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This article explores the effect of a narrative turn in ethics on health care institutions. Narrative ethics may have a profound impact on health care institutions, making them much more democratic. Principlist ethics originally set out to make all of society's institutions, including health care institutions, more democratic. Basic moral principles are supposed to be transparent even to those of minimal intelligence. To claim a place at the table where ethical issues are being discussed, the principlist alleges, all one has to do is to offer reasons for one's proposed course of action phrased in terms of these widely shared principles. There might be experts in the history and nature of moral philosophy, but there are no experts in making ethical decisions. No privileged elite can claim to own the process of deciding. If it is a sign of democratization that patients' rights are taken much more seriously today in health care than they were several decades ago, then indeed principlism has had a stunning victory. But if nurses, allied health workers, and other hospital employees remain disempowered in the process, the victory is not as great as it seemed at first. In order to be most useful in conventional ethical decisionmaking processes, the principles have to be framed in quite an abstract and general way. The creation of an ethics elite could recur in narrative ethics if the day arrives when people come to earn degrees in or do fellowships in narrative ethics.

This article points that in the absence of the patient's narrative, medical care fails and is unethical. Primary care medicine is concerned with everyday life. Here, ethical dilemmas arise from the lived life--individual preferences, beliefs, attitudes, choices, and decisions, and how individuals interact with one another as well as care for one another. Ethical dilemmas in primary care are often subtle, but they are not invisible; most are recognized easily by careful observers. The ethical dilemmas of primary care are different from those occurring in the hospital setting, but they are no less meaningful. Narrative informs clinical medicine. Understanding such narrative works as pathographies, novels of illness and healing, and memoirs about medical practice enhances personal awareness, expands the physician's concept of the patient's illness experience, enables interpersonal connections and recognition of emotions, and thereby offers a fuller understanding of the moral life as enacted in health care. Patients' stories as heard and then interpreted by physicians are narratives too. Such clinical cases can, like literature, demonstrate particular points about the moral life. The retelling of these stories by physicians, nurses, or members of the ethics team is also a narrative activity. Such retelling may have consequences for the listeners, just as reading a poem may influence the reader in some deep way.

This article introduces topics related to the practice of narrative ethics. The practice of narrative ethics has developed organically, over the past two decades or so, germinating throughout North America, the United Kingdom, Europe, and parts of Asia, suggesting that this approach to ethics has answered a widespread need within the field. Not a top-down activity, narrative ethics emerged from individuals' ethics practices as they, often on their own, found themselves listening in new ways to their patients and thinking in new ways about cases. The public life of narrative ethics is but a distal part of this process: nurses, doctors, ethicists, and patients have already made local discoveries that health care's primary duties are to bear witness to patients' suffering and to honor their experiences of illness. From those activities--if pursued with rigor, honesty, humility, and accuracy--flow choices, decisions, and actions. From them also flow healing dividends for patients and for caregivers. Narrative ethics arose as doctors, nurses, ethicists, and patients found themselves taking seriously their acts of reading, writing, and telling. telling. From patients' pathographies and caregivers' stories from practice to ethicists' written cases, what unified these early efforts was the recognition of the centrality of narrative in the work of health care.