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NARRATIVE ETHICS IN MEDICINE
By

Susan Elena Brown

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Interdisciplinary Program in Health and Humanities

l 996

ABSTRACT
NARRATIVE ETHICS IN MEDICINE
By

Susan Elena Brown

This paper describes the various approaches characterized as “narrative ethics” in
medicine and evaluates their relationship to traditional principle-based methodologies. A brief
account of the antifoundational movement in philosophy and the subsequent development of
narrative ethics as an alternative to principlism is provided. The basic claims for narrative, and its
points of similarity and difference with principled approaches, are presented and evaluated. Five
basic types of narrative method are identifed: (1) story-classifying (casuistic) approaches;

(2) story—reading (literary and empathic) approaches; (3) story-telling (lifeplan and subjectively
based) approaches; (4) interpretive or hermeneutic approaches; and (5) stories as moral exemplars.
Two abortion narratives, Gwendolyn Brooks’ “The Mother” and John Irving’s The Cider House
Rules, are used to illustrate the features of narrative-based moral reflection. Finally, the paper
describes the necessary interplay between principles and narrative, which results in more finely

detailed and responsive moral deliberation.

Conyright by
SUSAN ELENA BROWN
1996

To my ethics teachers: Dennis and Joanna Brown, Joveliano C. Trinidad [11, Lisa Michele Brinn,
Robert J. F ehrenbach, Hans O. Tiefel, and Tom Tomlinson.

iv

ACKNOWLEDGMENTS

It seems there are more thanks due than there are pages of this manuscript, which I
suppose means I have been unusually blessed.

Thank you to my parents, Dennis and Joanna Brown, who raised me to care about such
things as this and who never doubted that I could accomplish whatever I set my mind to. Thank
you to my almost-husband, Jay Trinidad, whose long-distance love carried me through the hard
times. Thank you to Lisa Brinn, my roommate and late-night discussion partner, for her patience,
understanding, and friendship. And thanks to Harriet Squier, who shared her insights and time
with me, even when both were at a premium.

I’d like to acknowledge my lasting debt to three professors at the College of William and
Mary. I cut my ethics teeth and learned to think in Bob Fehrenbach’s classes on English
Renaissance drama. Peter Wiggins’s English courses challenged me to find the abiding life in the
text. And Hans Tiefel’s course in medical ethics put the match to the fuse.

I also want to thank my thesis committee, the members of which provided just the right
combination of support and constructive criticism: Howard Brody, A.C. Goodson, and Tom
Tomlinson. I am indebted to Dr. Brody for his enthusiasm and helpful advice, especially as
regards Chapter 3, and to Professor Goodson for his thoughtful comments and objective stance.

Most especially, many thanks are due to Tom Tomlinson, my thesis advisor and mentor at
Michigan State. His refusal to accept anything less than a cogent answer has made me a better
thinker and writer. He took my measure and made me live up to it. I didn’t always enjoy the
challenge, but I am grateful for it. He continues to be an unfailing source of good counsel on
matters academic and otherwise. I feel fornmate to have passed through the Interdisciplinary

Program in Health and Humanities during his tenure as director.

TABLE OF CONTENTS

INTRODUCTION ............................................................ 1
Chapter 1: PRINCIPLISM AND ITS DISCONTENTS ................................ 3
Principlism ........................................................... 3
Challenges to Principlism ................................................ 5
Chapter 2: WHAT IS NARRATIVE ETHICS? ..................................... 15
What Is Narrative? .................................................... 16

What Makes Narrative Ethical? ................................... . ....... 18

What Does Narrative Ethics Look Like in Practice? ........................... 24
Casuistic Approaches ............................................ 24

Story-reading Approaches ........................................ 26

Storytelling Approaches .......................................... 31
Interpretive/Henneneutic Approaches ............................... 32

Stories as Moral Exemplars ....................................... 35

Challenges to Narrative ................................................ 35
Chapter 3: NARRATIVE ETHICS AT WORK .................................... 4O
Gwendolyn Brooks, “The Mother” ........................................ 44

John Irving, The Cider House Rules ....................................... 46
Chapter 4: CONCLUSION .................................................... 61
BIBLIOGRAPHY ........................................................... 66
GENERAL REFERENCES .................................................... 69

INTRODUCTION

The lines have been drawn: theorists on one side, anti-theorists on the other. The conflict
between these two camps of philosophers is over which kind of normative ethical theory or
methodology is best—or, failing that, which is least inadequate to give a complete and balanced
account of how people should live. One of the alternative, nonprincipled (so called)
methodologies that has been much discussed in recent years is narrative bioethics.

Since its inception in the 19805, the meaning of the term “narrative bioethics” has become
increasingly vague as more and more philosophers and literary theorists consider the role of
narrative in ethics, and specifically in medical settings. Problematic are (l) the various definitions

”2 and (3) examples

of just what counts as narrative', (2) how narrative, as a methodology, “works,
of what a narrative approach to a given issue (let alone a particular case) might look like. I will
address each of these problems by (l) proposing a definition of narrative that I believe will be
most useful for the purposes of bioethics, (2) explicating how narrative does (or fails to do) what
its proponents claim it does, and (3) applying a narrative methodology to the question of abortion
as a sort of “trial balloon,” using both philosophy and literature to evaluate the practical value of

this approach. If it is true that narrative can play a productive role in making ethical judgments,

the implications for both medical education and clinical bioethics will be worth considering.

 

lKathryn Montgomery Hunter is one theorist who emphasizes time over other elements of
narrative; she considers virtually any event or process that happens through time a narrative. She
would, for example, consider the natural history of a disease process a narrative. Other theorists
(including Martha Nussbaum and Cora Diamond) use narrower (and more useful) criteria for
defining narrative.

2Most discussions of narrrative ethics are heavy on stories and poems and light on analysis
of how these are supposed to assist in forming or clarifying ethical judgments. Many
presentations of narrative bioethics consist of a simple introduction (e.g., “Stories are good and
tell us about ourselves”) and one or more narratives that (one supposes) are meant to speak for

themselves. 1

2

Narrative ethics represents a different approach from conventional deductivist approach.
The differences include a move toward the concrete and away from unnecessary abstraction; a
renewed emphasis on context and relationship; an important role for emotion and experience in
moral deliberation; and a view of ethics as a process rather than a body of academic knowledge.
As will be explained in the chapters that follow, these attributes fill the gaps in principle-based
theories, yielding a hybrid ethics that is finely tuned and responsive to particulars. The narrative
method frames our understanding of the conflict at hand as part of a continuing story bounded by
particular relationships, circumstances, and history; and philosophical rules and principles serve

as a necessary reality check to help us maintain fairness and consistency from case to case.

Chapter 1

PRINCIPLISM AND ITS DISCONTENTS

In the broadest sense, nonnative ethical theories tell us how we should act as moral
beings. Some philosophers see the theoretical enterprise as one of systematizing, organizing, and
making consistent our moral judgments. Others adopt a more narrow and practical focus, saying
that ethical theories are meant to resolve moral dilemmas and help the members of a given
community to reach agreement about what is right. In this chapter, I will provide an overview of
the current state of theory in medical ethics, framing the discussion as a comparison of principlism
and proposed alternatives.

Principlism

I mean here by “theory” a subset of normative ethical theories that has come to be labeled
“principlism”: mle- and principle-based theories that take abstract, universal, and atemporal
principles or rules as the top level of justification and that rely upon a linear, deductive process to
move from principles to rules to judgments about specific cases.3 Beaucharnp and Childress
characterize these methodologies as “deductivism” or the “covering-precept model.” The model
“is inspired by justification in disciplines such as mathematics, in which a claim is shown to
follow logically (deductively) from a credible set of premises . . . . [J ]ustification follows if and
only if general principles and rules, together with the relevant facts of a situation. support an

inference to the correct or justified judgment(s).” (14) The chain of justification inherent in

 

3 My working definition excludes other (no less “theoretical,” in the broader sense)
approaches to ethics, including wide reflective equilibrium, coherentist theories, and casuistry.

3

prinicpled theories is represented belowz‘

Ethical theory 1‘ Principles 0 Rules 3 Particular judgments
Ethical theories issue principles, which are the basis of practical mles. These rules can then be
applied to individual cases to arrive at moral judgments.

The dominant paradigm for medical ethics has been the “four-principles approach,” which
takes the principles of respect for autonomy, nonmaleficence, beneficence, and justice as the basis
for moral philosophy in the medical environment. These principles provide a reasonably
comprehensive account of the norms that should guide the professional behavior of health care
providers and institutions. The decisions competent adults make in their own behalf ought to be
respected (respect for autonomy); health care providers must not intentionally harm their patients
(nonmaleficence) and should endeavor to do good for them (beneficence); and we should be fair
in our distribution of health care resources (justice).

In the interest of fairness and impartiality, principlism favors abstraction. Cases are
described primarily in terms of the issues and values at stake. This approach is intended to lessen
the opportunity for moral judgments to be unfairly biased. There is ample historical reason for
ethicists to be concerned about this matter. One of the original crises that helped give birth to the
field of medical ethics concerned the rationing of then-rare dialysis machines in the 19605. In
Seattle, Washington, a committee was established to choose which patients would receive
treatment and which would have to go without. Committee members had to decide what criteria
should apply in a choice between, say, a middle-class wife and mother and a homeless prostitute,
or between a police officer and a drug dealer. George Annas writes,

When the biases and selection criteria of the committee

were made public, there was a general negative reaction against
this type of arbitrary device. Two experts reacted to the “numbing

 

4Adapted from Beaucharnp and Childress, 14.

4

accounts of how close to the surface lie the prejudices and

mindless cliches that pollute the committee’s deliberations,” by

concluding that the committee was “measuring persons in

accordance with its own middle-class values.” The committee

process, they noted, ruled out “creative nonconforrnists” and made

the Pacific Northwest “no place for a Henry David Thoreau with

bad kidneys.” (187)
To avoid such prejudices, principled approaches have since tried to downplay information that can
open the door to unfair discrimination. For this reason, certain information about particular
patients and cases—such as background about a patient’s criminal history, race, age, ability to
pay, religious affiliation, professional status, or gender—is deliberately excised from discussion of
the ethical issue at stake.
Challenges to Principlism

In recent years, some philosophers have asserted that principles aim at the wrong target.

Margaret Urban Walker highlights the fact that, under the standards set by the dominant traditions
within moral philosophy,

a moral theory is not merely any comprehensive, reasoned, and

reflective account of morality, of ways and means, point and value,

of a moral form of life. . . . a proper moral theory is instead a

highly specific kind of account of where moral judgments come

from: a compact code of very general (lawlike) principles or

procedures which, when applied to cases appropriately described,

yield impersonally justified judgments about what any moral agent

in such a case should do. (33)
This statement illuminates some of the points I will discuss in this chapter. First, there is the
emphasis on broad and relatively empty rules and principles, which are then to be applied to
highly specific, content-laden cases. This is what Arthur Caplan has dubbed the “engineering
model,” in which ethicists “see the theoretical aspects of ethics as confined to the pure or basic
side of ethics. . . .[and] take theoretical insights from the basic researchers and apply them to the

resolution of concrete moral dilemmas.” (26)

Second, Walker‘s definition speaks of “cases appropriately described.” Whereas

principlist systems tend to favor simplification on the rationale that it highlights the morally
relevant features of the conflict at hand and reduces bias, many antitheorists see “thick
description”5 as integral to a full and morally satisfactory description of the case. Third, the
traditional insistence on “impersonally justified judgments” has also been rejected by antitheorists
as unreasonably equating special relationships (such as those that exist between friends) with
unfair bias. Finally, the proponents of a nonprinciplist approach would argue, there may be no
single “right answer” to a given moral conflict. At the very least, antitheorists would take issue
with the idea that the right thing to do would be the same thing for “any moral agent in such a
case.” Although some number of relatively straightforward cases may admit of a single right
answer (for example, we might agree that any moral agent who sees a small child drowning
should try to help), the antitheorist wants to apply a more context- and agent-specific measure of
appropriateness than do principlists; so that the right thing for X to do in a particular case may be
different from what someone else should do. This determination would be based partly on who X
is in the context of this case: Is she a physician? A daughter? An innocent bystander?

Some antitheorists criticize principled methodologies based on their efficacy (that is, they
claim that principles do not work), while others take issue with the mechanics of the theory
(arguing that principles do not work the way their champions say they do). Many of the anti-
theorists’ claims are quite strong, and some of their arguments are less critical than they are
polemical. Nonetheless, they do raise serious questions about both the usefulness and the warrant

of such theories. Criticisms fall into four general categories:

1. Moral principles do not, in themselves, contain sufficient information to direct
behavior.
2. Theories appear, ultimately, to be justified by an appeal to intuition.

 

5The phrase is from anthropologist Clifford Geertz.
6

3. Moral theories are inadequate for dealing with the depth and variety of human
relations.

4. “Doing ethics” consists not in accumulating and applying knowledge of rules and
principles (i.e., Caplan’s engineering model), but in the application of certain
skills of perception, interpretation, and negotiation.

In the second half of this chapter, I will explain the reasoning behind each of these points.

One criticism of principled approaches is that moral principles do not contain sufficient
information to direct behavior. That is, to get from moral principles to prescriptions for action or
judgment in individual cases, interpretation (not deduction) is needed. In most cases, this means
that extratheoretical premises—not the moral principles or rules that are the basis of the
theory—are the engine that powers “deduction.”

One difficulty with abstract moral principles is that, as Stanley Clarke and Annette Baier
point out, they are not directive in any practical sense. Baier uses the example of “Thou shalt not
kill,” which

presupposes a complex set of culturally specific rights, powers,

and prerogatives . . . [a]ny popular version of a short set of moral

don’t’s. . . brings with it a very rich cultural baggage, if it is to

have any content at all. Either it is a purely formal moral code, not

yet prohibiting or enjoining anything, or else the form gets its

determinate filling, in which case we are committed not merely to

these “negative” rules but to the rules of background institutions

and ways of life that supply the determinate content to these

prohibitions. (Clarke, 238)
Consider the rule, “Physicians should respect patients." This sounds like a good rule for doctors
to follow. It also seems straightforward and unproblematic. After all, someone might say, we all
know what it means to treat another person with respect, and surely we would hope that physicians

would be respectful of their patients. At the abstract level, the rule makes perfect sense; but in

actual practice, the meaning of this rule is anything but obvious. Health care providers in the real

world must often deal with messy cases—cases in which what it would mean to respect the patient
before them is unclear. Imagine, for example, the case of an elderly man, Mr. N, who is admitted
to the hospital following a bathtub fall. He is uncooperative with the medical staff. who cannot
determine what caused the fall. The attending physician suspects that the fall was precipitated by
a stroke; but the patient refuses permission for any of the indicated diagnostic work. What would
be the respectful thing for the physician to do in this case? Should she argue with Mr. N? Should
she try to reach his daughter in Boise, though Mr. N has said that he has not spoken to her in 20
years and does not wish to see her now? Ought she seek a court order? Gambling that the
patient’s judgment is clouded by stroke, should she go ahead with the diagnostic workup in the
belief that this course of action is most respectful of the “real” Mr. N? Or should she allow Mr. N
to leave the hospital against medical advice, in an effort to respect his autonomy?

The physician in this case is faced with two levels of conflict. First she must determine
which principle is paramount. ls autonomy (that is, respect for the patient’s decisions about his
treatment) more important than beneficence (her obligation as a physician to do what is best for
the patient)? Once she has answered this question, she must figure out what course of action will
best actuate the principle she has chosen. If her intent is to respect Mr. N’s autonomy, should she
call his daughter? Should she try to talk him into the diagnostic tests he has so far refused to
consent to? Should she not call his daughter and not order the workup either?

Our notions of respect are bounded by such elements as culture, ethnic background,
generational mores, institutional concerns and training, and basic moral and religious
commitments. Thus the very emptiness that is required of moral principles for them to apply
across cases (in the way that “Physicians should treat patients with respect” would be meant as a
rule to be applied to all physician-patient interactions) also makes them too general to apply

usefully to individual cases (as in the example of Mr. N). Such general moral principles are, in

short, doomed to inadequacy, if not on one count then on the other: either they are too general to
apply to individual cases, or they are too specific to serve as general rules and thus fail to provide
the kind of comparability and consistency needed to establish a coherent system of moral rules
and principles. Walker sees this as an important difference between narrative and principlism:

The need to “apply” principles at the level of abstraction typical of

codelike moral theories creates pressure to shear off complicating,

possibly “irrelevant” details to magnify “repeatable,” even

“universalizable” features general enough to map cases onto

available theoretical categories. Emphasis on narrative

construction pulls in the opposite direction—from premature or

coercive streamlining of cases toward enrichment of context and

detail. (35)

Because rules and principles are relatively devoid of content, they cannot account for
some of the everyday phenomena of moral life: the virtues, for instance. Clarke notes that virtues
such as humility and kindness, which “do not cry out for principles,” cannot be accounted for
under a rationalistic, deductivist theory because no rule can be formulated that says anything about
what it means, in concrete terms, to be humble or kind. (240)

The last criticism in this vein is that if rule- and principle-based theories were truly
deductive and not interpretive, then dilemmas would cease to exist. They have not. As Clarke
puts it,

[M]oral conflicts arise in circumstances in which the relevant

norms imply mutually incompatible obligations. If such conflicts

are irremovable, then the requirement of rationalist theory that

there be one and only one morally correct answer, justified by

norms, cannot be met. (239)
There are two ways of looking at the problem of clashes between principles. The first one, that of
the committed principlist, is that we simply have not yet hit upon the right system of rules and

principles. A really good theory, the argument goes, would be so constructed as to eliminate these

conflicts. That is, in principle, there is no reason principled theories cannot work. The more

critical view is that no set of principles can exist that would resolve equally well every conflict,
and that conflict among principles is unavoidable.

Another critique of principled theories is that they appear, ultimately, to be justified by an
appeal to intuition. The practical test of whether a theory works and should be accepted seems to
be whether it allows us to hold inviolate (at least) our most highly valued moral intuitions. To
date, no persuasive alternate justification for starting principles has been advanced. If theory is in
fact based on intuition, then there would appear to be little need for theory. Bernard Williams
writes that the worth of an ethical theory can be judged only “by reference to the everyday
distinctions it is supposed to replace or justify, and by a sense of the life it is supposed to help us
to lead[.]” (115) Edmund Pincoffs likewise asserts that “moral truisms,” such as “Murder is
wrong," are “bedrock;” further justification is neither necessary nor possible. He writes,

[W]hat if the skeptic rejects all moral truisms; what if he demands

a proof for all of them together, for a whole network of truisms?

Then what is there to say? If we cannot go back to a truism, where

is thereto go? We have no purchase on the subject. . . If [the

skeptic rejects all moral truisms], we must flag the skeptic as a

person who may be unamenable to moral reasons or even as a

person whom we must be wary of and must warn others of. (56)
We cannot safely say that the fact that intuitions precede theory means that theory is nothing more
than a reiteration (albeit in a more philosophically respectable form) of intuitions. What we can
say, however, is that some theory may be a mere back-formation of moral judgments, using theory
to justify preexisting intuitions and commitments.

Noble claims that “the principles used to ‘justify’ the social practices are only highly
abstract descriptions of norms already embodied in those practices.” Her concern is that
principles themselves masquerade as “culturally and socially neutral truths and this impression is

not threatened by any concrete social analysis.” (9) Noble is especially critical of claims to

objectivity and expertise in a process of moral reasoning.

lO

But is it true that theorists justify their theories by appeals to intuition? Let us turn to an
example. In the following passage, H. Tristrarn Engelhardt, Jr. writes about prohibiting the killing
of certain kinds of nonpersons.

What one must seek are the grounds that may justify the practices

through which infants, the profoundly mentally retarded, and the

very senile are customarily assigned a portion of the rights

possessed by entities who are persons strictly, including being

protected from being killed at whim. . . . To find grounds for

protecting such entities, one will need to look at the justification

for certain social practices in terms of their importance for persons

so as to justify a social role one might term “being a person for

social considerations.” (Foundations, 116)
The giveaway in this passage is the “must” in the first line. Why “must” he seek grounds for
preventing the whimsical killing of infants, the profoundly mentally retarded, and the very
senile— given that under his own definitions of personhood, such beings simply are not entitled to
the sort of treatment accorded to persons? In the absence of an answer to this question, we can
conclude only that Engelhardt must harbor some pretheoretical conviction that such killing is
wrong and ought not be allowed. The theory does not lead him to this conclusion; rather, the
theory seems to be formulated in such a way that it justifies and reinforces his moral commitment
on this issue.

A similar example is provided by Peter Singer’s argument about abortion. Singer sets out
to prove that self-consciousness is the primary criterion in determining whether a being has a right
to life. He tries to do this by means of a thought experiment in which he assumes the subjectivity
of a horse and then switches to the subjectivity of a person. He then imagines an objective “third
position” in which he can recall both what it was like to be a horse and what it was like to be a
person. His conclusion is that

In general it does seem that the more highly developed the

conscious life of the being, the greater the degree of self-awareness
and rationality, the more one would prefer that kind of life, if one

11

were choosing between it and being at a lower level of awareness.
Perhaps that is the best we can hope to say about this issue. (90)

Singer’s thought experiment thus leads us right back to where we started: with humans at the top
of the scale. “In general . . . it seems”: this is not the sound of deduction.

It has also been asserted that moral theories are inadequate for dealing with the depth and
variety of human relations. Theory cannot capture just what goes on between real people in actual
situations. To apply abstract moral principles and rules, the philosopher (or the health care
provider) must sift through the facts of the case and determine just which ones “count.” Rather
than being driven by the undifferentiated facts of the case, the deductive process is driven by what
the theory takes to be salient. As both Caplan and Noble point out, the philosopher is inclined to
frame the problem in a way that makes it susceptible to resolution using the tools he has at hand.
In fairness, it must be admitted that we all do this to some extent, philosophers or not; but Noble’s
criticism is that in asserting objectivity, philosophers lay claim to an expertise they cannot
possibly possess.

For example, say that we subscribe to a principle of respect for persons. When we
consider an actual case involving a conflict of values among living, breathing people, the
questions we most urgently want answered concern the particulars of the case. Who are these
persons we are to respect? What are their interests and preferences? What events and
preconditions have brought the players to this pass?

Consider Engelhardt’s discussion of Dax’s case. Dax, formerly known as Donald
Cowart, was 26 years old when an accident killed his father and lefi Dax with second- and third-
degree burns over 68 percent of his body. Throughout the course of his treatment, he asked
repeatedly to be allowed to die. His mother and his physicians overruled his demands, and Dax
was treated against his will. After treatment, Dax said publicly that although he was glad to be

alive, he felt that his mother and the treatment team were wrong to have continued treatment that

12

he did not want. On Engelhardt’s view, Dax’s case is best seen as a simple conflict between
autonomy (Dax’s demand to die) and paternalism (the desire of his family and physicians to do
what they felt was best for him, even over his protests). Engelhardt’s article never once mentions
Dax’s name, let alone any of the contextual factors one might reasonably take into account, such
as Dax’s life plans and ambitions, his mother’s aggressively held religious beliefs, his physicians‘
attitudes and motivations, or even the fact that Dax is a Texan with the sort of rugged individualist
outlook often associated with that state. This is how Engelhardt writes about Dax’s case:
. . . what are the alternatives which are morally open: (I) to
compel treatment, (2) at once to cease treatment, (3) to try to
convince the patient to persist, but if the patient does not agree,
then to stop therapy. Simply to compel treatment is not to
acknowledge the patient as a free agent (i.e., to vitiate the concept
of consent itself), and simply to stop therapy at once may abandon
the patient to the exigencies of unjustified despair. The third
alternative recognizes the two values to be preserved in this
situation: the freedom of the patient and the physician’s
commitment to preserve the life of persons. (52)
This description of things is curiously unpopulated. Dax is not mentioned, and neither are the
other players in this drama. Engelhardt talks about “altematives,” not choices, perhaps because
the latter word more clearly implies a chooser. Still more odd is the fact that, in Engelhardt‘s
vision, the manifestation of respect for persons is the complete erasure of the personal identity of
the patient and of the specific circumstances in which he and the other people involved in making
this decision find themselves. Engelhardt is not inconsistent in this; on the contrary, according to
his theory, respect is necessarily impersonal.
Finally, some antitheorists take issue with the fundamental conception of ethics as a body
of knowledge about moral truths, instead conceiving of ethics as an essentially practical enterprise
whose existence lies in the doing of it. They see ethics as praxis, not knowledge. On this view,

ethics is knowing how, not knowing that. Walker asks,

Could full moral competence really consist entirely in intellectual

l3

mastery of codelike theories and lawlike principles? What of skills

of attention and appreciation, of the practiced perceptions and

responses that issue from the morally valuable character traits, of

the wisdom of rich and broad life experiences, of the role of

feelings in guiding or tempering one’s views? (34)
If we accept the engineering model—in which ethics is fundamentally a set of rules and principles
that are to be used to resolve moral conflict—then it is reasonable to say that adepts of the
applicable rules and principles are in fact moral experts. But to say that moral expertise rests in
such knowledge flies in the face of our everyday experience, where we see attributes other than
philosophical education as primary.

Imagine, for example, a situation in which we are trying to decide which of our friends, A
or B, we should ask for advice on a moral problem we face. It is in this sort of situation that we
look for the virtues. Which person, A or B, do we think is wiser, more compassionate, more fair?
The question is not which one has read philosophy, but which has the practical wisdom we
require. Which knows, by virtue of his way of looking at and responding to the world, how to
judge rightly? Henry James meant just this sort of everyday moral deliberation when he said that
“the philosophy which is so important in each of us is not a technical matter; it is our more or less
dumb sense of what life honestly and deeply means. It is only partly got from books; it is our

individual way of just seeing and feeling the total push and pressure of the cosmos.” (I) As we

will see in the next chapter, narrative ethics is first and foremost a pragmatic enterprise.

l4

Chapter 2

WHAT IS NARRATIVE ETHICS?

It is into the conflicted state of affairs I have just described that narrative ethics was bomf
Narrative was one of a few new approaches to ethical decision making that began to be discussed
in the early 19805 as an alternative to foundationalist, principled approaches. My first goal in this
chapter will be to try to explain just what is meant by narrative ethics. This is a tall order, for as
we will see, there is little agreement to be found on this point. Next, I will survey the claims
advanced on behalf of narrative to see how it differs from principlism. Finally, I will evaluate and
critique these claims.

Narrative ethics has been spoken of as a new field, a “new discipline,”7 but in a larger
sense, its proponents point out, stories have always been an important—perhaps even the most
important—way of knowing who we are and how we ought to behave.8 Biblical parables,
Aesop’s fables, Native American legends, fairy tales, “horror stories” told by attending physicians
to their residents and medical students,9 the Greek tragedies: all have used stories to teach moral
values, to convey what is required of members of the society, and to propose a vision of the
good. Narrative ethics has been advanced as a corrective to the abstraction and reliance on

principle of the leading philosophical approaches.

 

6Or resurrected, depending on your point of view. If narrative is nothing more than a
resurrection of casuistry, then it can hardly be called innovative.

7The first volume of Literature and Medicine, in fact, was entitled “Toward a New
Discipline.”

I’As has been described by Jerome Bruner, among others.
9I am thinking of Charles Bosk’s Forgive and Remember.

15

16

On an intuitive level at least, it seems that narrative may indeed supply the missing piece.
Many people (and surely those who consider themselves readers) have some sense, however
vague, of literature as ethically relevant. More importantly, we have all heard and used stories to
illustrate moral points or to shore up moral arguments. The question is whether narrative has any
noninstnrrnental value to moral philosophy: Can it be a mode of ethical reflection in and of itself,
or is it merely a different way of packaging principles? Before we can answer this question, we
must first get clear on what narrative is.

What Is Narrative?

The units of analysis in narrative ethical analysis are familiar to many of us from high-
school English classes. Stories, or narratives, are made up of a particular configuration of
character(s); a conflict or event; a setting; a plot with a beginning, middle, and end; and a narrator
or narrative point of view that can belong to a character in the story or to an implied narrator.
Each of these elements contributes to the way in which narrative represents and comments on
morality, and each supplies its own reasons for why things turn out the way they do in the world
of the story.

On the standard definition, all narrative is built around some central conflict, quest, or
event. In some cases, the conflict is obvious (as in the case of the average murder mystery). In
others, the conflict may be more subtle. In Hamlet, for example, the central conflict centers
around the murder of Prince Harnlet’s father and his mother’s marriage to the murderer, who
happens also to be the king’s brother. Hamlet grapples with several other conflicts as well:
difficulties with his mother, with the ghost of his dead father, and with Ophelia, for starters. He
must also face the inner turmoil of feeling bound to revenge his father, although he knows
vengeance is a sin against God. In presenting conflicts, and in presenting certain characters in

certain situations, literary narratives make the reader privy to characters’ deliberations, their

17
process of moral reasoning. How this information is presented depends in part on the narrative
point of view, which we will get to in a moment.

The setting circumscribes the Options available to the characters in the story. The time,
place, culture, social strata, and economic class characters come from and operate within inform
and sometimes constrain the options that are available to them—just as these factors shape real
lives. The setting is important partly because it helps the reader understand characters’
motivations and actions, but also because the same story in a different setting might well be a
different story. Imagine, for example, a modern director trying to update King Lear by bringing
the play into the 19905. If he could find a contemporary metaphor that would do for Lear’s
journey from throne to moor, he might succeed in telling the same story: but if not, not.

Plot concerns the action of the story. Events take place in time, and there is a beginning
and an end to every story. But note that it is not only suspense thrillers that keep us wondering
what happens next. Characters in stories, no less than the rest of us, find their lives shaped by
forces beyond their control. What we call the story is the combination of what happens; how the
characters respond to these events, either through external action (e.g., Harnlet’s argument with his
mother) or internal resolution (e.g., Hamlet’s decision to stall for time by acting mad); and why
they respond as they do.

And what of the narrator’s role? The narrator is perhaps the most important of all, for he
tells the story. His view of the world colors our view of the world, or may even be our view of
the world. This is not to say that we as readers must take everything he says at face value. On the
contrary, we can make judgments about what kind of person he seems to be and evaluate his
judgments and descriptions with a grain of salt when that seems appropriate. If we trust the
narrator and share his view of things, we put credence in his account of the facts. But if we find

instead a moralistic, sarcastic, or dishonest narrator, we are likely to view his story with a more

18
critical eye. Sometimes, as in William Carlos Williams’s or Richard Selzer’s short stories, the
narrator unwittingly gives us reason to mistrust or dislike him. This, too, colors our perceptions,
for such a narrator can—if we readers are not on our guard—lead us places we would rather not
go and make us unwitting, and perhaps unwilling, conspirators.
What Makes Narrative Ethical?
Through the orchestration of narrative elements, the author presents a certain view of the
good and asks that we go along for the ride. It is this dynamic Wayne Booth alludes to when he
comments that the central questions of ethical criticism are, “What kind of company are we
keeping as we read or listen? What kind of company have we kept?” (10)
The feature of narrative that has received the most attention in philosophical discussions
(at least so far) is its coherence, its internal connectedness. Motivations cannot be separated fi'om
the fact that we come to the story in medias res. The story has a beginning, a middle, and an end,
and for us as readers to understand where we are now, we must know something of what has gone
before. Howard Brody explains how the shift fiom a fragmented view of a person’s life to a
vision of the life as an integrated, ongoing story entails important changes for ethics:
The concept of “story” suggests appreciation of a narrative
mode—that certain sorts of events can be fully understood only as
portions of an ongoing narrative and not as disconnected events
occurring in isolation. In contrast, much of modern medical ethics
is “rule”- and “decision”-oriented, suggesting that precisely such
an ahistorical, nonnarrative form of ethical analysis is optimal.
(Stories, xiii)

One of the cardinal rules of narrative is that context counts.

The change to a narrative view of the patient’s life story also implies a heightened regard
for the patient’s point of view. If we focus on the patient’s story not merely as the story of her

life, but as the story she tells about her life, we cannot help but recognize the primacy of

subjectivity, the particularity of this patient, and how this health event fits into the larger story she

l 9
is constructing. On a narrative view, the meaning of illness should be understood first and
foremost as it is lived by those it touches.

This emphasis on the patient’s subjectivity implies another change, as well. Most of the
rule- and principle-based theories are devoid of subjective references, partly in the interest of
fairness. What is important to note is that, almost by default, the implied decisionmaker in such
discussions is not the physician. By giving pride of place to the patient’s subjectivity, narrative
challenges the physician-centered model of medical ethics that values physician distance and seeks
to codify appropriate professional behaviors, sometimes at the expense of responsiveness and
sensitivity to the individual patient.

Some critics, thinking to downplay the need for a renewed emphasis on subjectivity, have
charged that there is already too much emphasis on patient autonomy in medical ethics; but this
charge only clarifies the distinction. Autonomy, in its barest form, refers to the right to make
one’s own decisions about one’s life, provided that those decisions do not harm others.
Subjectivity is concerned not so much with the right to decide as with the right decision,
considering the patient’s values, emotions, relationships, and so on. Imagine an elderly man
whose wife is dead. He is living with his daughter’s family, which includes her husband, four
small children, two dogs, a cat, and a parakeet. It is a busy, noisy, but happy home. The man
might well have the right to stop eating and to refuse artificial feeding; but it might also be true
that the reason he wants to die is that he feels he is a burden to his daughter’s family. Respect for
a stripped-down version of autonomy will not lead us to the right decision in this case. Respect
for subjective experience, on the other hand, would prompt us to ask him (in a nonconfrontational,

caring way) why he thinks death is the best choice.

20
But a richer definition of autonomy is possible. Bruce Miller identifies four different

senses of autonomy. ‘0 Autonomy as free action he defines as an action that is “voluntary and
intentional.” Autonomy as authenticity

means that an action is consistent with the person’s attitudes,

values, dispositions, and life plans. Roughly, the person is acting

in character. Our inchoate notion of authenticity is revealed in

comments like, “He’s not himself today” or “She’s not the Jane

Smith I know.” For an action to be labeled “inauthentic” it has to

be unusual or unexpected, relatively important in itself or its

consequences, and have no apparent or proffered explanation. (24)
The third sense Miller identifies is autonomy as eflective deliberation, which means that the
person sees himself as being in a situation in which he must make a choice, knows the alternatives
and their consequences, weighs them, and uses that information to make his decision. Autonomy,
in this sense, is protected in medical contexts by the requirement for informed consent.
Autonomy as moral reflection, Miller’s fourth sense,

means acceptance of the moral values one acts on. The values can

be those one was dealt in the socialization process, or they can

differ in small or large measure. In any case, one has reflected on

these values and now accepts them as one’s own. This sense of

autonomy is deepest and most demanding when it is conceived as

reflection on one’s complete set of values, attitudes, and life

plans. (25)
Two of Miller’s senses of autonomy—as authenticity and as moral reflection—are impossible to
conceive, much less protect, without a narrative understanding of the patient’s life story. Without
knowing that story, the health care professional has no way of knowing whether a patient’s
decision to refuse treatment is in character. Without knowing that story, the nurse or doctor
cannot tell whether the patient’s decision “fits” into the narrative flow of that life. As Margaret

Mohrmann puts it, the “[narrative] perception of the true owner and protagonist of the story

evokes a much richer sense of patient autonomy” than does a principle-bound approach. (72)

 

'01 am indebted to Howard Brody for this reference.

2 1

Another facet of narrative analysis that can be used to enhance physician-patient
communication is consideration of the audience to whom the narrator addresses the story and his
or her purpose in doing so. This point may be illustrated by an example fiom Robert Coles’s The
Call of Stories. Coles, a physician, recounts an exchange with a young man admitted to the
emergency room following a suicide attempt. The patient spoke with Coles awhile, and then

. . . he asked me—I’d been with him only an hour or so—whether
there were any “woman psychiatrists” in the hospital. I was
surprised at the question. I said yes, there was one woman
psychiatrist on our house staff. He was quick to request that she be
his doctor.

I was ready to assent on the spot, but I said no more than
that I’d tell the staff of his request. “All right,” he said, “what will
be will be.” But as l was half out the door of the emergency room
cubicle where he lay on a movable stretcher, his head propped on
two pillows, his right arm by his side, with an intravenous
dextrose-and-water solution flowing into a prominent vein on the
back of his hand, he gave me something to think about: “I don’t
know if I could tell the whole story to a man; I’d tell him a
different story, I’m sure. (15)

Not all patients, one might think, are so selective of their audience. Maybe not; or maybe this
young man was possessed of greater self-awareness than most of us.

There are a few more general claims that are advanced on behalf of narrative ethics. The
first is that narrative, unlike principled philosophical approaches, avoids unnecessary abstraction.
Instead of searching for universal principles, narrative focuses on the particular features of the
instant case. In this respect, and in its emphasis on responsiveness rather than judgment, narrative
has some features in common with the strain of feminist philosophy that issues from the findings
described by Carol Gilligan in In a Diflerent Voice. Narrativists (and perhaps feminists too,
although that question is beyond the scope of this paper) subscribe to a broader definition of what
is relevant than do principlists.

The next general claim is related to the valuing of particulars: narrativists want to move

away from the idea that justice must necessarily be blind (read impersonal). A5 Hilde Lindemann

22

Nelson puts it, narrative ethics was revived by philosophers who “gave moral theory a ‘personal
turn’ by challenging the orthodox assumption that ethics has primarily to do with right conduct
among strangers—an ethics that favors no one and has dictates that are universalizable.” (1) A5
Cora Diamond points out, there is no reason to suppose that

. . . if we follow the temptation to regard a rational hierarchy

wholly independent of the heart’s affections as a paranoid fantasy,

we must he landed with a hierarchy entirely dependent on

unmodified personal affections[.] That we are thus stuck is a

reasonable conclusion to draw only if one makes an unreasonable

assumption, namely that the only way to lead someone from his

initial personal affections to a “recognition of moral status going

beyond the things he initially cared for” is by appeal to purely

rational considerations [i.e., using the tools and forms of traditional

philosophical argumentation]. (28)
Rather than require the setting aside of particular moral commitments and personal ties in favor of
principles, these philosophers argued for an approach that would take these special relationships
into account in a fair and systematic way. There is at least an intuition underlying this idea that
seems to make sense. We commonly feel that the bonds of love and loyalty between parent and
child, or between friends, do create moral obligations that do not apply to other relationships.

Another way in which narrative differs from principled methods is that it values emotion,

whereas traditional philosophy tends to see emotion as at best suspect and at worst dangerous.
The emotional appeal inherent in ethical fiction, its proponents argue, is an integral part of its
efficacy as a mode of ethical reflection. For example, Diamond claims that Wordsworth’s “The
Old Cumberland Beggar” “does morality” without using the conventions of moral philosophy.
On her view, the poem itself, together with Wordsworth’s preface,

make clear that the moral force of the poem is created by the way

objects are described and feelings given in connections with each

other: that is how Wordsworth thinks to enlighten the

understanding and ameliorate the affections of those readers who

can respond to such poems. (30)

Narrative makes us care about what happens to the characters in a story in a way that principled

23

approaches cannot. It is easier for most of us to care about someone we know than for someone
we have never met, or for the person who stands ahead of us in line at the grocery checkout.
Consider again Engelhardt’s description of Dax’s case. This account is unlikely to bring tears to
the reader’s eyes, even though many of us might think tears a suitable reaction to Dax’s
predicament once we have heard Dax’s side of the story. Engelhardt’s case description may
makes us care about the resolution of the conflict, but it does not leave room for us to care about
Dax qua Dax. We know Dax only qua bum-patient-who-doesn’t-want-treatment. If we want to
care about Dax qua Dax, we need to ask for more information. Narratives introduce us to former
strangers and causes us to identify with them, to see things from their point of view. The creation
of empathy (what Diamond calls fellow-feeling) is an important part of how narrative works.

Narrative ethics is unlike principlism in that it is anti-reductionist. The foundationalist
assumption that abstraction and simplification are necessary preconditions for impartialityis
inaccurate. On the narrative view, such simplification does not serve to clarifi» the conflict; rather
it changes the very definition of what is the case, highlighting some details and burying others that
may be equally—or even more—important to tmderstanding. Narrative does not seek to eliminate
complexity, but rather to explore and make sense of the intertwined strands of the story. Because
it does not shy away from the messy details of real life, narrative may more realistically represent
life as it is lived, including the sometimes dispositive force of contingent events beyond
individuals’ control. Connected with this claim is an implicit rejection of the idea that morality,
like medical science, can be reduced to relatively straightforward rules that can be objectively
described and applied.

There is a strong pragmatic, almost populist flavor to much of the narrativist rhetoric.
Narrative is a considerably more accessible approach to moral philosophy than are the

conventional paths of philosophy. Stories, unlike texts on moral philosophy, surround all of us

24
and make up the world of our daily experiences. As Wayne Booth puts it,

The ethical effects of engaging with narratives are felt by everyone
in all times and climes, not just some special group of victims or
beneficiaries. No human being, literate or not, escapes the effects
of stories, because everyone tells them and listens to them. You
and I may care a great deal about the ethics of medicine and the
ethics of law, but these subjects would surprise an ancient hisorian
like Herodotus, or many a citizen in many a land today. If I am
among those billions who never go to doctors or lawyers, their
ethical code need not concern me greatly. Even the ethics of
nuclear warfare, of mortal concern to everyone in our time, cannot
rival the daily, hourly impact of the stories human beings have told
to one another, and to their own private selves, awake and
sleeping. Indeed, even our ideas about the nuclear threat are
shaped primarily by the stories we hear about it: the “thing itself”
is unknown to all but some survivors in Japan and Chernobyl. The
questions we ask about such stories, and the innumerable kinds that
fill each day—Should I believe this narrator, and thus join him?
Am I willing to be the kind of person that this story-teller is asking
me to be? Will I accept this author among the small circle of my
true friends?—these might well have been asked about any story
from the beginning of time. (39)

Narrative is everywhere, coloring our judgments whether we are aware of it or not. The trick is to
be a critical reader and hearer.
What Does Narrative Ethics Look Like in Practice?

The answer is: It depends. There is no single accepted definition of what is meant by
“narrative ethics.” There appear to be five general possibilities: (I) story-classifying (casuistic)
approaches; (2) story-reading (literary and empathic) approaches; (3) story-telling (psychological
and Iifeplan) approaches;” (4) interpretive or hermeneutical approaches; and (5) stories as moral
exemplars.

Casuistic Approaches
In a casuistic (story-classifying) method, the moral universe is organized into a set of

paradigm cases. These are cases on which it is agreed that the moral maxim (what to do in the

 

”Hilde Lindeman Nelson identifies the first three in her article, “What’s Casuistry?”

25
case) is clear. For example, we can imagine the following as a paradigm case for refusal of
medical treatment. Mrs. A is a 70-year-old woman who has been diagnosed with pancreatic
cancer. Her husband died three years ago, and she has no children. She lives alone. Since her
husband’s death, she has had little social involvement and spends most of her time reading and
gardening. When Mrs. A receives her diagnosis, she decides that she will accept only treatment to
provide symptomatic relief. Mrs. A is comptent to refuse consent for other kinds of interventions
and chooses to do so. In this case, most of us would agree that both Mrs. A’s right to make this
decision and our obligation not to interfere are clear.

According to Jonsen’s account, the casuistic method consists of three separate steps:

(1) morphology, which determines the facts of the instant case; (2) taxonomy, the placement of
the case within the appropriate category of like paradigm cases; and (3) kinetics, the process by
which a judgment is made through the use of discernment and practical wisdom. This process is
not unlike legal argumentation, with its reliance on relevant precedent and establishing which prior
cases are “on point.” Like law, casuistry relies on reasoning by analogy, locating relevant
similarities and differences between the case in question and a body of cases that have already
been decided.

Now imagine the case of Ms. B. She is 18 years old and lives with her parents and two
younger brothers. She has just graduated from high school and has been diagnosed with insulin-
dependent diabetes. Ms. B doesn’t like needles and refuses to use insulin. Without it, ketoacidosis
(diabetic coma) will result. How much like Mrs. A’s case is Ms. B’s case? What are the morally
relevant features of each case? The casuist would need to determine whether Ms. B’s youth

makes a difference; whether the fact that her diagnosis, unlike Mrs. B’s, is not terminal; whether

26
the fact that she has a family (who presumably have some interest in her welfare) should carry
any weight in her decision; and so forth.
Story-reading Approaches

The second type of narrative ethics, the story-reading class, has been most thoroughly
described by Martha Nussbaum, who argues that one can develop himself into “a person on whom
nothing is lost” by reading (in a certain way) certain kinds of fiction. Reading carefully and
paying close attention to the business of “seeing what is there to be seen,” she claims, refines our
understanding of the good. Nussbaum traces the roots of narrative ethics back to Aristotle.
Aristotle’s sense of “ethos” and ethics was that one’s actions flowed from one’s general character
and temperament. We act, on the Aristotelian view, out of who we are; and who we are is best
understood narratively.

Nussbaum’s claim is not merely that stories are an alternative to philosophical discussion,
another mode of conveying moral truths, but that novels—in their very form—depict moral truths
that are otherwise ineffable. She writes that there is “a distinctive ethical conception . . . that
requires, for its adequate and complete investigation and statement, forms and structures such as
those that we find in [certain] novels.” (6) Following the Aristotelian question (How should we
live?) and method, Nussbaum describes narrative ethical inquiry as

both empirical and practical: empirical in that it is concerned with,
takes its “evidence” from, the experience of life; practical, in that
its aim is to find a conception by which human beings can live, and
live together.

The inquiry proceeds by working through the major
alternative positions (including Aristotle’s own, but others as well),
holding them up against one another and also against the
participants’ beliefs and feelings, their active sense of life.

Nothing is held unrevisable in this process, except the very basic
logical idea that statement implies negation, that to assert
something is to rule out something else. The participants look not
for a view that is true by correspondence to some extra-human

reality [such as the principle of autonomy] but for the best overall
fit between a view and what is deepest in hmnan lives. They are

27

asked to imagine, at each stage, what they can least live well

without, what lies deepest in their lives, and, again, what seems

more superficial, more dispensable. They seek for coherence and

fit in the web of judgment, feeling, perception, and principle taken

as a whole. (25-26)
There are several key points deserving of comment here. Nussbaum’s emphasis on imagination is
important for a couple of reasons. The first is that reading requires imagination and so do
empathy and compassion, modes of “feeling with” another person. If reading causes the reader to
imagine deeply what it would be like to be that character in that situation, and thereby to also
develop a greater awareness of how her own life story shapes her ability to relate to others, it may
have the potential to increase our capacity for empathy and compassion. Second, if the inquiry
requires trying on different moral worlds, there can hardly be a less risky way of doing so than
literature.

Another distinguishing feature of Nussbaum’s approach is the fact that the inquiry has as
its end not one sovereign right answer, but rather coherence. Whereas the traditional
philosophical approach consists in a series of principle-versus-principle prizefights (e.g., in
Engelhardt’s conception of Dax’s case as Autonomy v5. Beneficence), this method employs a
balancing, all-things-considered test: Given this particular complex of personalities, values, and
relationships, what is most appropriate?”

Nussbarun points to four elements that the novel shares with Aristotelian ethics. The first

is what she terms the noncommensurability of valuable things, which is also her explanation for

why hierarchical systems of principles cannot work alone. The reason is that principles

 

12It is worth noting that, although a comparison is beyond the scope of this paper, this
conception of ethical deliberation has much in common with coherentist theories like those
advanced by Norman Daniels, Henry Richardson, and Stanley Clarke. In such systems,
deliberation takes place in the context of endlessly revisable principles, considered judgments, and
background theories. The drive in such theories is not toward deduction but toward coherence, or
“making the best fit” among principles, judgments, and theories.

28
encapsulate values that are qualitatively different, whereas hierarchies are made for things that are
measurably, quantifiably different. One explanation for the ambivalence we feel when we face a
true moral quandary, Nussbaum explains, is that the thing chosen (whichever thing it is) is
different in type from the thing sacrificed. It is not a simple difference of quantity, but a choice
between two equally important but ftmdamentally different values. In Nussbaum’s view, novels
are built around just such conflicts. They are the form best suited for the exploration of moral
dilemmas because there is time and space enough to show “patterns of choice and commitment,”
which speaks to Miller’s understanding of autonomy as authenticity and autonomy as moral
reflection. (37) In a refusal of treatment case, for example, the patient’s choice may be more
complicated than a simple probabilistic weighting of the possible outcomes of each option. The
goods themselves are different. It may, for him, be the difference between being heroic and being
cowardly, or between trusting in God and abandoning a long-held religious faith.

Nussbaum also insists on the priority of perceptions, claiming that the ability to see things
rightly—“to discern, acutely and responsively, the salient features of one’s particular situation”—
is the heart of practical wisdom (37). To see what is there to be seen, one must focus on the
concrete. Citing both Aristotle and Henry James, she writes, “One point of the emphasis on
perception is to show the ethical crudeness of moralities based exclusively on general rules, and to
demand for ethics a much finer responsiveness to the concrete—including features that have not
been seen before and could not therefore have been housed in any antecedently built system of
rules.” (37) Even if, say, every breast cancer is the same as every other breast cancer (which
seems unlikely), no two women with breast cancer are the same. Differences in their values, their
community of family and friends, their religious convictions, their cultural beliefs and traditions,

their personal history and psychology, and so forth, mean that the right decision for a 70-year-old

29
Filipino breast cancer patient may look very different from the right choice for a 40-year-old
Italian-American woman with the same type of cancer.

Narrative also contains an important role for the emotions, not as mere decoration or
byproduct but as an integral part of moral deliberation. Nussbaum rejects the assumption that
emotion is an irrational force and points out that, on the contrary, emotions are quite closely tied
to cognition:

if one really accepts or takes in a certain belief, one will
experience the emotion: belief is sufficient for emotion, emotion
necessary for full belief. For example, if a person believes that X
is the most important person in her life and that X has just died,
she will feel grief If she does not, this is because in some sense
she doesn’t fully comprehend or has not taken in or is repressing
these facts. Again, if Y says that racial justice is very important to
her and also that a racially motivated attack has just taken place
before her eyes, and yet she is in no way angry—this, again, will
lead us to question the sincerity, either of Y’s belief-claims, or of
her denial of emotion. (41)

Nussbaum also claims that narrative challenges the Socratic dictrun that the good person
cannot be harmed by depicting worlds in which unconUollable events define what kind of life is
possible for the drarnatis personae. Novels, by their very structure, emphasize “the significance,
for human life, of what simply happens, of surprise, of reversal.” (43) This criterion is especially
important in medicine: patients suddenly faced with terminal illness, chronic illness, or disability
often see the event as a tuming point in their lives. The point (so to speak) of a turning point is
that things could go either way. The patient’s story from there on is necessarily a response to what
has happened. Given the event, and the chances it brings about, what will he do next?

Cora Diamond is another advocate of the story-reading approach. She too sees emotion
and perception as central and rejects the assumption that logical argumentation is the trump card

of reason-giving. On her view, a change from

. . .particularistic affections to a more objective hierarchy of
values . . . depends on our coating to attend to the world and what

30
is in it, in a way that will involve the exercise of all our faculties;
and. . . religion, poetry, and science, if uncontaminated by self-
indulgent fantasy, are the most important modes of thought leading
to that kind of attentive imaginative response to the world. (29)
Diamond’s notion of paying attention is essentially the same as Nussbaurn’s emphasis on
developing fme-timed perception.

Diamond explains that philosophical argument relies on a set of assumptions that does not
apply in all cases. Arguments possess logical force which, it is assumed, is stronger and more
reliable than any other sort of convincing. The arguer also assumes that any reasonable person
responds to argumentation. Even granting these assumptions, however, we can see that there are
still those who remain unconvinced, to wit the person who does not understand the argument and
the person who is simply not open to argument. The tendency of philosophy is to say that these
people are unreasonable, insofar as they simply cannot be convinced when they ought to be
convinced, and that their objections therefore need not be taken seriously. But, Diamond
comments, given the fact that not all people are convinced by argument, it seems unfair (or at least
inconsistent) to say that narrative does not work because not everyone finds it convincing. She
believes that the argument for argument is based on the idea that true convincing must be done by
way of argument, in which “the capacities of [the] head and not of [the] heart will be involved.”
(28) Using David Copperfield as an example, she notes that Dickens’s goal seems quite clearly
to be to change the settled inclinations of those who disagree with him—not by argument, but by
engaging the reader’s sympathies with young David’s plight. Diamond sees the novel as an effort
on Dickens’s part to “enlarge the moral imagination” of the reader. Another example is
Wordsworth’s Lyrical Ballads, of which she writes:

One expression of [Wordsworth’s] moral view may be found in
“The Old Cumberland Beggar,” when the response of the villagers
to the beggar is explained; we have all of us one human heart. But

what is it to be convinced of that? What sort of conviction is it
that such poems aim at? It cannot be separated from an

31

understanding of oneself, from an acknowledgment of certain
capacities of response in oneself as appropriate both to their object
and to one’s own nature. Rather a lot to expect! Wordsworth
believes that we have a capacity to respond with deep sympathy to
the feelings of other people—that is, when they are moved by the
“great and simple affections of our nature,” “the essential passions
of the heart.” The poet’s representation of a person under the
influence of such a feeling can excite in us a feeling appropriate
both to what is described and to our own nature, the
appropriateness being something we can come to recognize in part
through the kind of pleasure such a poem gives. (31)

Storytelling Approacha

The third type of narrative ethics, which emphasizes storytelling, is that described by
Howard Brody in his book, Stories of Sickness. Brody argues that the life stories we construct for
ourselves are how we make sense of our lives. In a commentary at the 1994 meeting of the
Society for Health and Human Values, Brody explained this idea:

The meaning of my life becomes the story that I would tell about
my life, and to the extent that my life has some sort of final or
ultimate meaning, in this realm, it is encompassed by the obituary
that I would ideally write for myself in advance of my own death.
Assuming that I am a person with some degree of integrity and
character, there ought to be some commitments to moral values
which form consistent threads or patterns running through my life
narrative. My actions and attitudes scent, in retrospect, to be most
worthy when they are consistent with these value commitments
(which I take to he, basically, what it means to be virtuous).

No doubt I have also done things which, once placed
within the context of my unfolding life narrative, diminish or
negate my commitment to one or more of my core moral values.
Sometimes this will be because of ignorance, inexperience,
uncontrolled passions or caprice, or short-terrn selfishness. Other
times, this will be because conflicts have appeared among my core
value commitments, and in adhering to one value I was forced to
weaken my commitment to another. Presumably I can be generally
satisfied with my life to the extent that, when I scan my “obituary,”
I see a reasonable preponderance of the actions and behaviors that
embodied a commitment to my core vaues, given the talents,
strength of character, intelligence, and other natural advantages or
disadvantages I started out with.

The conception of life as an ongoing story connects with virtue ethics in the following

32
way. When we contemplate what to do in a given situation, we consider not only which course
would be consistent with what has gone before, but also which course would be consistent with
where we want to go and with what kind of people we want to be.

Margaret Urban Walker also proposes a storytelling view: “A story, or better, a history is
the basic form of representation for moral problems; we need to know who the parties are, how
they understand themselves and each other, what terms of relationship have brought them to this
morally problematic point, and perhaps what social or institutional frames shape or circumscribe
their options.” (35) These contextual factors help explain not only how the patient ended up
where he is, but also where he might want to go fi'om there.

Margaret Mohrmann sees the change from principles to narrative as a change from
problem-solving to “writing the next chapter” of the story. She lays out three goals in this regard.
The next chapter must belong to the patient, by which she means that it must attend to the fact that
he is the hero and protagonist of his life story. The next chapter must also cohere with what has
gone before. Echoing Miller’s comments on autonomy as authenticity and moral reflection,
Mohrmann writes, “There is no sense in trying to tack the last chapter of Anna Karenina onto the
first half of Gone With the Wind. Scarlett would never have thrown herself in front of a train,
even if there had been any railroad tracks left in Georgia, and there is no point in considering such
an incongruous outcome.” (79) The new chapter must also “continue the themes that have defined
the hero’s life . . . and should be able to lead the story on to the other chapters that are to follow.
It must be not only continuous with what has gone before but also generative of what is to come:
the re-forrned, reintegrated life of a whole person.” (80)

Interpretive/Hermeneutic Approacha
Rita Charon is a leader in this school of thought. She has written that narrative

contributes to the “trustworthiness” of medical ethics by first offering ways to describe a situation

33

and then by assessing the most appropriate interpretations of those descriptions. Charon
summarizes the contributions of narrative ethics:

To begin with, the ethics deliberation seeks to recognize the

narrative coherence, however obscured, of the patient’s life. In

addition, the medical ethicist faces narrative tasks in identifying the

multiple tellers of the patient’s story, the several audiences to

whom the story is told, and the interpretive community responsible

for understanding it. The medical ethicist relies on [interpretive]

methods to examine contradictions among the story’s multiple

representations, conflicts among tellers and listeners, and

ambiguities in the events themselves. (261)
Just as students of literature learn to construct a reading of a text by considering and weighing its
interwoven elements, so ethicists and health care providers can learn to interpret better the “real”
stories of the patients they serve. Ultimately, the argument goes, more careful and sensitive
interpretations will help to produce better and more humane treatment of patients.

This postmodernist view also emphasizes “the ubiquity of interpretation,” (leder, 241)
and tends to see almost everything as a text whose meaning is created through intrepretation.
Drew Leder and Kathryn Montgomery Hunter both see bioethics as a complex of intersecting and
disparate texts (including the patient’s body, laboratory reports, health law, interpersonal
communications, and institutional procedures and biases), each of which is subject to a variety of
interpretations. Conflicts in medical ethics arise when these interpretations conflict. The
interpretive approach acknowledges that there is no objective point of view but stresses that

Though one must enter the [hermeneutic] circle through one’s
prejudgrnents and expectations, these always remain provisional
and the text itself can extend, modify, or challenge them. A
sensitive reader permits the interpretive object its othemess; such a
reader does not merely subsume the text within preformed
categories, but engages it as a partner in respectful dialogue.
(Leder, 242)

This view is like the storytelling view in that it aims at making sense of the patient’s experience in

the context of his or her own life. But in the work of some theorists, the focus on interpretation

34
can slip into seeing the patient to be seen as the text itself, rather than the narrator and protagonist
of the text. ‘3 The hermeneutic approach can thus inadverdently objectify patients.

Nancy M.P. King and Ann Folwell Stanford sounded the alarm in a 1992 article in which
they cautioned against a tendency to see the patient as the story and the physician as the reader and
interpreter. They liken such a conception to the ploy of a certain physician who makes house
calls. Once in the patient’s home, he pretends to get lost looking for the bathroom while he cases
the joint for information about the patient’s “household composition, income level, personal
habits, and over- (and under-) the-counter drug use—all in order to know and understand his
patients better.” (186) Despite what are likely good intentions, this physician betrays his patients’
trust and autonomy by denying them the opportunity to decide what parts of their lives he will be
granted access to. Ironically, good providers with good intentions may be most vulnerable to this
rrrisstep:

In their desire to ascertain the true or deeper story of a patient’s life
and illness, conscientious physicians may over-read or may impose
private interpretations without having a corresponding
interpretation from the patient. This monologic method of
gathering and interpreting information about patients relies
primarily on one-sided reading. It may include patient input in the
way of story, but it does not seek patient corroboration and
collaboration in interpreting that story. (189)

Anne Hudson Jones shares these concerns, noting that as productive as the interpretive
point of view can be, it risks objectifying patients.

I have become uneasy . . . about the ready acceptance of the idea
of the patient as text, and I fear that in popular usage the analogy
has become reductive. Its corollary, the idea of the physician as
reader and interpreter, privileges the physician to give meaning to
the patient’s story. This is what physicians do. But to the extent

that thinking of the patient as a text to be read and interpreted
distracts physicians from remembering that patients are persons,

 

l3As Anne Hudson Jones notes, the fact that Hunter’s book is called Doctors ’ Stories and
not Patients ' Stories is illustrative of this point.

35
not texts, the analogy contributes to the very reification and
dehumanization of the patient that we in literature wanted to help
counteract. (192)
Storia as Moral Exemplars

This category treats narratives as purely instrumental. On this view, stories are simply a
more palatable way of packaging principles. They are best used to illustrate the application or
practical truth of principles, as most recently in the case of William Bennett’s two anthologies,
The Moral Compass and The Book of Virtues. These collections are intended to “aid in the task
of the moral education of the young,” not by providing a space in which they can wrestle with
life’s difficult questions, but by “[serving] as reference points on a moral compass, giving our
children a sense of direction in matters of right and wrong, helping to guide their actions in day-
to-day living, as well in those occasional, momentous decisions required of every individual.”
(Compass, 11)

This use of narrrative is analogous to Lakoff and Johnson’s “container metaphor,” which
sees linguistic expressions as “containers for meaning.” (1]) As the authors point out, this way of
understanding language works well only in situations in which “context differences don’t matter
and where participants in the conversation understand sentences [or, in our case, stories] in the
same way.” (12) As we have seen, however, many bioethics conflicts arise out of differences in
point of view and values; so if narrative is to be of help, it must be in some noninstrumental way.
Instead of productively complicating moral issues, the instrumental use of narrative tends to
oversirnplify the discussion and ignore the existence of multiple interpretations.

Challenges to Narrative

Having sketched some of the claims and uses of narrative in moral reflection, it is time to

turn to potential problems with narrative. One question concerns moral relativism. If multiple

interpretations are possible, how is validity to be judged? If we accept the postmodernist dictum

36
that every interpretation is the product of the interpreter’s particular perspective, then how are we
to settle conflicts between intrepretations? Recall that one of the criticisms of principle-based
theories is that they are not dispositive, insofar as irresolvable conflicts between principles exist.
In narrative ethics, presumably we have done away with the conflicts among principles, but we are
still not out of the woods: Conflicting interpretations of the same story seeem to present an
analogous difficulty.
The short answer is that not all interpretations are equally valid. First of all, the facts of

the case admit of only some interpretations. As Wayne Booth has noted,

The blooming [the process by which a text gains meaning through

its interpretation by a conscientious reader] will not occur, of

course, until the right “valuer” comes along: that much truth is

self-evident in the view that all interpretations depend on the

conventions of a community. But to deny any kind of reality to the

potential of “the play itself” is finally to cripple our thought about

it. As Marshall Alcom neatly drarnatizes the point, even if “an

infinity of different readers can (I would say “could”) produce an

infinity of different readings of Othello. . . such an infinite set of

interpretations would exclude the infinite munber of interpretations

produced by readings of Moby Dick.” (88)
So the facts of the case (or the details of the story) rule out some interpretations. One might
argue, however, that the Sideboards Alcom mentions (one set of interpretations for Othello and a
separate, nonintersecting set for Moby Dick) certainly leave plenty of room for an exceedingly
broad range of interpretations. What to do with those conflicts?

Here we fetch up against a criticism that has been lodged against casuistry. The casuists’

answer to conflicting interpretation is, at bottom, an appeal to authority. " He with the most

 

l4As Howard Brody points out, casuistry may be seen instead as an “ongoing moral
conversation.” Given the rushed and often confused environment in which clinical ethical
dilemmas most often occur, however, my focus is on methods of moral reflection that can be
dispositive (so far as possible) with particular real-life cases. An ongoing conversation may be
productive in a general sense, but I suspect that the appeal to authority is more commonly seen in
practice, not least because it leads more unambiguously to a decision.

37
practical wisdom (however conceived and assessed) should be the one to decide. This sounds
suspiciously like the principlist’s claim to moral expertise that Noble took to task. The difference
here is that the claim to authority is based not on immutable, impartial principles but rather on the
decision maker’s character and experience in constructing interpretations (or “readings”) of moral
conflicts. This distinction embeds yet another problematic claim: that (professionally trained?)
readers possess more practical moral wisdom than do nonreaders. One of narrative’s earliest
champions, the physician-writer William Carlos Williams, acknowledged this difficulty in a
conversation with Robert Coles:

Sure, if you could get medical students to read certain novels or
short stories it might make a difference. But, I’ll tell you, don’t bet
too much of your money on it, because you know what can happen
with any book, even George Eliot’s Middlemarch, or Chekov’s
stories. Have you noticed what goes on when literature professors
get together in a room? Are they saved by George Eliot or
Chekov, by Shakespeare or Dickens or Hardy, or even by
Dostoevsky and Tolstoy, who tried like hell to save us all, poor
bastards that we are? Tolstoy had one hell of a time trying to live
up to his own ideals—and boy, did his wife and kids have to pay
for the moral struggle he waged There must have been plenty of
times when he was worse than the most arrogant doc you and I can
conjure up in our imagination! So it isn’t “the humanities,” or
something called “fiction” (or “poetry”) that will save you medical
students or us docs. Books shouldn’t be given that job, to save
people, to improve their psychology, or their manners, or the way
they talk with their patients. (110-111)

The appeal to authority seems not to hold water. Most of us can think of people we know who,
though avid readers, are something less than paragons of virtue in their everyday lives.

Jonathan Franzen, himself a novelist, advances another possibility—not that readers are
better people, but that through reading they seek an escape from a world in which discussion of
the hard questions is unpopular or impossible. Readers, he believes, want to share in public life'5

and are dissatisfied with modern “virtual communities whose most sniking feature is that

 

lsI mean this in Hannah Arendt’s sense.

38

interaction within them is entirely optional—terminable the instant the experience ceases to gratify
the user.” (43) Franzen cites the work of Shirley Brice Heath, a linguistic anthropologist who
has spent a decade researching the reading habits of what she called “serious readers.” Heath’s
conclusions overlap with many of the claims made on behalf of narrative ethics. Heath found that
readers read because books were, for them,

the only places where there was some civic, public hope of coming

to grips with the ethical, philosophical, and sociopolitical

dimensions of life that were elsewhere treated so simplistically.

From Agamernnon forward, for example, we’ve been having to

deal with the conflict between loyalty to one’s family and loyalty

to the state. And strong works of fiction are what refuse to give

easy answers to the conflict, to paint things as black and white,

good guys versus bad guys. . . . [To readers,] reading good fiction

is like reading a particularly rich section of a religious text. What

religion and good fiction have in common is that the answers aren’t

there, there isn’t closure. The language of literary works gives

forth something different with each reading. But unpredictability

doesn’t mean total relativism. Instead it highlights the persistence

with which writers keep coming back to fundamental problems.

(49)
And, Nussbaum might add, the role of uncontrolled happenings in the quest to live a good life.

We have already discussed the critique of narrative as an anti-intellectual method whose
primary appeal is emotional, as opposed to rational. The “as opposed to” here is important. The
assumption of those who raise this criticism is that one can be either emotional or rational, but not
both—or at least not at the same time. There is no reason, however, why this should necessarily
be so; and there does seem to be some value to empathy and fellow-feeling in moral reflection.
Tom Tomlinson raises an important question when he remarks that even if narrative is one

way of walking in another person’s shoes, it is surely not the only way or (more importantly) the
best way. He asks, “Isn’t it by talking to the actual patient, seeing his real suffering, feeling
sympathy for his genuine plight, that we cross the bridge between the patient on the one side and

the doctor, nurse or ethicist on the other? A vicarious literary experience would be a poor

39
substitute.” (4) The most a story can do, he goes on to say, is provide some insight about how a
certain person might feel in a certain situation. But if all narrative does is provide a window on
some “general truths about human nature,” then despite all its good words about the particular and
concrete, narrative is not so different from principles after all. (4)
Martha Nussbaum addresses this point in true philosophical style, by making a distinction:

If we consider, for example, the scene between Maggie and her
father [in the Golden Bowl], we might have an inference of the
form, “If a person were like Magic and had a father exactly like
Adam, and a relationship and circumstances exactly like theirs, the
same actions would again be warranted.” But we might also have
a judgment of the form: “One should consider the particular
history of one’s very own relationship to one’s particular parents,
their characteristics and one’s own, and choose, as Maggie does,
with fine responsiveness to the concrete.” The first universal,
though not of much help in life [as Tomlinson points out], is
significant: for one has not seen what is right about Maggie’s
choices unless one sees how they respond to the described features
of her context. But the second judgment is an equally important
part of the interaction between novel and reader—as the readers
become, in Proust’s words, the readers of their own selves. And
this judgment tells the reader, apparently, to go beyond the
described features and to consider the particulars of one’s own
case. (39)

This still appears to be a case of drawing a general principle, except that the principle is something
more like “Pay attention to particulars” than “A person like Maggie may feel/think/act this way in
this sort of siutation.”

One final critique concerns the ability of an accomplished storyteller (whether novelist,
poet, patient, health care provider, or ethicist) to construct a story that is deceptive. Because
narratives “aim for the heart,” in Diamond’s phrase, they may bypass the critical faculties we
generally reserve for intellectual argument. We may find ourselves being led to judgments we
find morally reprehensible, or being made to identify with characters we find abhorrent. What is
needed, it seems, is a place to stand so that we may be critical readers and hearers of stories. As I

will explain in the chapters that follow, this is where principles and narrative intersect.

Chapter 3

NARRATIVE ETHICS AT WORK

In this chapter, I will turn to specific applications of the narrative method. I have selected
the abortion issue because it is arguably the most intractable medical ethics issue in the United
States today. Rule- and principle-based theories have thus far lefi us at an uncomfortable, even
hostile, impasse. My goal in this chapter is to determine whether narrative can succeed where
principles have failed.

The standard principled arguments regarding abortion are probably familiar to most
readers. The most common pro-choice argument centers on the personth of the fetus, and it
depends on a distinction between biological species membership (being a human being) and
having status as “one of us” (being a person). Nonpersons may have a right not to be mistreated,
but they do not have a right to be treated as persons. Antiabortionists deny this distinction and
call it dangerous, asserting ensoulment at the time of conception or gesturing toward a slippery
slope of maltreatment or extermination of anyone who is not perceived as a worthwhile
(intelligent, productive, etc.) member of society. Another argument holds that the rights of
existing persons (pregnant women, for example) count for more than the rights of potential
persons. Antiabortionists oppose this argument on the grounds that there is a special fiduciary
relationship between the woman and the fetus (provided that the pregnancy was unforced) and that

the potential person has a right to be protected from harm tmtil it can defend itself. '6

 

1"Additional references for and these and other arguments may be found in the list at the
end of this paper.

40

41

Although these arguments have not resolved the abortion debate in this country, it should
be noted that the underlying principles remain essentially uncontested Few would disagree that it
is wrong to intentionally kill an innocent person, for example. Not even the strongest proponent
of abortion sees himself as advocating the killing of innocent persons. Another underlying
principle is respect for autonomy, in the form of women’s reproductive freedom. Few would
argue that women ought not have control over their bodies. At the same time, there is a rule that
accords protection to defenseless people, including children. These higher-level principles serve
to remind us of the values we as a community generally think are worth protecting. We should
not kill persons. We should not deprive people of their right to self-determination. We have an
obligation to protect children. The complicating factors in the case of abortion are the unique
relation of the pregnant woman and the fetus and the indeterminate status of the fetus. To date,
principles have been unable to progress beyond this point.

Narrative ethics involves, first of all, taking a fine-grained look at the facts of the case as a
whole, and at the context in which it takes place. Instead of winnowing out the morally relevant
factors and weighing each one, narrative attempts to make a judgment about the particular case in
its entirety, considering as important its idiosyncratic complexities. Because there is such wide
variation among women who seek abortion and their reasons for doing so, narrative may be a
useful way to consider htis problem. There are two goals here: to make good moral judgments in
individual cases, and to at the very least open a space for productive discussion between the pro-
choice and pro-life camps.

It may be that the reason the rhetoric around abortion in this country has reached its
current vitriolic, deafening levels is that neither side can hear (much less imagine) the other’s

story. Instead of telling stories, each side promotes its message through bumper-sticker language

42
and logic. “It’s a child, not a choice.” “If you can’t trust me with a choice, how can you trust me
with a child?” “Abortion stops a beating heart.” “Pro-child, pro-choice.” Such slogans make
handy weapons (after all, who wants to be called anti-children?) but they reveal little about the
reasons one might hold either position. Each side in this debate has adopted a radical,
unequivocal position and rhetoric, and it now appears that neither group feels it can move to more
moderate ground without conceding total failure.

One author has referred to abortion as the “clash of absolutes,”l7 and so it seems. So long
as the question is framed as a zero-sum conflict between women and fetuses (or between women
and a repressive patriarchal social order) we cannot really see the stories we are talking about.
One result of the way the debate is currently structured is that each side is able to attribute
reprehensible motives to the other. The invective is sharp on both sides: pro-life lobbyists call
pro-choice lobbyists baby-killers. Pro-choice lobbyists declare that their adversaries simply do
not care how many women die as a result of unsafe abortions and assert that pro-lifers want to
impose their own narrowminded morality on others who may or may not agree with them. Just
what is at stake in this debate? Women’s bodily integrity? The lives of unborn children? The
social and political rights of women? Eternal damnation?

Another possible advantage of narratives is that they may help us to get clear about just
what the word “choice” signifies in the context of elective abortion. To paraphrase Judith Jarvis
Thompson, there are choices and then there are choices. Through narrative, we may be able to
distinguish some choices that look a lot like necessities, while other choices more closely resemble
preferences—even if all of these women have an equal right to abortion. The choice of a woman

who seeks abortion because pregnancy does not fit with her career plans looks different to most

 

l7Lawrence Tribe’s book examining the social and legal history of abortion in the United
States bears this subtitle.

43
people from the choice of a woman who seeks abortion because prenatal testing has told her that
the fetus she is carrying has Tay-Sachs. The choice of a woman who cannot provide for yet
another child may be still another sort of choice.

Principlists will say that if we look to stories, we will be looking at causes and not
reasons. By this they mean that a change of principle based on experience or emotion does not
count as much as does a change of principle based on philosophically sound reasoning.
Experience-driven or intuition-driven changes are taken to be unreflective, uncritical, and
irrational. But these criticisms rest on the mistaken assumption that philosophical reasoning is the
only practice of reason-giving that can be trusted.

Paul Ramsey’s “The Morality of Abortion” suggests another mode of reflection, one that
makes much of context. In this paper, Ramsey gives an account of how the sacredness of human
life is a concept that is an important part of longstanding religious tradition. He presents a vision
of human lives as sacred “in human biological processes no less than . . . in the human social or
political order.” (66) Although he relies heavily on biblical sources, Ramsey notes that the Judeo-
Christian tradition is not the only one that supports such an understanding. Any belief system that
sees humans first and foremost as creatures, whose lives are bestowed by and accountable to
some higher force, shares this concept. On the view that life is intrinsically valuable, Ramsey
explains that a human life hardly begun is no less human for that. On the contrary, he argues, it is
as helpless, wholly dependent beings that we are most human, for then our intrinsic value is our
only value. (69) It is only within the rich context of our spiritual and social tradition that this
claim can make sense. To estrange the question of the value of human life from this context
would be to deny any possible justification for Ramsey’s belief.

In the next section, I will present two examples of abortion narrratives and examine how

they may help frame our understanding of what is at stake in the abortion debatefl'he first is a

44
poem, Gwendolyn Brooks’s “The Mother,” and the second is John Irving’s novel, The Cider
House Rules. Looking at two different forms will help us to understand not only what narrative
can do that principles cannot (and vice versa), but also what different literary forms can contribute
to moral reflection.
Gwendolyn Brooks, “The Mother”

The title of Brooks’ poem is ironic: the narrator grieves for her lost motherhood as well
as her fetuses’ lost childhoods. Her “dim dears” seem to haunt her; they “will not let [her] forget.”
One does not have the sense that the decision to have these abortions was easily made, or that her
mind was fitlly made up even as she decided to do so: “Believe that even in my deliberateness l
was not deliberate.” Or perhaps this evaluation is made in hindsight, and what seemed deliberate
then no longer seems well thought out. At any rate, the voluntariness of the choice she made
seems questionable.

The use of the second-person “you” in the first line (“Abortions will not let you forget”)
does two firings at once. First, it stands as an impersonal “one”: anyone who has had an abortion
cannot forget it. The narrator’s subjective experience is thus broadened into a general account of
what it is like to have had an abortion. Second, the “you” serves to distance the narrator from her
experience by classifying it as the common experience, not as idiosyncratic or “just” personal.

The poem is an apology that the narrator is almost afraid to make, perhaps because she
feels she has little right to grieve or regret the necessary and forseeable results of her decision.
(“Though why should I whine,/Whine that the crime was other than mine?”) She wishes that she

could say that these children “were never made,” but finds that claim “faulty.”l8 The whole

 

'81 cannot speak to Brooks’s intentions, but the diction she uses here is interesting.
Accusing one’s opponent of making a “faulty claim” is a tactic of argumentation. To my mind,
this line underscores the inability of logical argument to settle the Mother’s case (or, more
importantly, her mind).

45
problem is that they were made, they “just . . . never giggled or planned or cried.” Nor does the
narrator seem to doubt that the aborted fetuses were anything less than pe0ple. She regrets
depriving these “children [she] got that she did not get”—children begotten but not bom—not
only of their existence but of all that life brings with it. The Mother also speaks of having stolen
their deaths: having never owned their lives, they could not own their deaths.

The poem ends on a plaintive note, with the narrator asking not quite for forgiveness
(which she does not feel she deserves) but rather for some kind of understanding. “Believe me, I
loved you all/Believe me, I knew you, though faintly, and I loved, I loved you/All.” The
repetition in these closing lines conveys a sense of hopelessness and desperation. The Mother
does not seem to expect that her “dim dears” will believe her, as perhaps she finds it difficult to
believe herself. The end of the poem suggests the “voices” the narrator hears in the wind, asking
the question that seems to haunt the narrator: if you loved us, why did you do this? How could
you kill us? No reasons are given in the poem. This silence leaves the question of reasons open
for the reader to ponder. What would count as a good reason for this woman? What would count
as a good reason for the reader?

This poem highlights the narrator’s experience in a way that principles and placards
cannot. After reading this poem, it seems strange to talk about whether the Mother had the right
to make the choice she did. Perhaps this is an appropriate legal question, but it seems not to be
the right moral question. Whether the Mother had the right to abortion is, in her own opinion,
beside the point. Assuring her that she had the right to choose abortion would not resolve her
moral misgivings, would not acknowledge her regrets. To speak to this woman about her rights
would be to talk past her concerns.

Now, a few words about form. “The Mother” leaves out much of the story. Why did she

choose abortion? Why does she regret having done so? 15 her regret genuine? What prompts this

46
confession? What would help the Mother get over her past? These questions cannot be answered
by the poem. The only thing that is clear is the “moment of insight” itself. '9 To the Mother, it is
clear, there is no question of whether the aborted fetuses were persons. They were children, her
children, and she loved them, “though faintly.”
John Irving, The Cider House Rules

John Irving’s novel, The Cider House Rules,20 has often been described in the popular
press as a pro-choice book about abortion, and so it is—but not in anything like a propagandist
way. The main character of the first part of the novel is Dr. Wilbur Larch, who opens a small
orphanage-cum-abortion clinic in the mostly abandoned mill town of St. Cloud’s, Maine, in the
19205. Throughout this section of the story, we are supplied with background not only on Dr.
Larch’s work, but also with his reasons for, as he puts it, delivering babies and, sometimes,
delivering mothers too. (67)

When Wilbur Larch was 18 and headed off to medical school at Harvard, his father
expressed his approbation by buying the graduate a night with a prostitute, a Mrs. Earnes. What
most sticks in Larch’s mind about the encounter is the fact that, afterward, he awoke to find Mrs.
Earnes’s teenage daughter in the room:

Later, when he would have occasion to doubt [his decision to
perform abortions at St Cloud’s], he would force himself to
remember: he had slept with someone’s mother and dressed
himself in the light of her daughter’s cigar. He could quite
comfortably abstain from having sex for the rest of his life, but
how could he ever condemn another person for having sex? (67)

So profound a lesson is this that the thought fi'equently occurs to Dr. Larch, in the same words,

throughout the book.

 

19Thanks to Howard Brody for this phrase.

20Excerpts from The Cider House Rules used by permission of the publisher.

47

A few years later, when Wilbur Larch is Dr. Larch, a resident at the Boston Lying-In, he
sees Mrs. Eames and her daughter again. Mrs. Eames is admitted to the hospital with a ruptured
uterus and a stillborn child. The cause of the mysterious and near-total disintegration of her
internal organs is unclear until the day after her death, when her daughter arrives bearing a bottle
of Mrs. Eames’s “French Limar Solution.” The aborticide had so inhibited the ability of Mrs.
Eames’s body to absorb vitamin C that she died of scurvy. Larch has now seen, first hand and up
close, the effects of one method of abortion turned to by women who have no other way of ending
an unwanted pregnancy.

Mrs. Eames’s daughter has another reason for visiting. She is pregnant but not yet quick;
and she wants a surgical abortion, not the potion that killed her mother, or the butchery she knows
is performed “Off Harrison,” where the illegal abortion clinics are. Having never faced this
question before, Larch does not know how to respond.

“You want an abortion,” Wilbur Larch said softly. It was
the first time he had spoken the word.
Mrs. Eames’s daughter took the sea-gull feather out of her
pigtail and jabbed Larch in the chest with the quill end. “Shit or
get off the pot,” she said. It was with the words “shit” and “pot”
that the sour stench of cigar reached him. (49)
Larch pauses to consider how he would do it, if he did: anesthesia, shaving, sterilizing the field,
which implements to use . . . As he drinks, she concludes that she will get no help from him and
leaves. The next time Larch sees her, she has been brought back to the hospital in bad shape. She
“seems to have been flung against the door,” has a high fever, and appears to have been severely
beaten. Larch examines her and finds that she is the victim of a botched abortion, which could
have taken any of several forms:
There was the water-cure school, which advocated the use
of an intrauterine tube and syringe, but neither the tube nor the
water was sterile—and the syringe had many other uses. There

was a primitive suction system, simply an airtight cup from which
all the air could be sucked by a foot-operated pump; it had the

48

power to abort, but it also had the power to draw blood through the
pores of the skin. It could do a lot of damage to soft tissue.
And—as the little sign said on the door “Off Harrison,” WE
TREAT MENSTRUAL SUPPRESSION ELECTRICALLY!—
there was the McIntosh galvanic battery. The long leads were
hooked up to the battery; the leads had intravaginal and intrauterine
attachments on insulated, rubber-covered handles; that way the
abortionist wouldn’t feel the shock in his hands.

When Mrs. Eames’s daughter died—before Dr. Larch
could operate on her and without having further words with him
(beyond the “Shit or get off the pot!” note that was pinned to her
shoulder), her temperature was nearly 107. The house officer felt
compelled to ask Larch if he knew the woman. The note certainly
implied an intimate message.

“She was angry with me for not giving her an abortion,”
Wilbur Larch replied.

“Good for you!” said the house officer.

But Wilbur Larch failed to see how this was good for
anyone. There was a widespread inflammation of the membranes
and viscera of the abdominal cavity, the uterus had been perforated
twice, and the fetus, which was dead, was true to Mrs. Eames’s
daughter’s prediction: it had not been quick. (51)

In Larch’s mind, a fetus that is not quick is not yet a person; it is a developing organism that can
be kept from becoming a person. He now has seen (and, he feels, been responsible for) the deaths
of two women and their fetuses: four deaths, all the result of improper abortion attempts.

The next day, Dr. Larch decides to visit Off Harrison.

He needed to see for himself what happened there; he wanted to
know where women went when doctors turned them down. On his
mind was Mrs. Eames’s daughter’s last puff of cigar breath in his
face as he bent over her before she died—reminding him, of
course, of the night he needed her puffmg cigar to find his clothes.
If pride was a sin, thought Dr. Larch, the greatest sin was moral
pride. He had slept with someone’s mother and dressed himself in
the light of her daughter’s cigar. He could quite comfortably
abstain from having sex for the rest of his life, but how could he
ever condemn another person for having sex? (51-52)

Larch “needs” to see Off Harrison because he needs to know what he is responsible for. When he
says no to a woman who asks for an abortion, to what fate does he consign them? He wants to

believe that he can safely wash his hands of it, believe that abortion is the province of the morally

49
inferior; but the memory of his own double transgression against Mrs. Eames and her daughter
(having slept with someone’s mother and dressed himself in the light of her daughter’s cigar) is a
goad to him.

Off Harrison is, as he had feared, a nightmarish scene. In place of anesthesia, Off
Harrison has The German Choir, whose singing reminds Larch of Mahler’s Kindertotenlieder."
The front room, in which the choir sings with nearly violent energy, is smoky and smells of cheap
beer. The next room is where the women wait. Larch approaches the man who seems to be in
charge of things and says he wants to meet the doctor. “No doctor here,” the man said. “Just
you.” This utterance can be taken at face value, or with the resonance Larch seems to hear. There
is no doctor at Off Harrison, no one who can provide a safe, sterile abortion to these women. 1f
Larch refuses to dirty his hands, dangerous abortions will continue to be performed by unqualified
people. The point of Larch’s visit is that he has begun to feel that perhaps his own moral pride
has led to a sin of omission.

Larch tells the man that he has some free medical advice for the person in charge and is
told to wait his turn. During that time, he hears a woman’s screams from the next room, blended
with the efforts of The German Choir; he also talks to a mother who waits with her pregnant
thirteen year old daughter and tries to convince them to leave. Angrily, she tells him that they
have no choice.

Larch’s turn to see the abortionist, who is known locally as Mrs. Santa Claus, finally
comes. He is somewhat surprised to see that she is an elderly woman, who to his mind “would
have looked at home in a pleasant kitchen, baking cookies, inviting the neighborhood children to

come and go as they pleased.” Both her age and her gender seem to be different from what Larch

 

21Kinder=children; toten=to die; lieder=songs: Mahler’s “Songs on the Death of
Children.”

50
had expected, as is her attitude. (55) He introduces himself. Her response is, “Oh, yes, Doctor
Larch. Come to shit or get off the pot?” (56) Larch is uncomfortable; he had expected to be in
control or at the very least to be treated with the respect commonly afforded physicians. In an
attempt to establish himselfin the operating room by showing his case in the environment, he
picks up the suction cup. Mrs. Santa Claus promptly begins the vacuum. Larch removes the cup.
realizing that she will continue until she draws blood.
“Well?” Mrs. Claus asked, aggressively. “What’s your
advice, Doctor?” As if in reply, the patient under the sheet drew
Larch to her; the woman’s forehead was clarnmy with sweat.
“You don’t know what you’re doing,” Dr. Larch said to
Mrs. Santa Claus.
“At least I’m doing something,” the old woman said with
hostile calm. “If you know how to do it, why don’t you do it? If
you know how, why don’t you teach me?” (56)
She leads him back out to the woman he had tried to get to leave. She makes the woman tell
Larch who the father is. Larch protests that it is none of his business; but Mrs. Santa Claus insists
on making it his business. It was the girl’s father. Mrs. Santa Claus tells Larch, angrily, that about
a third of her patients are incest victims. “And what are you going to do about it?” is the question
that hangs in the air.

The cumulative effect of these events is to cause Dr. Larch to change his mind about
whether he should perform abortions. Larch does not change his mind on the basis of rational
argumentation but in response to the force of lived experience, both his own and those of the
women he has seen suffer. If asked the reasons for his position, Larch would describe the events I
have just recounted. The point of narrative is that these are reasons and not mere causes. Not
only that: they are strong enough reasons to cause Larch to change his settled opinion on the issue

of abortion.

It is not only Larch who believes that experience counts as reasons. The narrator, too,

5 1
secs experience as a kind of reason.22 This impersonal, omni5cient narrator tells the story in such
a way that these events are causally linked. Larch changes his mind because he has reasons (in
the form of Mrs. Eames, Mrs. Earnes’s daughter, and Off Harrison) to do so.

Another form of deliberan'on goes into Larch’s changing his mind about abortion. This is
based on his unwillingness to be a certain kind of person, that is, the kind of person who would
protect his own moral scruples at the expense of the welfare of others. When Larch looks at
himself and gauges his decisions against the kind of life he wants to live and the kind of person he
wants to be, he finds that refusing to perform abortions does not fit with his life goals or with his
conception of personal virtue. He does not want to be a hypocrite, which is why he constantly
reminds himself that he once slept with someone’s mother and dressed himself in the light of her
daughter’s cigar. What right has he—a privileged member of society who indulged himself with a
prostitute without regard for the possible consequences—to condemn the choices of pregnant
women who cannot or do not want to carry to term?

This is important, for here we see an example of where principles and narrative intersect.
Wilbur Larch is determined to be a certain kind of person, to live according to a certain set of
principled moral commitments. When he faces a conflict between these commitments (“Abortion
is wrong” and “Hypocrisy and willful ignorance are wrong”), he turns to narrative for reasons to
judge between them. What kind of actions would keep a person from being a hypocrite? What
reasons do his own experience and what he knows of the world around him offer in support of one
principle or the other? Weighing these reasons, Larch decides that the principle to which more

extenuating circumstances pertain is the first one. His decision, finally, is practical. Given his

 

22It is probably safe to say, as well, that John Irving believes in experience as a practice of
reason-giving. Such an assertion would be a red flag to some literary critics and theorists,
however, so I will merely make mention of it here. My goal is not to get bogged down in
distinctions between authors, implied authors, and autlrorial intent. The general point should be
clear.

52
experience of the world, performing abortions seems to be the lesser of two evils.

Once he has arrived at this decision, Dr. Larch takes over the state-am orphanage and,
unbeknownst to the state, quietly begins to perform abortions as well. At St. Cloud’s, Larch and
his two nurses create an oasis of caring, where all comers—women seeking abortions, women
seeking to deliver and leave their children there, and orphans—find support and love. St. Cloud’s
embraces the people no one else wants. The small staff is extremely protective of its charges,
although they are careful to avoid the word “love” and outward displays of affection. Ironically,
this is also meant to protect the children and the women of St. Cloud’s. Larch firmly believes that
he has a responsibility not to raise the orphans’ or the women’s expectations to a level that is
unlikely to be met in what he calls “other parts of the world.” His intention is to spare them
disappointment. If they expect nothing, they are less likely to be hurt if they receive nothing; and
they will be happy for what little they do get.

The second major character in Cider House is Homer Wells, an orphan who grows up at
St. Cloud’s and never quite manages to leave. Larch and Homer have almost a father-son
relationship; and when it becomes clear after a string of star-crossed adoptions that Homer is not
leaving the orphanage, Larch decides to make Homer his apprentice. Before Homer is 20 years
old, he is an experienced midwife and surgical assistant. The one thing he has not done is perform
an abortion.

It was understood by both Larch and Homer that Homer was
completely able to perform one, but Larch believed that Homer
should complete medical school—a real medical school—and
serve an internship in another hospital before he mrdertook the
operation. It was not that the operation was complicated; it was
Larch’s opinion that Homer’s choice should be involved. What
Larch meant was that Homer should know something of society
before he made the decision, by himself, whether to perform

abortions or not. (115-116)

Larch wants Homer to get out into the world before he decides whether to become an abortionist

53
because he expects Homer’s life and the world around him to provide him with reasons for
deciding one way instead of the other.

Larch, in the meantime, begins searching for a way to get Homer into medical school,
thinking to put the issue ofi until then. The question comes to Homer, however, in the form of a
fetus Larch has asked him to prepare for autopsy. A local woman had been stabbed to death, and
her nearly full-term fetus had been killed as well. Larch’s efforts to save the fetus had failed, and
he wanted to know why. On opening the fetus’s chest, Homer sees that the ductus arteriosus23 was
severed. Suddenly it occurs to Homer that human life is nothing but a process of development:

Homer Wells had seen the products of conception in many stages
of development: in rather whole form, on occasion, and in such
partial form as to be barely recognizable, too. Why the old black-
and-white drawings [of embryos and fetuses in Gray ’3 Anatomy]
should have affected him so strongly, he could not say. In Gray '3
there was the profile view of the head of a human embryo,
estimated at twenty-seven days old. Not quick, as Dr. Larch would
be quick to point out, and not recognizably human, either. What
would be the spine was cocked, like a wrist, and where the
knuckles of the fist (above the wrist) would be, there was the ill-
formed face of a fish (the kind that lives below light, is never
caught, could give you nightmares). The undersurface of the head
of the embryo gaped like an eel—the eyes were at the sides of the
head, as if they could protect the creature from an attack from any
direction. In eight weeks, though still not quick, the fetus has a
nose and a mouth; it has an expression, thought Homer Wells.
And with this discovery—that a fetus, as early as eight weeks, has
an expression—Homer Wells felt in the presence of what others
call a soul. (168)

Homer decides, on the spot, that he will not perform abortions. He does not find fault with
Larch’s decision,
[b]ut that quick and not-quick stuff: it didn’t work for Homer

Wells. You can call it a fetus, or an embryo, or the products of
conception, thought Homer Wells, but whatever you call it, it’s

 

23According to Dorland 's, the ductus arteriosus is a blood vessel that connects the left
pulmonary artery directly to the descending aorta, thereby bypassing the fetus’s lungs. The vessel
normally closes shortly afier birth.

54

alive. And whatever you do to it, Homer thought—and whatever

you call what you do—you’re killing it. He looked at the severed

pulmonary artery, which was so perfectly displayed in the oopen

chest of the baby from Three Mile Falls. Let Larch call it whatever

he wants, thought Homer Wells. It’s his choice—if it’s a fetus, to

him, that’s fine. It’s a baby to me, thought Homer Wells. If Larch

has a choice, I have a choice, too. (169)
Homer feels something like love for the baby in the autopsy tray. In a moment of insight similar
to that we see in “The Mother,” Homer “just sees” that the fetus is a person. From there it is no
distance at all to the judgment that killing fetuses is wrong.

Homer tells Larch of his decision not to perform abortions, and Larch reacts angrily.
Larch was in favor of Homer’s having a choice until it became clear that his choice would not be
Larch’s. Larch does not force Homer to perform an abortion, but over Homer’s protests, he
requires that Homer observe and learn how to do the procedure. Larch says, “You are involved in
a process. . . . Birth, on occasion, and interrupting it—on other occasions. Your disapproval is
noted. It is legitimate. You are welcome to disapprove. But you are not welcome to be ignorant,
to look the other way, to be unable to perform [if you change your mind or are faced with a
situation in which you must perform].” (188) Larch appeals to Homer’s sense of responsibility in
hopes that what changed his own mind will also sway Homer, but with no luck.
The next point on the continuum of Homer Wells’s thought about abortion occurs when

Candy Kendall and Wally Worthington, wealthy college kids from Heart’s Haven, show up at St.
Cloud’s needing an abortion. Homer is dumbstruck by Candy, who is blond, tanned, and pretty
and utterly unlike any woman he has ever seen. The couple arrives in the midst of a crazy day at
the orphanage. Amid the frenzy it is Homer who first figures out why these people with the
Cadillac are at the orphanage: Candy is there for an abortion. It is “shattering to Homer to

recognize in the expression of the beautiful stranger he had fallen in love with something as

familiar and pitiable as another unwanted pregnancy.” (195) Homer leads the couple inside but

55
tells Larch he will not assist with the operation. Larch chalks the refusal up to Homer’s obvious
feelings for the girl.

While Larch has Candy in surgery, Homer goes outside and talks with Wally and tries to
set him at ease. Wally’s family owns a large apple orchard in Heart’s Haven, and he tells Homer
that he would like to donate some trees to the orphanage. He invites Homer to return with him
and Candy to Heart’s Haven to discuss the matter and to pick up the trees. Homer, who has never
had real fiiends before, is eager to go; and Larch, recognizing that it is time for Homer to begin to
make his way in the world, reluctantly encourages him to go.

Homer does go to Heart’s Haven, where he moves into the Worthingtons’ home and
spends the summer with Candy and Wally. He works in the orchard and the apple mart, and stays
on even after his fiiends return to school. This goes on for years, and all the while Homer is in
love with Candy; and all the while Larch is plotting for Homer to retina to St. Cloud’s and take
his place when he retires. Then Wally is drafied into the second World War. His plane gets shot
down and he is presumed dead. In the meantime, Homer and Candy have an affair and a son.
They conceal the fact that the child is theirs by going to stay at St. Cloud’s “to visit.” They return
to Ocean View Orchards after the child is born, with the story that Homer’s adopting the boy is
his way of giving something back.

During this time, Larch becomes increasingly short-tempered with Homer, partly because
he misses Homer and does not know how to express it, and partly because he is beginning to
worry about the fate of his abortion clinic. If he is replaced with an outsider who obeys the law
and refuses to do abortions, what will happen to all those women who so badly need his services?
He writes Homer,

If abortions were legal, you could refuse—in fact, given your
beliefs, you should refuse. But as long as they’re against the law,

how can you refuse? How can you allow yourselfa choice in the
matter when there are so many women who haven’t the freedom to

56

make the choice themselves? The women have no choice. I know
you know that’s not right, but how can you—you of all people,
knowing what you know—HOW CAN YOU FEEL FREE TO
CHOOSE NOT TO HELP PEOPLE WHO ARE NOT FREE TO
GET OTHER HELP? You have to help them because you know
how. Think about who’s going to help them if you refuse. (518)

Larch is clearly recalling his own experience with the Eames women and Off Harrison as he

writes this; but rather than telling Homer how he himself arrived at his position, he tries to change

Homer’s mind by argument. He continues,

Here’s the trap you are in. . . . And it’s not my trap—I haven’t
trapped you. Because abortions are illegal, women who need and
want them have no choice in the matter, and you—because you
know how to perform them—have no choice, either. What has
been violated here is your freedom of choice, and every woman’s
freedom of choice, too. If abortion was legal, a woman would
have a choice—and so would you. You could feel fiee not to do it
because someone else would. But the way it is, you’re trapped.
Women are victims, and so are you. (518)

This argument goes on for years, with the two men trading reasons for their positions. One of

Homer’s replies to Larch reads, simply:

Larch replies,

I. I AM NOT A DOCTOR.

2. I BELIEVE THE FETUS HAS A SOUL.

3. I’M SORRY. (545)

1. YOU KNOW EVERYTHING I KNOW, PLUS WHAT
YOU’VE TAUGHT YOURSELF. YOU’RE A BETTER
DOCTOR THAN I AM—AND YOU KNOW IT.

2. YOU THINK THAT WHAT I DO IS PLAYING GOD
BUT YOU PRESUME YOU KNOW WHAT GOD
WANTS. DO YOU THINK THAT’S NOT PLAYING
GOD?

3. I AM NOT SORRY—NOT FOR ANYTHING I’VE

DONE (ONE ABORTION I DID NOT PERFORM IS
THE ONLY ONE I’M SORRY FOR). I’M NOT EVEN
SORRY THAT I LOVE YOU. (546)

57

The same day he mails this message to Homer, Larch dies. Homer does not learn of Larch’s death
until he calls the orphanage looking for Larch’s help. One of Larch’s last acts was to try to
explain to Homer the reasons for his stance on abortion. But it will take something other than
reasons and argument to change Homer’s mind, just as it did in Larch’s case. Homer’s view of
abortion is still based on the flash of recognition he experienced looking at the autopsied fetus
back at St. Cloud’s. In Homer’s mind, other things being equal, the fetus is a baby, and it is
wrong to kill it.

By this point in the story, Homer and Candy’s son, Angel, is a teenager. He has a crush
on the daughter of the orchard’s crew boss. The girl, Rose Rose, is pregnant, for the second time,
by her father. (N 0 one but Rose and her father knows this.) Angel wants to help her and she
finally tells him that what she really needs is an abortion. Angel, of course, has no idea that his
father could perform the operation, and tries to figure out how he can get together enough money
for the abortion without Homer knowing about it. He cannot come up with a plan, and he finally
tells Homer and Candy what is happening.

Homer’s first reaction is that it is not important who the father is. He says that “the main
thing is to get her an abortion.” (558) They ask around and find out that the local abortionist is a
retired biology teacher whom Homer had for a class at the local high school years ago. “Homer
Wells knew exactly which Mr. Hood it was. Homer also remembered that Mr. Hood had once
confused a rabbit’s uteri with a sheep’s. He wondered how many uteri Mr. Hood imagined
women had? And would he be more careful if he knew a woman had only one?” (559) He is
resolved not to allow Rose Rose near Mr. Hood and says they will need to go to St. Cloud’s. That
night, Homer calls to tell Larch he is coming and learns that his surrogate father is dead.

They go to St. Cloud’s anyway, and Homer reluctantly concludes that he must perform

the abortion himself. He does not want to, but he reminds himself that Larch would have said that

58

“[H]is happiness was not the point, or that it wasn’t as important as his usefulness.” (561) Other
things being equal, Homer had believed, the fetus is a baby and it is wrong to kill it. For the first
time, Homer is confronted with a case in which it appears painfully clear that other things are
simply not equal. As attached as he may feel to Rose Rose’s unborn baby, he realizes that he does
not, cannot, love it more than he loves Rose Rose. As he performs the abortion, he thinks about
what this decision means.

After the first one, thought Homer Wells, this might get easier.

Because he knew he couldn’t play God in the worst sense; if he

could operate on Rose Rose, how could he refuse to help a

stranger? How could he refuse anyone? Only a god makes that

kind of decision. I’ll just give them what they want, he thought.

An orphan or an abortion. (568)
Homer gives Rose Rose an abortion because he loves her; and he will provide abortions to other
women because it would be unfair for him to withhold his skill from other women who are
equally in need. Homer steps into Larch’s shoes and takes charge of St. Cloud’s, using the false
identity Larch had so painstakingly set up for just that pmpose. And so Homer Wells becomes an
abortionist.

In a few places in the novel, there are comparisons between fiction writers (or storytellers)
and physicians. Helping to create a story that turns out well for the people (and patients) one cares
about seems to be the primary parallel. Larch is running an abortion clinic in the orphanage and
managing to hide it from the authorities. To protect Homer from being drafted into the war, Larch
falsifies his medical records to create a record of a heart defect Homer does not actually have. He
develops an elaborate scheme to establish a false identity for Homer as Dr. F. Stone (using poor
dead Fuzzy’s name) so that Homer can eventually take over St. Cloud’s. Incongruously for a man
who spends so much energy trying to make things turn out well, Larch professes not to believe in
happy endings. (236)

Homer has his moments, too. One day young Homer notices that one of the Iittler boys is

59
gone, his bed empty. This boy, Fuzzy Stone, had been born prematurely and had serious lung
problems. He had been hooked up to a “breathing machine” that Larch built. Homer knows what
must have happened, and when he asks about Fuzzy Stone, Larch confirms his suspicions. Larch
asks Homer what the other orphans should be told, and Homer replies that they should just say
that Fuzzy was adopted. (110) On page 409, the narrator says, “If Homer Wells had been an
amateur historian, he would have been as much of a revisionist as Wilbur Larch—he would have
tried to make everything come out all right in the end. Homer Wells, who always said to Wilbur
Larch that he (Larch) was the doctor, was more of a doctor than he knew.” And at the very end of
the book, following the revelation that Candy and Homer’s son becomes a novelist, the narrator
tells us, “To Candy, a novelist was also what Homer Wells had become—for a novelist, in
Candy’s opinion, was also a kind of imposter doctor, but a good doctor nonetheless.” (584)

The difl’erence in effect between “The Mother” and Cider House can be attributed at least
in part to form. Poetry and novels move in opposite directions. Whereas the poem seeks to distill
and contain an experience, the novel is expansive and context-rich, implying a world beyond
itself. This is most clearly seen if we compare the moment of insight in each narrative. “The
Mother” painstakingly describes the narrator’s moment of insight. Cider House sets Homer’s
epiphany (seeing the baby in the autopsy Hay and recognizing it as a person) and the subsequent
evolution of his thinking on abortion in a larger context. In Cider House, we know the characters
are; we have some idea about how we might evaluate the authenticity of their moral judgments,
because we have observed their actions and thoughts over time. We also know, more or less, how
and why they arrive at those judgments and what they think of themselves afterward. It is for
these kinds of reasons that Nussbaum sees novels as the most appropriate narrative medium for
moral reflection.

In either case, we should ask how the moment of insight can be made available for critical

6O
moral evaluation. One possibility is that longer narratives can critique shorter narratives. For
example, if we knew the larger story that “The Mother” is a part of, we would have the
opportunity to think about whether her insight makes moral sense. Without that context, however,
we are hard pressed to provide reasons to say either that she is right or wrong for judging as she
does. Without that context, our only recourse is to principles, which provide at least some general
guidance about making moral judgments.

In Cider House, there is room and time for the characters (and the narrator) to show or
explain why they choose as they do. Principles are at work on two levels in the novel. First, the
principles that operate in the story-world can be seen and critiqued (e.g., Larch’s principle that it is
wrong to protect one’s scruples by refusing to help people). Second, the principles that operate in

the reader’s world can be brought to bear on the story-world (e.g., principled judgments can be

made about Larch’s principles).

Chapter 4

CONCLUSION

We have looked at the theoretical basis for narrative and a few literary examples. But
what about where the rubber meets the road, so to speak? How does narrative function in real life,
in the medical context? And what is its relation to principles? Narrative implies at least an
admonition to listen closely, to pay attention, and to hear what is really being said. It also
provides some information about how to do that, and how to learn (or how to teach) how to do
that. What is needed is a synthesis of narrative and principles. Walker describes some of the
ways in which principles and narrative can be complementary:
A narrative picture of moral understanding doesn’t spurn general
rules or broad ideals, but it doesn’t treat them as major premises in
moral deductions. It treats them as markers of the moral relevance
of certain features of stories (“But isn’t that lying?”); as guidelines
to the typical moral weight of certain acts or outcomes (“But surely
we ought to avoid lying”); as necessary shared points of departure
(“We’ve got a problem here with undermining the patient’s trust in
the physician’s candor”); and (with any luck) as continuing
shareable points of reference (“Might the patient not still see that
as rnisleading?”) and reinterpretation (“Withholding isn’t
necessarily deception, though”) that lead to a morally intelligible
resolution. (35)

This passage illustrates some of the ways in which principles serve as shorthand for the moral

ground we have already negotiated and agreed upon.

Principles can take us only so far on their own. Think back to Engelhardt’s description of
Dax’s case. Engelhardt sees this case as a conflict between blind paternalism (treating Dax
without regard to his pleas) and blind respect for autonomy (stopping treatment without forming a

judgment about whether this is the best decision for the patient). Engelhardt proposes a

compromise that in his opinion would recognize the importance of both beneficence and

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autonomy: the physician should try to talk the patient into accepting treatment, but if the patient
refuses, then the physician should respect his wishes. This scenario assumes that treatment would
be in the patient’s interest. If the physician were to switch to a more narrative way of looking at
the case, however, he might see that trying to talk the patient into treatment is not necessarily the
right thing to do. Imagine that the physician gets to know the patient and tries to understand the
reasons behind the patient’s refusal, instead of simply rehearsing the reasons he thinks the patient
should choose treatnent. The physician may find that this patient has thought very carefully about
his options and has concluded that dying without treatment is, under the circumstances, flre most
fitting end to his life story. Or the physician could find that the patient’s decision is based on
inaccurate information or fear of the future. Without a grasp of what the choice means to the
patient, the physician cannot judge whether it would be in the patient’s interest to accept
treatment.

Perhaps the most important role for principles is as a safeguard against relativism. The
great strength of the story—that it draws us in and makes us care—may also be its greatest
weakness, if it keeps us from being able to think critically about the moral goods being
represented. Once we are inside the story, so to speak, it can be difficult to maintain an impartial
stance. It is in this situation that principles can help us to be fair. The “emptiness” of principles
that some narrativists have criticized is precisely what makes them a necessary complement to
narrative. Because principles exist independent of the particular story and are broad enough to
apply to many different stories, they can bring us as close as we can get to an objective
perspective. At the very least, principles can serve as our “trail of breadcrumbs” out of the story
by helping us remember the general values our community holds.

The generality of principles is important also because it encourages consistency and

fairness. While we want to be responsive to particulars, we do not want to be capricious or unjust.

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Two cases that are exactly the same should be judged similarly; and differences in judgment
should stem from difierences in the cases. Without some set of overarching principles, it would
be exceedingly difficult to determine whether a judgment about a particular case is fair in the
larger moral universe.

On the other hand, narrative provides a check against the oversimplification that principles
can sometimes produce. If we use a deductive method to get out of a moral quandary, and if the
method and our application of it are sound, then we cannot doubt the judgment that results.
Unlike principled approaches, narrative leaves room for ambiguity, guilt, regret, and other moral
loose ends. This may not seem like much of an advantage at first blush. After all, someone might
say, isn’t our goal the clear resolution of moral conflicts? If it is, I would submit, we need to
reevaluate our goal-setting practices, because there seems to be little chance of our completely
resolving true quandaries. Any so-called quandary that can be resolved without reservations is not
a true quandary. The best we can do with a true quandary is to try to mediate between the most
possible good and the least possible bad. A system of moral reasoning that is based solely on
principled, deductivist processes has no way of striking such a balance. Narrative supplies the
factors that tip the scales in each individual case, as when Homer changes his mind about abortion
because Rose Rose needs one. He does not feel glad about the change, and he is not entirely
comfortable with his decision, but he sees it as a practical necessity, a modus vivendi.

We have seen, watching the changes in Homer Wells’s thinking on abortion, how
narrative can be used in individual decisions. Consider the general issue of abortion. ls it
possible—is it even desirable—to eliminate the moral reservations we feel about abortion? Even
those who are on the side of choice do not claim that abortion, per se, is a good. In a perfect
world, there would be no need for abortion. In the world we live in, abortion may be the lesser

evil. Moral reservations are the product of what Nussbaum called the noncommensurability of

64
goods. What do we do when we two incompatible but equally important values are at stake? We
do not want to kill fetuses, but neither do we want to force women to continue pregnancies against
their will.

Here we see another place where narrative and principles are complementary. Narrative is
very helpful in making moral judgments about individual cases; but it is difficult to see how
narrative could help us with policy decisions. To develop a public policy on abortion, we would
need to refer to principles. Say that we developed a policy that permitted abortion in the third
trimester only in cases in which grave danger to the mother is likely. In applying the policy we
might return to narrative to answer questions about what counts as “grave danger” in the
individual case.

Margaret Mohrmann provides another example of a narrative approach in action when she
describes making an organ-donation decision about her deceased aunt who, during her life,
repeatedly expressed her personal opposition to organ donation. Mohrmann writes that respect for
her aunt’s life story prohibited her from giving permission for donation:

To give permission for organ donation from my aunt’s body would

be to violate the story of her life. Donation under those

circumstances could not be considered good use of her body, the

body that is an inseparable part of the story that defines her. I

might wish it were otherwise; I might wish she had lived the sort of

life that would be appropriately capped with the gift of a body part

afier death. However, my primary obligation is to honor her in her

death, not to rewrite her life. (102)
Narrative thus permits and encourages a richer understanding of autonomy—and not only the
patient’s autonomy, but the physician’s as well (viz. Wilbur Larch and Homer Wells).

The combination of narrative and principles promises to achieve the best of both worlds:
fine-grained responsiveness to particulars, together with safeguards against unfair bias and

relativism. The timehas come for the name-calling and territorial skirmishes between theory and

antitheory to stop. Medical ethicists need to regroup, consider once again the practical needs that

65
gave rise to the field in the first place, and look to interdisciplinary approaches to improving
medical care. Taking narrative as seriously (no more and no less) as principles is an important

step in that direction.

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