AMA Journal of Ethics^®

Brody H, Clark M. Narrative ethics: a narrative. Hastings Cent Rep. 2014;44(1):S7-S11.

Don’t be fooled by the first four words—“Once upon a time”—in Howard Brody’s and Mark Clark’s challenging 2014 article “Narrative Ethics: A Narrative” [1]. You would be mistaken to think you were in for a simple tale with a clear-cut lesson. “Narrative Ethics: A Narrative” begins by recounting the short history of narrative medicine and narrative ethics from the late 1980s until about 2010. The narrative medicine part of the account is straightforward enough: attending to patient stories reaps benefits. Such narratives reveal patients’ explanations for their illnesses and the meaning the experiences have for them; they give patients a voice in the medical story the physician is constructing. Physicians dedicated to healing welcome the understanding of their patients that these narratives provide.

Things get murkier with the attempt to “use narrative toward ethical ends” [2]. The relationship between understanding a patient’s illness experience and making ethical decisions about his or her care—without recourse to such other ethics approaches as principlism, casuistry, or virtue ethics—is neither obvious nor uncomplicated. Narrative ethics’ claim is that one can “gain ethical insight and wisdom directly from narratives and without appealing to rules, principles, or other ethical constructs” [2]. Aesop’s fables make a similar claim—the morals derive from the stories. If the grasshopper sings and dances all summer (while the ant is laying-in food), and he therefore starves in winter, a child unschooled in moral theory or principles can deduce that the grasshopper’s actions have brought him a certain sort of harm—death. (Unless, as in some revisionist versions of the story, the saintly ant pities the grasshopper and takes him in for the winter).

But, just as with principlism and even virtue ethics, the trouble comes when the narratives (or principles or virtues) conflict. Listen to the grasshopper’s side of the story. The miserable little ant spends the glorious summer carrying crumbs as big as she is on her back—she can neither see the sun nor feel its warmth—all to sustain life in an uncomfortably cold mound during the winter waiting for the next summer’s drudgery to begin. (Aesop’s fabled insects lived multi-year lives.) “You call that living,” the grasshopper might declaim as he goes out in a blazing dance of defiance during the red and gold profusion of autumn. This all sounds quite silly, but can be deadly serious when the grasshopper is a 20-something motorcyclist who refuses leg amputation and life-sustaining burn treatment or the ant is a 70-something woman whose caregiving for a demanding, sick spouse has hastened her own death.

As the intentionally simple example above suggests, the “ethics” part of narrative ethics is achieved by comparing stories—“one critiques a story with other stories…. The stories with which one is attempting to do ethical work can usefully be compared both to other particular stories and also to more general stories or genres” [3]. Narrative ethics derives its warrant from the comparative critiquing of stories.

At this point in the discussion, Brody and Clark say that “it helps to know something about narrative structure and how stories operate” [3], and they turn to the 2010 work of sociologist Arthur Frank, Letting Stories Breathe: A Socio-Narratology for that knowledge. Frank has contributed much to narrative medicine throughout its 30-plus-year history, and Brody and Clark say that the 2010 book, in which Frank creates and names the discipline of socio-narratology, might also be read “as a treatise primarily about ethics” [4].

I did not detour to read Frank’s book in order to complete my review of the Brody and Clark article, accepting their judgment on which aspects of Frank’s work are key to the narrative ethics enterprise. They refer to many; I will use a couple. The first is the generally acknowledged role of narrative in organizing and making sense of the quotidian. Frank goes so far as to say that events that happen every day are merely “candidate experiences” in a person’s life until they match up with an explanatory story that turns them into real “experience” [3]. He says that the repertoire of stories that cultures and individuals carry around teach people what they should pay attention to and value and what they can ignore or hold in contempt [5].

A second idea of Frank’s, and the one that is critical to ethics work, is that new stories that don’t fit with existing stories “make trouble” [2]. These stories, one presumes, arise from candidate experiences that do not “fit” with existing narratives but for some reason cannot be ignored. We count the idea or experience as “real” but do not know whether to value it or hold it in contempt. Growing up in the antebellum South, for example, we may have daily “candidate experiences” with the workers on the plantation that do not fit the “Aesopian” version of the lazy slave that our culture lives by.

How do we know when the trouble these dangerous stories make is beneficial (i.e., moral-growth-promoting) and when it is harmful (i.e., moral-growth-stunting)? The ethics work of narrative can only be done if we “tack back and forth” between stories that make sense of our lives and stories that challenge those existing stories and cause us to “exchange overly simple views of the world for more nuanced and complex ones” [6]. Stories that “keep us from seeking alternative stories” [7] or that “call us to violence toward other groups and simultaneously make it seem disloyal to seek other points of view” [8] are dangerous in a harmful way because they do not allow us to perform ethically essential comparison. What is not said outright in the article is that closed philosophical and belief systems that dictate “right action” could possibly foreclose opportunities for comparative critiquing of “trouble-making” narratives and, hence, for moral growth.

It is because narrative ethics is, thus, essentially open and dialogic that it is so difficult to describe, so indeterminate: “certain things will remain unclear and in tension because of the very nature of narrative ethics,” Brody and Clark say [2]. I would say, “ because of the very demands of narrative ethics.”

Beyond Narrative Ethics

Brody and Clark touch briefly on virtue ethics and even more briefly on the debate in moral psychology over the comparative roles of reason and emotion in ethics. I will leave the topic of virtue ethics alone for now, but take up the latter—the roles of reason and emotion in ethics—to “widen” Brody’s and Clark’s message in “Narrative Ethics: A Narrative.” The broader message I want us to think about is this: The dialogic approach to discovering moral knowledge is the way not just of narrative ethics but of all humanist endeavors. Humanism is a “hermeneutic and dialogic enterprise,” just as Brody and Clark state that narrative ethics is [2], but humanism is a far more encompassing one. Humanism is not a philosophy, set of principles and maxims, or a religion. It is not a closed, coherent system for explaining events in the phenomenal world. It is an educational ideal, the goal of which is to make the most of what it means to be human—the use of logos (language and reason), development of fellow feeling (sympathy and empathy), desire for self-knowledge, and a confidence that rules for ethical conduct can be drawn from the affairs and interests of humans without recourse to divine revelation. Humanism has no manifestos or treatises that tell us what action is the right one in a given set of circumstances; that knowledge must be worked out in coming to “know thyself” and in the examining of each life.

Fully realizing what it means to be human, then, demands unceasing comparison of our current, settled understanding of the world, our culture’s collection of stories, and new narratives that don’t match the existing stories. Each time a mismatch occurs, the humanist asks, “What do I believe and how do I feel about the collection of narratives I live by and this new candidate?” It is only by rigorous, truthful, often painful self-examination and reflection that a tentative new place to stand is arrived at. To touch on the debate in moral psychology, feelings cannot be abandoned in favor of thoughts, or vice versa, in establishing the “new place to stand.” The Greek tragedians knew the importance of emotion in the development of self-knowledge long before neuroscience connected emotion to physical health and recognized its necessary role in decision making.

In narrative ethics, the continuous process of realizing our humanity entails comparative critiquing of stories; in communicative ethics, it entails arriving at the uncoerced consensus of all those who will be affected by a proposed action [9]; John Rawls calls the process reaching “wide reflective equilibrium” [10]. Whatever the vocabulary, it is the process by which we hone, through rigorous, unblinking comparison—and compromise—the narratives that will guide our decisions until the next dangerously challenging narrative comes along. And it is yet another reason why medicine is incomplete without study of the humanities that, collectively, humanism comprises.