Narrativity in Bioethics: with special reference to medical ethics

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- N. Yasemin Oguz, M.D., Ph.D.
Unit of Deontology, Faculty of Medicine,
University of Ankara, Sihhiya, 06100 Ankara, TURKEY
Eubios Journal of Asian and International Bioethics 9 (1999), 130-134.


Introduction

During the last decade, bioethics developed in Turkey according to information-transfer from the West, mainly from the Anglo-Saxon references. Hence, the trends in ethical reasoning was very similar to those in modern western societies. As time goes by, the developments in the field of bioethics show us that we are getting closer to deontology, which has already been there for a long time. Declarations, codes and ethics committees appear to be more important than ethical reflections. The processes which require ethical reflection in biomedical ethics have become a bureaucratic process, which has to be fulfilled, signed and approved. According to thes development we could say that prescriptive bioethics gained the dominance (1). One of the reasons for this fact is claimed to be our lack of experience in philosophizing, but for me the main reason is the cultural difference between our society and the ones which I have previously mentioned. The ethical "theories", which were created in Western philosophical tradition, used to ignore traditions and other cultural differences, and assumed that a certain kind of cultural characteristics can be generalized to all humanity. In order to resist this cultural ignorance non-Western academicians should work on their own values and pay more attention to descriptive bioethics (1). Western theories of bioethics take all humanity as one and unique. The basic ideas that underlie this aim, are either these characteristics are the ones that ought to be reached, or the Other can only be identified and understood with reference to the mentioned characteristics. This understanding of humanity is an illusive point of view, which pays no attention to practices, codes, symbols, metaphors and narratives that are the primary determinants of moral comprehension. Although non-Western academicians have to pay more attention to the descriptive bioethics, a purely descriptive study on values suits more to sociology rather then bioethics. In the same way, a purely prescriptive study suits deontology. Balance should be the key concept for studies of bioethics. Interactive bioethics does not seem to guarantee this balance by definition, but it can be worked out according to this understanding (1). Both of the categories need to be revised in the light of ethics, because in my opinion bioethics needs more ethical reflection. Otherwise it will lose its justification as a field of ethics and rather become a field of morals.

In Turkey, the growing interest in bioethics began in medical domain. At first it was the pressure of foreign periodics which sensitized Turkish physicians for ethical issues in medical practice, especially in clinical research. As a result, only researchers felt the need for ethical guidance, but today this need has become a widespread routine in medical practice too. After the society has got used to the word "ethics", we begin to hear this term in other areas of practice, such as communication, policy etc. It is generally used as a synonym of "moral". Just as its development started in medicine, its decline has also started from there. Most of the people, who have talked about ethics, begin to gain irrational power and aim to use this power in dictating some general rules, for the sake of ethics. These rules are mostly been translated from Western "ethical authorities" and presented as the general moral rules of humanity. This approach to biomedical ethics only helps to make it a hybrid of law and deontology, leading to an insensitiveness among physicians, who have never actually reached a full awareness of the importance of ethical reasoning in medical practice. Actually they have not been able to find the necessary points of references in these ethical "theories" while reflecting on daily ethical issues, which are often tradition-related. Today a few ethicists and some sensitive academics are trying to turn this trend down and build a new one which gives more recognition to cultural features instead. I think that narrative approach is the best route to an intercultural ethical reflection, and has a primary role in this attempt. As my main area of interest is medical ethics, I will try to emphasize the importance of narrative approach in bioethics, especially in medical ethics, in this article.

Narrativity and Hermeneutics in Bioethics

Anglo-American ethics, and Northern ethics as its follower, use the term "ethics" as a project to construct a fundamental theory, applicable to everyone (2). This approach carries an assumption that a universal good is possible and all humanity should be thought as a single body. Can ethical decisions be deduced from a theory of norms and ideals isolated from tradition-related meaning systems? (3) This question has been asked many times, but mostly by the main-route western philosophers of modern times, not by the ones they refer to as "the Other". According to Charles Taylor, it is not possible for someone to think or act outside the framework where an ultimate view of good life determines the point of view he or she adopts in forming ethical judgments and decisions (4). McIntyre also supports this idea by saying, every rationality is dependent on a tradition (4). As ethics is an integral of human ratio, a reflection on "the good", we can say that our ethical reasoning can not appear outside of our narrative traditions. Ethical reasoning is a reflection on moral meanings and there is no meaning without our understanding. People can observe, understand and communicate meanings, can present them for understanding, but this process is a closed in process (5). Understanding and communicating meanings are particular experiences. Philosophy, as hermeneutics, works on this particularity in every understanding. Ethics is a hermeneutic of moral meanings and an interpretation of our ability to understand what is morally meaningful. Meaning is beyond our domination, because it is culturally founded and it itself has something to say (5). We could only comprehend meanings and adopt them, by facing them routinely in the narratives of our culture (like literature, practices etc.). We can analyse our moral preferences by interpreting texts, institutions and actions expressing the understanding of meanings, and by cross-reading them with other texts, institutions etc (5). As we have shown why ethics must be hermeneutical, we need just a small step to understand why narrativity is an important means for it.

Van Tongeren defines narrativity, as the name for an ordering, an ordering that combines many events in one story configuring the pure sequence in a meaningful account. As the historicity of our lives occur in a narrative order and as we extract the knowledge about ourselves from it, the knowledge about ethical meanings will also have to be narrative (5). In this sense narrative texts are more useful than theoretical texts. Literary texts (here the term "literary texts" is used as the broad sense that includes all kinds of cultural expressions) are rich sources for self-understanding, and self-understanding itself is also a text to be interpreted (5). Although the importance of cultural differences in bioethics have frequently been emphasized, the question of how these differences will be placed in the ethical "theories" have not been answered yet. Narrative approach in bioethics could be an answer. Actually studies of descriptive bioethics are necessary for understanding the relation between the narration and the value, in the very begining of the narrative studies. Narrative approach also adds something crucial to interactive bioethics. Studies of interactive bioethics should include the discussion and commentations on the meaning of the peoples' acts before discussing of the relation between how they act and how they should act.

Cultural Differences and Narrativity

In narrative approach we read and re-read various texts from different sources, then we have to cross-read them with the texts of different cultural origins in order to comprehend moral expressions that are interwoven in them. By doing these we obtain the clues of moral meanings and also we can escape from sticking ourselves in a cultural iron cage by taking our own culturally established vocabulary too seriously. When one attributes authority to only one's own traditional context, intercultural ethical differences of opinion appear insurmountable. McIntyre suggests that narrative traditions could overcome their epistemological crises by incorporating enriching insights from other traditions, even when they are not, at first sight, commensurable (4). Otherwise one can inevitably act as a multiculturalist who frequently emphasizes the importance of "difference", but never tries to understand it in its own vocabulary of meanings. This approach use to hide its involuntariness to embrace cultural differences, and its aim to keep every tradition as pure as possible within its own boundaries without facing one another, behind a provisional mask of interest and respect (6). By locking the traditions in absolute frames, a multiculturalist also sacrifices the individual, namely the other, for the sake of the Other which is called one's own culture. For example there is an image of Oriental cultures for the Western societies which is fed by all their literature and art. But every oriental individual has his or her own narration, somehow different from this image, which can be noticed in the development of the Oriental societies and conflicting the Other itself.

Transculturalist approach surpasses the problem in recognizing cultural differences created by multiculturalist view, but it hurls immediately to the other radical end. Transculturalists sacrifice their own vocabulary for the sake of the Other. They try to reach a point where every tradition will find something from itself, but cannot totally dominate it. According to Visker this situation can be defined as a point where everybody is guest and host at the same time. The main theme of this project is neither unity nor diversity, but interaction. With a closer look, this is a universalist theory (6). How can you both accept the cultural differences in these senses and discuss on the clitoreal circumcision of many African girls? According to Rorty an ironic approach is the answer.

Ironists are those who come to doubt their own truth, because they are impressed by the seriousness with which others are attached to a different truth. So they neither sacrifice their own nor ignore the Other, but while refering to themselves they are always restless about the truth itself. Their target is to reach a final vocabulary, which is quite an ideal, and on the way to that target they are always in the search of a better vocabulary than the one they are using at the moment, but without a criterion for deciding what is better (6). Narrative approach is the essential of this task. By reading every text thoroughly, theoretically we can reach a "final vocabulary" at the end, but on the way we can make a more competent vocabulary. This can be called repairing the boat on sail.

"Ethics had to offer a theory that would provide a basis for the principles guiding us in our moral behaviour. At the first step a theory is needed in order to guide us in determining which facts are relevant. The theory was to start from a view-point that transcends the inconsistency of individual practices. It would thus be able to generate universal principles that can correct the many imperfections of individual existence. Such an ethic was thoroughly fundamental and universalist in all its versions" (2). As we already have an ethical home, which is an integral of the historicity of our lives and which determines our understanding of ourselves and also our way of reading the existence, we cannot be bound by the abstraction "humankind" or "reason", nor by the randomness of our desire. So what we need now is an open theory which we can express our local differences in any degree.

By publishing this paper in EJAIB, I want to help formulate a better vocabulary through which some ignored meanings of Asian culture will be more competently expressed. Asian culture is an important part of the existence of my country, and determining the features of a Asian ethics will improve the opportunity of our understanding of our moral environment and ourselves. As I have mentioned before, all approaches are trying to overcome this task by suggesting a different understanding and expressing of meaning systems. Their claims are different, but their method is the same, it is an understanding of self through narrative texts. At this point, I would like to return to medical ethics, which is my main area of interest, and try to draw the outlines of narrative approach in this field.

Narrativity in Medical Ethics

Medicine has a special and constructed method for producing knowledge about individuals. Although science remains medicine's "gold standard", clinical knowing is a narrative, interpretive and practical reason (7). In Nicomachean Ethics, Aristotle distinguishes practical reasoning or phronesis from scientific knowing or episteme (8). Scientific knowledge is the knowledge of stable physical phenomena which can be generalized by overarching laws. Practical reasoning is a means of operating in the world, a matter of understanding how best to act in particular circumstances that are not thoroughly expressed in general rules (7). Aristotle frequently uses medicine as an analogue for moral reason. Both in medicine and in moral reasoning, narratives have great importance.

In medicine, the principal tool of practical reason is the case. Starting with formulating a patient's history and followed by the narrative organization of clinical procedures, narrative approach is a sine quo non of clinical processes. Narrative is thus the principle medium of reasoning in medicine (7). Moral reasoning in medical practice can not be separated from medical judgement. Because narrative represents events embedded in the lives and on-going concerns of human beings, it is essential for moral reasoning. In narrative, circumstances unfold through time in all their contingency and complexity. Endings may often seem inevitable, but only after the fact (7). For both the moral reasoning and medical practice, an accessible store of experiences through narratives is necessary. Therefore, a narrative approach could enrich traditional philosophical and legal approaches to medical ethics.

These "formal approaches" as Brody called them, try to provide ethical solutions to a wide range of different cases using relatively small number of very general principles. As they mostly focus on categorizing every case according to these principles, ethical reasoning becomes a mechanical exercise that requires much less philosophical insight. The unit of ethical analysis, which is usually a single case separated from the whole life comprehension of the interpreter, is overly summarized and the details about the life history and prior experiences of the participants, or the social and cultural settings are seldom taken into account. Emotions are almost always neglected in order to save objectivity. There is another fundamental criticism against formal approaches. Some feminist critics claim that these approaches rely on the sorts of rules that govern contacts among strangers. As neither health care provider-patient, nor patient-family relationships are (and they also should not be) stranger to stranger relationships, although good in intentions, a stranger ethic cannot reflect the truth of our important relationships, and cannot escape from indifference. Narrative approach would contribute to these ways of ethical reflection, which are not and cannot be ignored in medical ethics, by bringing in the cultural and historical context of the case. Ethical reflection can be rational and rigorous, but it cannot be reduced to the exactness of a mathematical model. The great danger for medical ethics is in order to be meaningful for medical practice, it has to become as calculating as technical medical thinking is become. On the contrary ethical thinking requires some skills like interpretation of the meanings of the particular facts of the case and reasoning by analogy with other cases (9). By learning the details of the case in hand and taking emotions seriously into account, an ethical insight through empathy will evoke and make our ethical decisions more justifiable and more humane, instead of being technical and mechanical.

Narrative approach can also avoid one-sided casuistry. Casuistry was established on the idea that there will be always a considerable space between general, abstract principles and the concrete facts of particular cases (9). Casuists base their moral reasoning on unique cases. Today case studies are frequently being used in biomedical ethics textbooks and gradually improving from absurd cases, which are often incompetently constructed to well narrated real ones. But a fundamental criticism against casuistry is still valid. As cases are like all other narratives, not found but constructed, they reflect the particular way of seeing events. Most of them are constructed in a way that promotes a certain perspective, and contain rhetorical strategies (10,11). The prior philosophical positions and attitudes can shape the selection, presentation, and interpretation of material in biomedical ethical cases (10). We have to become aware that when ethicists write cases, they are rhetorically imposing a world upon us, a world that excludes or includes those particularities that allow us to make the best possible moral decisions (10). Reading various narratives of the same case, written by different narrators and paying attention to the rhetoric of narrative is necessary in overcoming this problem. Therefore narrative approach has much to contribute to casuistry as well.

In the last part of my article, I will try to show the application of hermeneutical and narrative approach both to a general ethical problem and to a literal case.

For the first application, I will quote Zwart's article which primarily concerned the concept of nature, with special reference to postmenopausal pregnancy (12). In his article, Zwart claims that when someone discredits the medical treatment of "older mothers" ethically because of its "unnaturality", his or her argument bases on a notion which appeals to moral significance of our biological nature. Zwart defends a position that the notion of naturalness is still a part of our moral experience, and contradicts the widespread attitude in ethics which discredits appealing to nature (12). According to Zwart, it is the notion of nature which has the main significance in the discussion of postmenopausal pregnancy, which invaded the schedule of medical ethics in 1993. As I have defended above, it is a one-sided point of view, which tries to offer a concrete ethical issue and its solution to the reader, or in other words it is only one particular reading of this case and it cannot lead to an overall ethical comprehension. In his article, Zwart is not understanding and reflecting on an ethical issue, but using it to support his position in the discussion about the significance of nature for moral reasoning. I will try to ask some other questions and re-read postmenopausal pregnancy from different aspects.

First of all, two women who were involved in this medical procedure and had rejected by a medical-ethical commission in London, were finally treated by Dr. Antinori, in Rome (12). The main concern of the commission which refused the medical intervention, was the age of these women. In my opinion, we have to understand what being "old" meant both for that commission and Dr. Antinori as well as what is natural for both of the parties. Secondly, another way of reading this case could be from a feministic point of view. What is the meaning of being a woman for the decision-makers in this case? As "being old" and "being an old woman" determine, to a certain extent, what we understand from the natural position of these women, and as these two important questions are also basic aspects of their places in our value systems, we have to go through them by giving a special attention to the difference between Anglo-Saxon and Asian vocabulary for them. There is another way of reading this case, namely, considering the meaning of having a child. In my opinion, there are fundamental differences between Anglo-Saxon culture and Asian culture in their comprehension of having a child. I will not go further on this example and narrate it in various different ways; this can be an interesting subject for another article. But I want to emphasize that though reflecting on the notion of nature is one and important aspect of this ethical issue, narrative approach leads us to notice other aspects as well in order to claim a full understanding of its moral meaning.

The second example will be a case, which is derived from the very well known novel of Albert Camus, The Plague. In this novel, Camus uses a disease, both literally and metaphorically, for the Nazi occupation of France. The plague is a symbol for that which obliterates human life, denies its meaning and cannot be finally overcome (13). Camus introduces his characters both in their responses towards the plague, which consists of different morally significant meanings and in their relationship with others. So Dr. Rieux and his allies fight the plague not by curing its victims or by eradicating the disease, but by asserting the duty of human solidarity and the dignity of resistance (13). In my presentation, I will not go through the whole novel, but I will work on just one dialogue, in which I believe Camus summarizes his moral position. In The Plague, Camus talks through one of his characters, "Le mal qui est dans le monde vient presque toujours de l'ignorance, et la bonne volont_ peut faire autant de d_g_t que la m_chancet_, si elle neest pas _clair_e." (13). In the dialogue which I have quoted here, he emphasizes the importance of moral understanding once more with the words of Tarrou.

Tarrou: In a fortnight or a month at most, you'll serve no purpose here. Things will have got out of hand.

Rieux: I agree.

...........

Tarrou: Well, I've heard that the authorities are thinking of a sort of conscription of the population, and all men in good health will be required to help in fighting the plague.

Rieux: Your information was correct. But the authorities are in none too good odour as it is, and the Prefect can't make up his mind.

Tarrou: If he daren't risk compulsion, why not call for voluntary help?

Rieux: It's been done. The response was poor.

Tarrou: It was done through official channels, and half-heartedly. What they're short of is imagination. Officialdom can never cope with something really catastrophic. And the remedial measures they think up are hardly adequate for a common cold. If we let them carry on like this they'll soon be dead- and so shall we.

Rieux: That's more than likely, I should tell you, however, that they're thinking of using the prisoners in the jails for what we call the "heavy work".

Tarrou: I'd rather free men were employed.

Rieux: So would I....But might I ask why you feel like that?

Tarrou: I loathe men being condemned to death.

Rieux: So....what?

Tarrou: It's I have to say. I've drawn up a plan for voluntary groups of helpers. Get me empowered to try out my plan, and then let's sidetrack officialdom. In any case the authorities have their hands more than full already. I have friends in many walks of life; they'll form a nucleus to start from. And, of course, I'll take my part in it myself.

............

Rieux: But I take it you know that work of this kind may prove fatal to the worker. And I feel I should ask you this: have you weighed the dangers? (... And Tarrou responds to Rieux who asks him what makes him come to this decision though he does not believe in God.)

Tarrou: ... I have no idea what's awaiting me, or what will happen when all this ends. For the moment I know this; there are sick people and they need curing. Later on, perhaps, they'll think things over; and so shall I. But what's wanted now is to make them well. I defend them as best as I can, that's all.

Rieux: Against whom?...Out with it, Tarrou! What on earth prompted you to take a hand in this?

Tarrou: I don't know. My...my code of morals, perhaps.

Rieux: Your code of morals. What code, if I may ask?

Tarrou: Comprehension.(14)

As you noticed, Tarrou establishes his moral responsibility on comprehension (15). This comprehension does not evokes from the scientific knowing, it is a consequence of practical reason. Tarrou interprets the narrative, which he has also been a part of, and arrives at a moral meaning, which obliges him to help the people of Oran. When he says he has to protect the inhabitants of Oran and Dr. Rieux asks from whom, (this is an unanswered question in the text) the answer is not just the plague, but everything this disease means to the whole society. This answer is what hermeneutics and narrative approach provide us.

Tarrou's argument during the dialogue, namely the narrative which Camus has constructed, gives us some clues about his Mediterranean inspiration, which has many aspects in common with Asian thought. These common values are quite in harmony in the Turkish society. First of all, he shows us voluntariness towards governmental organisations are much less favored by the public. The organisation, which efficiently works as we are told in the following chapters of the book, is rather an organization of friends. They start from the capability of imagination. Tarrou claims that formal solutions are lack of imagination and they treat the plague as they do for common cold. He knows that when you ignore all the narrative aspects of the plague, and actually this is what formal approach does, it appears to be a disease just like common cold. Besides its seriousness, formal approach takes it as something to fight against and cure, like common cold. Tarrou also prefers to be in an organization where freedom is an important characteristic of the participants. By emphasizing this trend, Camus refers to both a Kantian approach and a Mediterranean preference. During the efforts of the organization, we notice that Tarrou and his friends are motivated by the provocative things symbolized in the plague, and they prefer a working strategy which is not dependent on a bureaucratic professionalism, but this motivation. In his approach, referring to Tarrou's attitudes, Camus favors civil initiative rather than technical and bureaucratic competency, which offers a chance to the individual to express his or her moral reflection. He also honors the possibility of heroism, which we can see as a basic theme in many other Mediterranean narratives. By pointing out his understanding, Tarrou summarizes his comprehension of all these and much more in his moral reasoning. We should celebrate Camus's competence as a narrator as he embraces all these meanings in one meaningful word and his straight-forwardness as a philosopher.

Conclusion

Biomedical ethics, because of its functionally differentiated approach, runs the risk of either reducing itself to a professional deontology with a limited view of responsibility or enclosing itself with other experts in an iron cage of technocratic, bureaucratic or instrumental rationality (2). Following this line will take us to an expectancy of exactness in ethics which can be obtained in mathematics. The current ethical approach is a form of calculating thought as Heidegger called it, its purpose is to develop a moral calculus with a few variables into which specific data related to the problem at hand can be inserted (12).

A narrative perspective on meaning, which precedes and surpasses any ethic, offers a framework where people can find meaningful moral responsibilities for themselves. When bioethics takes this approach into consideration, the overly technical and bureaucratic procedures in making ethical decisions will be expanded to become an integral human ethic (2). Ethicists's duty is not establishing general rules and regulations for some categories of popular ethical issues, but to reestablish many lost or ignored meanings pushed aside by an overly technical approach in bioethics, which sacrifices most of the cultural colours for the sake of an impossible universality (2).

As moral life is very complex for a single approach to embrace in all aspects, I think narrative ethics has an important role in completing any ethical approach. This must be a functional cooperation of all approaches, which are claimed to be the ultimate solution of ethical reasoning.


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