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living with dementia (Gibb, Morris, & Gleisberg, 1997) or HIV infection during pregnancy (Kelly, 2013); identity reconstruction following spinal cord injury through playing sport (Smith & Sparkes, 2005); and life-writing among older adults (Synnes, 2004). Broadly defined, then, “narrative care” entails listening openly and respectfully to some portion or version of the story of a person's life, with the person being listened to experiencing an increased sense of insight, meaning, and empowerment, and thus a measure of emotional–spiritual healing. What these approaches have in common, I think, are the following features. First, narrative is in some way experiential. Indeed, Crites (1971) has argued that experience is laid down in memory in narrative form. Second, narrative in some way brings meaning to experience—for example, in the construction of restitution or quest narratives that help people understand illness in the context of their lives (see Frank, 2013). Such meanings are situated in experience, relationships, place, and history. Third, narratives are unique—they are told by a particular person to a particular audience, at a particular time and in a particular way for a particular purpose (Phelan, 2007). Fourth, narratives are inherently relational—at the very least involving the author/speaker and a reader/listener, even if the reader/listener is the author her/himself, as in the case of the narratives of private journals. Most narratives are, of course, intended for an external audience and are thus constructed accordingly. The story of my divorce, for instance, may be different according to whether the audience consists of my colleagues at work or my wife's divorce lawyer. Many narratives are more deeply relational in that they are coconstructed between author/reader–speaker/listener. This is a fundamental tenet in such narrative approaches as narrative therapy (see White & Epston, 1990), but can also be found in other approaches such as dementia care (see Williams & Keady, 2005). Fifth, narratives are fundamentally unstable, in the sense that they can be rewritten, with different meanings attributed to events, and with different future trajectories (see Freedman & Combs, 1996). Finally, narrative is seen as a means of facilitating change within individuals; in narrative terms, a form of character development. These six features of narrative care rest, I suggest, on three, related understandings of narrative—that the self is constituted in and through narrative, that narrative is a primary means of communication, and that narratives act in the world. Narrative and the self It is commonplace, although not uncontested, nowadays to refer to the “narrative self.” This term, in and of itself, begs more questions than it provides clarity, and, indeed, what different authors mean by the narrative self is often very different. Broadly speaking, there are two approaches to the narrative self: the first views narrative as a means through which to access the self, a self that is pre-existing but finds expression in and through narrative. This is the approach found in many narrative studies of identity and is what I shall call here the “weak” sense of narrative self. The second approach utilizes a deeper conceptualization of narrative, narrative as constitutive of the self. In Oliver Sacks's (1998) words, “We have, each of us, a lifestory, an inner narrative—whose continuity, whose sense is our lives. It might be said that each of us constructs and lives,

a ‘narrative,’ and that this narrative is us, our identities” (p. 110, emphasis in the original). This “strong” sense of narrative self is found in psychology with authors such as Schechtman (1996) and Bruner (1987a, 1987b, 1990, 2006) and, as far as the self is constituted in and through experience, in more philosophical works such as those of Crites (1971) and Carr (1986), who argue that experience itself is structured narratively, and Dennett (1992), who conceptualizes the self as the center of narrative gravity. Two further considerations extend these notions of the narrative self. First, drawing on Levinas (1969), it is important to note that even a deep narrative understanding of another individual does not exhaust what can be known about that person, and, ultimately, that person is radically other “in the sense of transcendence, of existing apart, of being beyond and surpassing” (Jopling, 1991, p. 413). In other words, no narrative can ever fully express what it means to be that person. Second, because of the fluid, dynamic nature of narrative, the self is always a self-in-becoming, the current narrative being unable to finalize the self. As Bakhtin (1984) says, “As long as a person is alive he lives by the fact that he is not yet finalized, that he has not yet uttered his ultimate word” (p. 59). Narratives of the self are constructed and may be told not only by ourselves but also by others and, of course, hybrids of self-other narratives. Personhood is, then, personal and interpersonal, individual, social, and institutional. Sometimes such self-other narratives converge, facilitating the construction and maintenance of the self as the center of narrative gravity; sometimes divergent narratives compete for privilege to be accepted in preference to other possible narratives and thus personhood becomes vulnerable. For example, people living with dementia often become increasingly unable to construct self-narratives in ways that are understandable to the cognitively intact. As this process continues, the narratives of others often become more important in the maintenance of personhood. In this people living with dementia are akin to Pirandello's Six Characters in Search of an Author, requiring others to complete their story. Often, this story is one of loss of self, as expressed by one family carer, “The loss of the person, the loss of their contribution to your life and who they were and the shared memories. The loss of all that person and the gaining of another difficult person in their place.” However, this need not be so, and other carers find stories to tell of their relatives that maintain a positive sense of self: She's part of the home, she's part of the family and she enriches us in ways that are phenomenal sometimes. This is the lady who has never been particularly fond of babies but she met her two great nephews, one is 1 and one 4. She's met one of them before, they've come from Australia, and she was enthralled with the baby. She's never loved babies in her life but at this moment in time babies are what fits, she likes babies and … to have that amount of pleasure given you, it makes everything worthwhile. The characterization of others in the stories we tell about them is, I suggest, an ethical issue. We can construct people in ways that focus on deficits, failings, impairments, challenging behavior, loss of self, and difficulty. Indeed, it is often such constructions that lead to diagnoses of mental disorder, labeling of deviance, and the imposition of social service

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intervention. In the field of dementia, this led to rise of the therapeutic nihilism and diagnostic overshadowing that dogged (and still dogs) people living with dementia. Alternatively, we can construct stories that focus on the maintenance of personhood, on the strengths and abilities that individuals retain, on the relationships that are deepened through such difficulties. This is not to argue that we take a Pollyanna approach that denies the difficulties faced, for example, by people living with dementia, but that we should not see these as central to their identity. Narrative, communication, and decision making In addition to shaping identity, narrative is also fundamental to communication and decision making. Phelan (2007) states that all narratives are rhetorical in that they are told by a particular person to another, for a particular purpose. As such, narratives are, in themselves, a form of communication. For Fisher (1984, 1985), the notion of narrative as communication is to be extended to include all forms of communication that appeal to reason and that narrative rationality—the convergence of coherence and fidelity—is often more powerful and persuasive than formal, logical argumentation. In politics, narrative as a means of communicating one's message is readily apparent—see, for example, Fisher's (1987) analysis of Ronald Reagan's success and Andrews's (2014) analysis of Obama's. In addition to being persuasive, narratives may also act as reasons for pursuing a particular path or making a particular decision. Tilly (2006), for example, explores how narratives can serve such justificatory purposes, and Keady, AshcroftSimpson, Halligan, and Williams (2007) and Elliott, Gessert, and Peden-McAlpine (2009) demonstrate how autobiographical narratives act as the grounding for decision making by family carers of relatives with dementia. Narratives as actors in the world Once told, narratives act in the world. Some stories, for example, are “sticky” in that they follow the individual and help shape the perceptions of others regarding the individual. One need only read Rosenhan’s (1973) study, On Being Sane in Insane Places, to appreciate how the narrative of schizophrenia stuck to the pseudo-patients, or to the diagnostic overshadowing common in dementia care (see Downs, Clare, & Mackenzie, 2006; Holland, 2000). Other authors, such as Nelson (2001), have sought to demonstrate how certain master narratives act to silence or to subordinate other narratives by acting as the background against which alternatives are evaluated. A humorous example of this is the cartoon in which doctors in white coats are holding down a patient, attempting to administer medication, with one of the doctors saying, “If you are not mad, why are you resisting our help?” In such a circumstance, whatever the patient's response might be, it would be invalidated by the master narrative of the benevolence and benignity of the helping professions. Stories can act also as either good or bad companions. The stories that we carry around with us, that we draw upon to guide us in our actions and relationships may, according to Frank (2010), serve us well or ill. Stories call upon the characters

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therein to become particular selves—much like the characters in Pirandello's play are seeking to become particular selves—and call upon the listener or reader to be transported into the world of the story and thus experience resonance with the story's characters. For Frank (2010), stories help show us what is right and what is wrong; they can serve to bring people together or to create boundaries between them; they can serve to liberate or to oppress and justify violence (see also Plummer, 1994, on the sociology of stories). Finally, narratives may promote change and, indeed, are sometimes are more effective than other means of doing so. Examples of such abound, from the impact of Uncle Tom's Cabin on the abolitionist cause; to the use of soap operas in the service of development (Slater, 2013); to overcoming resistance to cancer prevention behaviors, screening, and messages (Kreuter et al., 2007). The narrative terrain of ethics With the growth of interest in narrative, it is not surprising to find a developing literature on the subject of narrative and ethics. Broadly speaking, narrative is viewed as relevant to ethics in a number of ways. First, it is argued that stories can act as a means of moral education (see Murray, 1997) either through the lesson they teach or, as Gregory (2009) expounds, through engendering empathy and ethical sensitivity, as ethical issues can be experienced (albeit somewhat vicariously) through transportation into another story world, can extend the range of ethical experiences to which an individual is exposed, and can allow the exploration of different ways of dealing with those ethical issues. Second, some authors think that narrative can provide rich, thick data that can inform ethical decision making (see Clouser, 1996). While indeed this may be the case, this approach does subordinate narrative to a supporting role for other ethical frameworks. Some authors attempt to reconcile narrative and other approaches (see, for example, McCarthy, 2003) but often implicitly favor the other approach(es) over narrative. The third approach is to view narrative as a way of ethical understanding and reasoning in and of itself. In other words, through exploring the stories of individuals, and the wider narratives impacting upon them, it is possible to determine the plot trajectory that emerges from and continues the story in an ethical fashion, any principles, rules, or notions being embedded within that story. This is a deeply narrativized approach to ethics and rests upon quite different philosophical foundations to some other approaches to health care ethics. It is this approach that holds the most promise for an ethics of narrative care as the two align well in terms of understanding the person, in ways that other common ethical theories do not. Common ethical theories and their limitations for guiding narrative care Three normative ethical theories frequently guide decision making in health and social care: consequentialism, deontology, and principlism. I want to suggest that none of these align well with the concept of narrative care. Rather than embracing the richness, uniqueness, situatedness, and history of each ethical encounter between two or more people, they limit their focus to one narrow facet of ethical choice. All three can roughly

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be called prescriptive or normative ethical frameworks, meaning that they have distinctive rules, principles, or norms that guide decision making. The following descriptions of these frameworks outline the central features and limitations of each. Consequentialism One of the most readily identifiable ethical theories, consequentialism stems from the works of philosophers Jeremy Bentham and John Stuart Mill and looks to the consequences of an action to determine if it is right or wrong. In other words, does an action bring about a harmful or beneficial outcome to the persons concerned? For example, some carers of a relative with dementia lock the doors and windows of the house so that their relative cannot leave. From the perspective of the carers, this can be seen as an attempt to ensure their relative''s safety, that is, preventing the potential harmful consequences of her/his leaving the house and becoming lost and distressed. Another frequent example of this dilemma occurs when a person with dementia is administered pills she or he may not wish to take. If the carers for that person feel that the outcome—the benefits the pills may give—is valuable, they might hide the pill in food against the person's wishes. A crucial problem emerges for consequentialism if we refer only to the consequences of an action to establish its rightness. To rephrase slightly, does the end justify the means? By attending only to the outcome of an action, it becomes acceptable to ignore the action itself: for example, is it acceptable to justify deceiving a person with dementia into believing he is being taken for a day out in the country when in fact he is being taken to respite care, care that he has refused in the past? This is not to say that paying attention to the outcome of a choice is not important, but that a decision should be made on the basis of more than just the results of a certain situation. And this “more than,” I would argue, is the narrative nature of experience (cf. Crites, 1971) in which consequences are only part of an ongoing story involving meanings, values, intentions, hopes, desires, disagreements, reconciliations, and so on. Deontology Although there are several forms of deontology, the most recognizable stems from philosopher Immanuel Kant and foregrounds duty as primary. Deontology in a sense inverts consequentialism to place importance on one's motives as the measure of ethical behavior instead of on the consequences. However, unlike virtue ethics (another ethical theory), which emphasizes the character of the person carrying out an action, deontology simply asks whether or not a person has a duty in a particular situation or if they should be following a rule. For example, one might say we have a duty to be honest and not to deceive others. However, there are some circumstances in which it is argued that it is better to administer medications surreptitiously (a form of deceit) because the consequences of not doing so outweigh the duty of honesty. The flaw in deontology is that it attempts to remove ethical reasoning from the flux of experience in which individuals experience competing duties and obligations, which can be navigated only by reference to features of experience other than duty (if, indeed they can be navigated at all). For example, one's relationship of caring for another may determine that

lying to that person is acceptable in certain circumstances whereas the duty to be honest does not. As with consequentialism, ethical decision making involves more pieces of the puzzle than merely adhering to duty. A deontological approach to ethics attempts to draw out universal norms, an abstraction process that flies in the face of narrative care, which focuses on the unique, concrete, personal experience of individuals. Principlism Originating in medical ethics, principlism is the position that there are a priori principles that can (and should) be applied in health care decision making. There are four foundational principles—autonomy, beneficence, non-maleficence, and justice—that highlight specific domains of ethical concern (Beauchamp & Childress, 2012). Principlism has gained widespread approval in bioethics and other medical-related fields; the four principles consequently are currently very influential in ethical decision making. In making a decision about locking the doors and windows or administering increased medication against the wishes of the person with dementia, principlism would seek to weigh up the undermining autonomy through restriction of liberty and covert administration against the benefits that such restrictions and the medication might achieve, alongside the potential side effects and harm to the carer/cared-for relationship should such subterfuge be discovered. Although principlism has substantial support in medical ethics, a number of issues related to this theory have developed from the vantage point of person-centered dementia care. One of the most glaring weaknesses lies in principlism's lack of consideration for personhood or the narrative trajectory of a person's life (Baldwin & Estey-Burtt, 2013). Indeed, in the latest edition of Principles of Bioethics, Beauchamp and Childress (2012), building on Beauchamp (1999), reject personhood as a basis for moral status. Thus, principlism makes no provision either for the uniqueness of the ethical encounter (between two or more narrative Selves, who cannot be substituted for other Selves without changing the ethical encounter), or for the communal nature of decision making, as it places the most importance on individual choice (Wolpe, 1998). Decisions regarding treatment for persons with dementia can potentially involve many different people at one time as families, doctors, and the person with dementia her/himself all offer a perspective on what should be done. The imposition of a monological ethical framework onto polyphonic encounters is, in effect, a form of Levinasian violence of attempting to regularize alterity through ethical totality (see Baldwin & Estey-Burtt, 2013). While each of these frameworks is problematic in its own way, underlying each of them is the abstraction of rules or principles from the narratives “within which they gain their sense and meaning, and from which they have been abstracted” (Goldberg, 1982, p. 35). As Goldberg (1982) later says: Neither “the facts” nor our “experience” come to us in discrete packets which simply await the appropriate moral principle to be applied. Rather, they stand in need of some narrative which can bind the facts of our experience together into a coherent pattern and it is thus in virtue of that narrative our abstracted rules, principles, and notions gain their full intelligibility. (p. 242)

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In other words, narrative precedes, shapes, and legitimizes the rules or principles that might be applied, not the other way around.

Some contours of narrative ethics If the above has gained any purchase as giving grounds to think that a narrative approach to ethics might have something more to offer to narrative care than other, more wellestablished frameworks, it is incumbent upon me to at least outline what such an ethics might involve. This outline cannot but be a general survey of the terrain, a mapping of contours, for to attempt to construct a detailed code with neatly outlined specifics would be to court the danger of establishing a totalizing system such as I have criticized above. First, at root, the ethical encounter is a meeting between two or more narrative beings, a meeting that is constituted and communicated narratively, and one which produces narratives that act in the world. We cannot, therefore, look to abstract systems or frameworks of ethics for guidance in such situations without undermining the uniqueness of the individuals or the encounter. Narrative ethics is concerned with both the story that is ultimately told and the process of coming to and telling that story; in Adam Newton's words, the Said and the Saying (Newton, 1995). In narrative care, this means paying close attention to the co-construction of narratives, being aware of the potential for shaping the narrative of another individual in terms of one's own ideas as to what story should be told and how. This requires a high degree of reflexivity on the part of the narrative care practitioner and a commitment to respecting the fundamental unknowability of the other. In practice, this means being sensitive to how the other person is attempting to shape her/his own story through dialogue and building on immanent issues, that is, the themes, tropes, topics, characterizations, and accounts of events that arise from within the individual's narration, and using the individual's own language. Where examinant issues, issues from outside of the individual's story, are thought to be of help, these should be translated into immanent ones “by anchoring [these] … in the narration and applying nothing but the informant's own language” (Jovchelovitch, Bauer, et al., 2000). In this process, there is space for the character development of all parties in the choice of what stories to construct and tell, and thus what sort of self (cf. Hauerwas, 1977, on narrative, ethics, and character). The dialogic nature of the ethical encounter places all parties in the position of becoming. A second guide to ethical narrative care would be to keep open the narrative future, to allow for future becoming. This can be done, in part, by avoiding totalizing frameworks or stories that stick when the desirability of such stories, or even their usefulness, has waned, and in part by forestalling narrative foreclosure. According to Freeman (2000, 2011), narrative foreclosure takes several forms: dead ends—where the future is already locked into certain possibilities, with no apparent way of breaking out; the point of no return—a point where one must decide whether one can continue in one's story the way one has been; irrevocability—a sense of impossibility in changing or repairing what has been done, that it is too late; and existential despair—or complete despair at the

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troubles of one's life, there seemingly being no possibility of reopening one's narrative, and that the end and/or death is imminent. Totalizing frameworks and narrative foreclosure both act to finalize (in a Bakhtinian sense) an individual's story and thus self. We may promote such openness through the retelling of key stories, as “significant and complex experiences do not yield their meaning in one narration” (Ruffing, 2011, p. 107), and eliciting three forms of the unsaid (see Ruffing, 2011): through seeking further details about the story being told, thus revealing further meanings and possibilities for the story; by drawing attention to what has been backgrounded in the story, thus “inviting the ‘unsaid' into explicit awareness” (p. 120); and by identifying the clues or secrets that remain unsaid so that these may be integrated into the rest of our stories at some later point (see also de Medeiros & Rubinstein, this volume). A third guide is developing a sensitivity to, and an appreciation of, narrative webs. Narratives do not exist along but within a network, a web, of other stories. For example, the story of developing dementia is at once an individual story of illness, a couple's story of standing together, and a professional story of diagnosis, prognosis, treatment, and care. The interactions between stories can thus be as important as the stories themselves because stories are, in a sense, performative; that is, by recounting a story, we are expecting it to have an impact, to affect others, and to affect other stories. We must therefore be aware of the potential impact of the story we are telling (although, of course, once it is told we have very little control over it). For example, overemphasis on one story might distort a narrative web by creating damaging tension between different stories, such as in the case of focusing on a story of continuing decline in cognitive functioning told through repeated psychometric testing, which can undermine other stories of retained abilities that uphold a sense of self and selfesteem. Fourth, we need to be concerned with countering the oppressive metanarratives that exert considerable power over social resources, moral agency, and self-understanding, often being linked to what is perceived as being “normal” or “given,” configuring our understandings of how things should be. Many such metanarratives displace or silence the stories of individuals or smaller groups, dictating the terms by which they should live (see Nelson, 2001). Although metanarratives are often deeply entrenched in our everyday lives, it is possible to challenge them through what Nelson (2001) identifies as counterstories: “Counterstory—a story that resists an oppressive identity and attempts to replace it with one that commands respect” (p. 6). In the field of dementia, for example, Bryden (2005) offers such a counterstory, challenging the pessimism and therapeutic nihilism often associated with the condition, focusing on living well with dementia, and insisting on the uniqueness of her own situation and story which cannot and should not be subsumed into the standardized medical narrative of decline: “I choose a new identity as a survivor. I want to learn to dance with dementia. I want to live positively each day, in a vital relationship of trust with my care-partners alongside me” (p. 170). Similarly, the metanarrative of aging as senescence may be challenged by stories that generate challenge and aspiration: the award-winning Dark Horse Venture Award Scheme, which seeks to address the loneliness, boredom, and isolation of many older adults through focusing

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on their achievements and aspirations (Dark Horse Venture, 2013); the political activism of the Raging Grannies, an international political movement promoting peace, justice, and social and economic equality through song (see Caissie, 2011; Narushima, 2004); and the celebratory performances of the Zimmers (2012), a British band with a collective age of over three thousand, established to give voice to the feelings and imprisonment experienced by older adults. Concluding remarks Narrative care is concerned with how people structure their stories and thus bring meaning and significance to their lives. It is also concerned with how people construct their identities in the face of life's vicissitudes, and how they characterize, and thus shape, their relationships with others and the world. Narrative care is thus personal, experiential, concrete, and communicative. On this basis, I have argued for an ethics that is also personal, experiential, concrete, and communicative—that is, a narrative ethics. Such an ethics has a number of advantages over more theoretical, abstract frameworks in the context of narrative care. First, such an ethics, emerging as it does from the situation, is rooted in the lived experiences of those affected by the decisions to be made, and there is thus continuity of lifestory and ethics. A narrative ethics thus respects story as the fundamental form of representation for moral problems (see Walker, 2003); knowing something about how the situation arose says something about what is being attended to, the decisions to be made, and the actions to be taken, and can thus “grasp some moral problems better than standard theoretical outlooks” (Paulsen, 2011, p. 28). Second, given that real-life situations are complex configurations of a person's values, experiences, situatedness, relationships past and present, biography, and desires, an ethics that can accommodate messiness, ambiguity, and indeterminacy is called for. In considering a person's narrative wholeness, narrative ethics can help us appreciate the possible impact of emergent stories on the self and understand the richness and complexities of individual lives, and in so doing forms a basis for ethical reasoning. Third, narrative ethics aligns well with the view of narrative as a means of communication and decision making. In nursing, Keady et al. (2007) have argued for grounding clinical practice and decision making in autobiographical narratives; in health care, Robinson (2002) has shown how narrative might set up particular possibilities and courses of action and close down others; and I have argued for the narrative framing of the decision making process with regard to people living with dementia (Baldwin, 2009). Finally, such an ethics allows for the ethical decision making itself to become part of the ongoing story. Rather than viewing the decision as divorced from the decision maker, a story-based ethic recognizes that decisions made both reflect and constitute the person(s) making those decisions—thus allowing for the continuing character development of the parties involved and forestalling narrative foreclosure. In sum, narrative ethics aligns well with the nature and process of narrative care. In sharing similar philosophical foundations and similar concerns, narrative care and narrative ethics establish a partnership that focuses on the individual in

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