Narrative based medicine: Narrative in medical ethics

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Abstract
The use of stories During the past two decades, stories have been important to medical ethics in at least three major ways: firstly, as case examples for the teaching of principle based professional ethics, which has been the dominant form of medical ethics in the Western world; secondly, as moral guides to living a good life, not just in the practice of medicine but in all aspects of one's life; and thirdly, as narratives of witness that, with their experiential truth and passion, compel re-examination of accepted medical practices and ethical precepts. Stories as cases for teaching principle based medical ethics When medical humanities programmes were first established in American medical schools in the 1970s and ‘80s, historians, ethicists, and lawyers usually preceded scholars of literature on the faculty. In the early years, the presence of literature in medical humanities programmes was often justified by its service in the teaching of medical ethics.1 Literary stories were useful in “fleshing out” issues or dilemmas in medical ethics by showing them embedded in a particularised human context complicated by powerful emotions and complex interpersonal dynamics. Works by physician-writers have become staples of such teaching, and the short stories of Williams2 and Selzer3 have become especially well known and frequently taught. Narrated retrospectively from the doctor's point of view, stories such as Williams's “The use of force”2 and Selzer's “Brute”3 offer insight into why a presumably good doctor with beneficent intentions none the less ends up harming his patient in an abuse of power. The first uses of these stories as cases for medical ethics may well have been limited to discussions of standard ethical principles such as autonomy or respect for persons, beneficence and non-maleficence, and social justice.4 In principle based ethics, or principlism, general ethical principles are applied in a deductive analysis of a case to determine logically the best ethical resolution of its issues or dilemmas.5 In both “The use of force” and “Brute,” a doctor physically assaults a patient in order to diagnose or treat. The ethical issue is whether such powerful medical paternalism can be justified by appealing to beneficence—that is, by claiming that what the doctor did was for the patient's own good. But by attending to the richly evocative language used by the doctor-narrators of these stories, readers have the opportunity to learn about more than patients' autonomy and doctors' paternalism. They can learn how ethical principles and arguments may sometimes be used to rationalise unethical behaviour that is driven by sexual attraction, anger, or pride.6–8 Although still controversial,9–11the use of such stories as literary cases to complement the teaching of principlism is the most basic way in which narrative has been important to medical ethics. Narratives as moral guides for living a good life The second way in which literary narratives have been important to medical ethics is best articulated by Coles, who is concerned with moral inquiry of a far ranging kind that does not limit itself to the practice of medicine.12 He is concerned with what it means to live a good life and, coincidentally, to practise medicine. Not professional medical ethics but existential ethics or virtue ethics is what he seeks to develop in his medical students. For this purpose Coles believes that reading novels such as Eliot's Middlemarch, Lewis's Arrowsmith, Fitzgerald's Tender Is the Night, and Percy's Love in the Ruins works better than studying analytic ethics. Although Coles chooses more complex literary texts than the short stories that are often used as cases for the teaching of medical ethics, he chooses novels whose main characters are doctors. Yet narratives that serve as moral guides for living a good life need not be topically about medicine, as Hawkins has argued in describing her use of Dante's The Divine Comedy with medical students.13 From this broader perspective, any narrative that might instigate moral reflection about what it means to be a good person, to live a good life, and to practise a profession in an ethical manner could be considered important for medical ethics. Narratives of witness Autobiographical accounts by patients or by their family members or friends can also be important for medical ethics.14 These works can have considerable value as narratives of witness. Some of these narratives offer commentary from the patient's point of view on such ethical issues as autonomy and respect for persons, truth telling and informed consent, beneficence and, sometimes, maleficence—doctors' negligence, incompetence, and errors. As these narratives have begun to appear on the internet, they have reached larger audiences and have had the potential for more influence on the practices of doctors and institutions.15 Patients and their family members and friends are not the only ones who write important narratives of witness. By writing narratives from their personal experiences, doctors and other healthcare professionals also can have a powerful effect on the public discussion of an ethical issue. In the United States, for example, it was doctors' narratives of assisting patients' suicides that broke through decades of professional silence and opened debate about this issue in American medical journals. In 1982,after Selzer published his fictional story “Mercy,”3 about a doctor's unsuccessful attempt to help a terminally ill patient die by giving him an overdose of morphine, he received hate mail. A few years later, when the journal of the American Medical Association (JAMA) published “It's over, Debbie,”16 an anonymous, presumably factual account by a doctor who had deliberately given a patient who was terminally ill with cancer an overdose of analgesics to speed her death, a...