Within the area of biomedical ethics, the most influential framework for ethical reflection has been the principlist model.  .  The textbook often cited is Tom L. Beuchamp and James F. Childress’s Principles of Biomedical Ethics, 4th ed., (New York: Oxford University Press, 1994).  Rita Charon and Martha Montello convened a group of practitioners to write of their experiences using narrative ethical theory.  There is a difference of perspective between the principlist approach and the narrative approach.  “Principles stand with one foot in a realm of theory and application, while narratives stand with both feet upon the ground of earthly human experience, be it factual or fictional.”(p. 151).  As to the application of narrative theory in an ethics consult, the ethics committee tries to find “ways to retell or reconstruct a narrative so that one sees new possibilities or realities not revealed by the first telling” of the story.(p. 151).  Rita  Charon, one of the editors suggests that principlist and narrative ethics are “ultimately complementary rather than competing.”(p. 149).

              The goal of this book is to provide a comprehensive view of the conceptual frameworks, methods, and powers of narrative ethics without giving the reader a set of rules or “steps” for its practice.  The editors drew from a wide range of practitioners in intellectual disciplines, health fields, and stages in their own professional development.  “The cases the clinicians bring under an ethical gaze consider the meaning of patients’ lives over time, reflect on how those meanings change during the course of illness and explore the way these changes in meaning give rise to the ethical questions at the heart of each narrative.”(p. x).

              Hilde Lindemann Nelson, in her essay, “Context:Backward, Sideways, and Forward”, refers to a case presented in the Hastings Center Report, Nov./Dec. 1991, p. 39 of a Hispanic male who was brought to the emergency room due to a gunshot wound.  The patient admitted to his attending physician that he was HIV-positive.  At discharge, the physician recommended daily home nursing wound care.  Medicaid would not fund the nursing home visit because there was already a caregiver at home who was the patient’s sister.  Hilde Lindemann Nelson suggests looking at the roles and responsibilities of each of the individuals affected by the discharge plan.  Of particular concern was the fact that the patient did not want his sister to know that he was HIV-positive nor that he was gay.  Nelson reframed the patient’s request for confidentiality by suggesting that the Hispanic male did not want his sister to learn that he was gay because he would be ostracized by his Hispanic Roman Catholic community.  The patient did not want his sister to know that he was HIV-positive even though it would pose a certain risk to the caregiver.  The sister of the patient, who had faithfully cared for her parents, now wanted to build a life of her own by going back to school at a local community college.  As a result of looking at the larger picture of this ethical dilemma, the author suggested a different scenario that would respect the privacy needs of the male as well as allow his sister to pursue her education.

              Suzanne Poirier, in her essay, “Voice in the Medical Narrative” helps the reader to think about how information is shared among healthcare professionals.  Within the team conference, information is shared by individuals from different disciplines.  She

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notes the teams “vary in the strictness of their hierarchy and the process by which a decision is made.  If the different narrative voices provide data only, without any

reflection on the meaning of that data or its relationship to other professionals’ data”(p.53) one fails to appreciate the worldview represented by the one giving the information.  That is, what are the assumptions of the person giving the information?

              Walter Robinson’s essay, “The Narrative of Rescue in Pediatric Practice” offers a particularly poignant assessment of the ethical reflection process in pediatric practice.  He compares two ethical processes for deciding about the care and prognosis of children with life-threatening diseases.  Underlying many pediatric decision processes is the rescue narrative, as he defines it.  Healthcare professionals in their efforts to do everything possible to save the life of the child sometimes fail to share with the families an alternative narrative that includes the death of the child.

              Susan B. Rubin, in her essay, “Beyond the Authoritative Voice: Casting a Wide Net in Ethics Consultation” recommends that as many people as possible be included in an ethics consult.  One should include not only family members but also a wide spectrum of healthcare workers from all shifts so that a more complete and accurate picture of the patient is provided and a decision made that is consistent with the patient’s needs.

              Marcia Day Childress’s essay, “Of Symbols and Silence: Using Narrative and Its Interpretation to Foster Physician Understanding”, reminded me of the practice of the Clinical Pastoral Education verbatim and reflection on the relationship between the chaplain and the patient.  “After every visit, students wrote brief narratives describing their interactions; students read their narratives aloud to their group and discussed their visits.  In the rich conversation that accompanied students’ presentations, faculty preceptors had ample opportunity to foster and test their students’ “critical reading” skills to help them attend not only to what the patients said (often in direct response to the students’ unwitting cues) and how and when in the interview they said it, but also to what they did not say and to what the patients may have meant by their words or, even, by their silences.” (p. 120).

              To build upon that idea, Julia E. Connelly, in her essay, “In the Absence of Narrative” described her efforts to listen more carefully and attentively to one of her patients who had dementia.  Rather than ignoring the patient and talking to the family member, she focused her attention on the patient to discover what the patient was saying despite of his cognitive impairment. 

              I have included these essays as examples of authors who apply narrative theory to their practice.  I found it to be a helpful compendium of work on narrative ethical theory and a healthy complement to the principlist approach.  This is an excellent resource for anyone who works in healthcare and who struggles with the challenges of biomedical ethics.

Rev. James Brandis, STM, BCC

Corporate Chaplain

Shepherd of the Valley Lutheran Retirement Services, Inc.

January 2, 2007