9/10 Narrative Ethics

narrative ethics

an approach to bioethics where we gain insight into ethical dilemmas + how to resolve them thru stories, rather than applying generalizable principles

How did narrative ethics emerge?

In the 1980s-90s through books like Arthur Kleinman’s Illness Narratives (1988) + Arthur Frank’s The Wounded Storyteller (1995)

narrative medicine

a field developed by Rita Charon, teaching clinicians literary skills to help them elicit + interpret patients’ stories and to tell their own stories about their work as healthcare professionals, + the values they hold

How do decisions in a narrative context differ from set applied rules or guidelines?

they’re made in response to an individual’s perception of his or her own story / the interpretation of the unique circumstances within which a particular set of options is available + the way that the narrator makes sense of his or her situation

Why are narratives useful in bioethics?

• helps identify tensions/frictions between different stakeholders’ values, expectations, + understandings of health conditions + treatment options

• reminds us to appreciate particular features of someone’s story or case rather than applying generalizable principles

• helps us better understand what it means to live a good life or be a moral person, beyond just how to make medical decisions

what do narrative ethics also help us understand?

• how do patients arrive at their values over time in the course of the stories they tell + under what conditions their values might change

• clinicians + healthcare professionals’ own values + how they arrived at those values in their own life stories, which may exist in tension with the values of patients whose stories differ from our those of the people delivering care

what are components of a narrative that we analyze?

voice, character, plot, resolution

voice

who is telling the story, and how does this influence how the events are recounted?

character

who is at the center of the story, and how are they represented?

plot

what is actually happening in the story, and what themes or messages are conveyed? what ethical choices are made?

resolution

how did the story end, and what does this teach us about ethics, morality, and patients’ lives?

symbolism

is there an object in the plot that holds a higher meaning to the speaker? does something in the story represent a certain message or value?c

context

is the story being told about the past, when people’s values, beliefs, or social roles were different? does the person telling the story come from a particular cultural background that shapes their values?

foreshadowing + irony

does the speaker hint at how the story will ultimately conclude, or what they hope for in the end? do they act or think in ways that later in the story, they do the opposite of?

master narratives

beyond just the stories that individuals tell, we also have prevailing tropes or stories in our culture that can shape ethical decision making

what’s an example of master narratives? what do they make us believe?

ex: life is not worth living if someone is paralyzed, as depicted in Million Dollar Baby (2004) + Me Before You (2016)

• these stories might lead us to believe that patients experiencing paralysis want to die, even if such patients tell different stories

• patients may tell counter narratives that challenge these tropes

Arthur Frank’s Typology of Illness Narratives (1995)

restitution: over the course of the story, the person is healed or cured of their condition

quest: the ill person is personally transformed by their condition in some way, even if it is not cured

chaos: the ill person finds no cure and does not heal from their condition; their healing journey has no clear resolution

mattering maps

how do people describe what matters in different social + physical settings

• how does what “matters” to clinicians in a hospital differ from what “matters” to patients in their family life?

• how might we reconcile what matters in these distinct spaces?

• not focused on “what to do” but “how we got here” + the intersection of what “matters” which might change depending on the context or circumstances

What is an example of narrative ethics from Montello (2014)?

Mr. Greman has lung cancer, says he will “fight” it

• health worsens, later intubated, daughters say to extubate + offer palliative care per advanced directive

• physician hesitated to honor this request, having heard the patient express a desire to “fight” the disease

• patient is extubated; physician feels he failed the patient, without recognizing that patient’s wife was intubated + in that context, he wouldn’t want to continue “fighting”

What was Mr. Greman’s mattering map?

• hospital POV: he wants to fight cancer in terms of hospital treatment

• family life POV: he has seen the pain vaused by ventilators + he/his daughters agreed that this wasn’t how he wanted to die

  • he didn’t want his daughters to suffer if he had a slow death

• Mr. Greman is a “fighter” in the context of his cancer, he has other priorities when it comes to ventilation + his daughters’ well-being

what are critiques of narrative ethics?

subjectivity, memory/recall, lack of guiding principles

subjectivity

because interpreting stories is ____, people may come to different conclusions abt how to resolve the ethical conflicts in the stories

memory/recall

human ___ is imperfect; someone telling a story may misremember or misrepresent events, distorting what’s actually happening

lack of guiding principles

bc narrative ethics doesn’t rely on unifying or generalizable theories, it can’t always offer consistent guidance on how to resolve dilemmas, especially comparable dilemmas

narrative ethics strives to be a more “___-___” approach to analysis than “top-down” approaches of moral theory + principlism

bottom-up

narrative ethics aims to recenter the voice of the ___ in dictating their own values + choices, which are shaped by their life story

patient

narrative ethics draws on skills from ___, like close reading + anaysis of different components of a story, to analyze dilemmas

literature