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This article explores the impact of narrative on oneself. Narrative inevitably expresses and transforms who we are at every level of our being: the organic, the symbolic, the social, and the spiritual. The narrative urge is central, although occasionally perilous, even in that complicated form of self and other enacted in bioethics practice. At the organic level, for instance, our bodies give birth to certain narrative ways of perceiving the world. After decades of believing that nothing can replace brain cells, once destroyed, scientists are using the new, sophisticated imaging techniques (nuclear magnetic resonance [NMR] scans and positron emission tomography [PET] scans) to reveal the exciting news that experience causes our brains to be reorganized. A growing group of scientists believes that behavior not only changes our personhood as understood broadly--this has long been axiomatic--but, more specifically, that behavior is the principal determinant of alterations in our nervous system. The stories heard and read by bioethicists are generally complicated symbolic structures. In my experience, it has proved helpful for caregivers intent on decoding such structures to learn that clinical stories can often be classified according to literary nomenclature for narrative and dramatic types.

This article explores the process of thinking with stories. The concept of thinking with stories is meant to oppose and modify (not replace) the institutionalized Western practice of thinking about stories. Thinking about stories conceives of narrative as an object. Thinker and object of thought are at least theoretically distinct. Thinking with stories is a process in which we as thinkers do not so much work on narrative as take the radical step back, almost a return to childhood experience, of allowing narrative to work on us. Thinking with stories likely constitutes for some people a stage--possibly an indivisible stage--in a dynamic, dialectical, dialogical process that includes thinking about stories. The stunning concept of stories that make you want to replace yourself might be said to underwrite an entire ethics of narrative. Until recently, readers conventionally understood stories as divided into separate and nonoverlapping types: fiction and nonfiction. Nonfictional stories purported to stake truth claims about characters and events, while fiction belonged in a realm of the made-up, imagined, or patently untrue. Narrative in its power to swallow up distinctions between fiction and nonfiction reminds us how far medicine now constitutes a nonstop cascade of dramatic events and gripping revelations, from soap operas to congressional hearings.

This article explores how narrative ethics might contribute to the understanding of genetics, medical research in genetics, or human subjects research more generally. The scientific problem with genetic determinism is its simplicity. Rather than the isomorphic formula--that is, one gene=one trait (or, one gene=one protein=one trait)--the pathways from genes to traits exhibit at least two kinds of heterogeneity. The first is a clinical heterogeneity. For example, the same genetic mutation in two people can lead to different outcomes. This is true, for example, for phenylketonuria (PKU), a genetic disease that results from the inability to metabolize the amino acid phenylalanine. If untreated, the disease leads to severe retardation. PKU is also an example of a second sort of heterogeneity, genetic heterogeneity meaning that different genetic defects can lead to the same clinical outcome. So, although PKU was at one time understood, like Huntington's disease, to be a rather simple embodiment of genetic determinism, the story is currently understood to be more complex. Yet despite this growing recognition of complexity at one level, simplistic gene stories depicting human essences and origins continue to be part of both the scientific and the popular imagination.

This article explores the relationship between patients and doctors. The hyphen is a key to understanding the relationship between patients and doctors. The hyphen simultaneously signifies separation and synergy, disjunction and conjunction. It calls attention to the distance between parties to the clinical encounter. And then, in the blink of an eye, it is a bridge across the divide. The hyphen does double-duty. It signifies the reserve, the holding back, that is no doubt necessary when doctor and patient come together to consider matters personal and sometimes grave. And it reminds us that recasting one's life story in response to illness or injury is a joint venture requiring doctor and patient to work together to achieve what neither can accomplish individually. Narrative theorists of medical ethics have put their minds to characterizing the many versions of the story-shaping conversation carried on in the liminal space, the in-between, of the doctor-patient relationship. Nearly twenty years ago, Jay Katz provocatively proposed the metaphor of silence to characterize the world of doctor and patient. He argued that physicians' historical "caring but silent devotion to what they believed their patients' best interests dictated" had become tantamount to psychological abandonment. Practitioners of narrative ethics share an attentiveness to the experiential dimensions of illness, a conviction that experiences of illness are story-shaped, and a commitment to relationality and reflexivity as preconditions for understanding such experiences. Beyond this shared attentiveness, conviction, and commitment, practitioners of narrative ethics theorize what transpires in interactions between patients and doctors variously.

This article examines narrative skills that help clinicians and ethicists carry out their work. Narrative capacity seems to be an innate human ability. However natural a part of the human equipment, narrative skill can be developed by exposure to environments rich in stories. Thus, even if people were all born with exactly the same narrative capacity, the narrative competence of adults would vary. Narrative capacity can be enhanced by the study of literature and the interpretation of complex texts. One consequence of the increasing interest in narrative ethics is the need to think about the kind of training that can enhance the natural narrative capacities of those ethicists whose professional training has not been focused on the study of literature or narrative. Narrative competence for clinical and ethical work includes at least the following skills: first, the reading and interpreting of complex texts; second, the writing and oral telling of complex clinical and ethical texts; third, the interpersonal relational and empathic capacities that depend upon mastery of the first and second set of skills; and fourth, the ability to think with stories. The writing and oral telling of complex clinical and ethical texts are routinely required of clinicians and ethicists as they carry out their work.

This article discusses day-to-day ethics in the work of medicine. Although these everyday, unthinking actions form the substrate of day-to-day interactions between doctors and patients, it is unclear whether they are the proper concern of bioethics. Governed, apparently, more by simple rules and habits than by careful moral deliberation and ratiocination, these tiny actions might appear to belong more to the realm of etiquette than to that of ethics. Nevertheless, they do make up the moral climate within which larger bioethical dilemmas occur. One way to conceptualize the distinctions among these different types of actions and the different views of morality that extend from their consideration is to distinguish between deliberative action and habitual action. Mainstream bioethics focuses primarily on deliberative actions. One problem with recognizing habitual actions as moral actions is that such actions seem to be almost involuntary. A doctor who treats patients respectfully and empathically does not seem to be making moral choices or deliberative decisions. Despite a growing research scholarship demonstrating that health professionals can develop interpersonal and intersubjective capacities to reach and understand their patients, mainstream medicine persists in thinking of these personal skills as fortuitous gifts.

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 explores ways in which narrative can improve clinical and ethical decision-making in psychiatry and psychotherapy. While the waning of psychoanalytic and psychodynamic teaching in residency programs and the increased effectiveness of psychopharmacologic interventions in clinical practice have decreased the profession's reliance on interpretive or talking psychotherapy, the influence of the medical humanities has increased interest and curiosity about narrative theory and application in the behavioral health fields. Managed care has had a negative impact on health care education and health care practice, and yet it has had a positive impact by fueling new discussion and reflection upon the fundamental ethical aspects that define the patient-professional relationship in health care. The fields of psychiatry and psychotherapy are closely tied to the clinical and ethical traditions of medicine and the claims of medicine to care for the whole patient. Many of the ethical issues relevant to general medicine are also important to the practice of psychiatry and psychotherapy. Like medicine, psychiatry and related behavioral health fields are dominated by the biomedical model. The person seeking help is conceptualized as a patient inflicted with disease and deficient through psychopathology. The patient presents the health care professional with a challenging riddle to be explored, described, and solved. Symptoms are data that support diagnoses. These symptoms are targeted by a new generation of psychopharmacological agents that calms these symptoms and treats the disease.

This article discusses why narrative competence is integral to the doctor's knowing both patient and self. Ethical ways of being and doctoring depend on knowledge of human particularity that the physician is always acquiring through attentive observation and reflection. Knowledge so gained--about the patient, to be sure, but also about the doctor--is just as crucial to the physician's clinical excellence as his or her fund of medical knowledge, and, together with this medical knowledge, it becomes the basis for the physician's understanding, for action, and for care. The practice of ethics in the context of clinical medicine is fundamentally a matter of attention and interpretation. In a narrative model of medicine, the patient-physician relationship is cast as an ongoing, constructive conversation leading first and most immediately to diagnosis, prognosis, and treatment. The physician is the critical reader, highly skilled both in eliciting and interpreting the patient's story, which encompasses all that the patient says, how he or she says it, and the myriad nonverbal cues that accompany this telling. The physician's responsibility is to listen to the patient in a close, careful, and nuanced way in order to elucidate and then explain the patient's narrative, bring out and reflect its coherence and meaning, and finally translate what the patient has said and enacted into the formulaic tale--the case presentation--with which clinical medicine works. In a narrative model of medicine, the ongoing patient-physician relationship itself becomes a means of continuing the physician's education.

This article outlines ways in which narrative methods can be useful in guiding the critical first step in ethics consultation--constructing the description of the case. Knowing what information to gather, how to gather it, and how to interpret it are all essential parts of the skill and art of ethics consultation. Narrative methods, with their attention to issues of narrative frame, voice, and interpretative skill, can help ensure that information is gathered and interpreted in an appropriate and competent fashion. Narrative methods can sharpen our attunement to issues of how the narratives of a case or ethical dilemma are constructed, whose voices are given authority, which plot lines are considered relevant, and which possible resolutions are given consideration. And finally, narrative methods can provide the necessary foundation for the normative work that follows. As part of the intake process, information and input are also sought from the patient, if he or she is well enough, the patient's family or close intimates as appropriate, and members of the health care team from all shifts, such as physicians, consultants, nurses, nurse's aides, respiratory therapists, social workers, case managers, and chaplains.

This article examines how heroic rescue, a common narrative of childhood illness, frames the thinking of pediatricians and parents who are faced with the potential death of a child. Narrative techniques operate in clinical practice as a set of clinical tools. Pediatricians ask questions and listen to a story and then organize that information into a stylized, linear narrative, the presenting history, which can function as a diagnostic and prognostic tool. Pediatrics is more explicitly concerned with families than are most other branches of medicine, and narrative techniques reinforce our understanding of patients not as localized collections of signs and symptoms but as characters in a family story that began before the clinic and will continue after the exam room. An important, and perhaps defining, model for the professional practice of pediatrics is the narrative of rescue. This narrative is an organizing set of beliefs and explanations about the work of pediatricians, born both of a contemporary faith in technological progress and of a belief that serious childhood illness is in some deep sense unnatural or outside the expected order of things. That such a narrative can take hold in pediatric practice is a testament to the successes of contemporary medicine. The rescue narrative sets up the pediatrician as the rescuer, a heroic warrior against illness and despair. The need to be seen as heroic may be necessary to permit pediatricians to harm children in the pursuit of healing them. Narratives in pediatrics do not supplant ethical principles but precede their invocation and inform their application. Narratives are the substrates for moral reasoning. Faced with ethical issues, pediatricians use narratives to frame the alternatives, explore the options, consider the consequences, and deliberate about right and wrong.

This article argues that it is the reader's role in the narratives of moral deliberation that most directly and powerfully connects the experience of literature with the deliberative processes of biomedical ethics. Of all the literary elements that come into play when we read or hear a narrative, it is the reader's role that is most often undervalued when we explore the meaning of a story. The case we want to build for paying attention to the role of the reader in biomedical ethics is a complicated one. It begins with contemporary literary theory defining the active role of the reader, moves to fifth-century Athens and the beginning of Western ethics in order to discover highly active readers at the very genesis of Western ethical method and intention, and then returns to the world of contemporary medical care, where we hope to demonstrate that understanding the reader's role matters a great deal when difficult moral decisions must be made. Narratives constructed from the stuff of daily life have always been powerful and necessary aspects of Western ethical discourse, whose fundamental processes of moral decision-making and reasoning, we believe, have always been narrative in nature.

This article discusses plot of the story in narrative ethics. Choice is essential to moral life, but both our options and our predispositions have been conditioned, even created, by social forces in the historical moment and by the momentum of our earlier acts. Narrative captures this inextricable tangle of necessity and freedom in human life, and plot enacts it in the selection and ordering of events and in the quasi-causal implications of its telling. Plot links the complicated and uncertain conditions that may--or may not--be essential ingredients in the events being represented, and then plot traces those conditions over time. The suspense of discovering what has happened and how it all turns out may be part of a plot's effect, but, at the story's close, contingency continues to seem inevitable--at least for these people in this one predicament at this time and place. That the story might have been otherwise lures us to listen to and tell other stories, even to retell this story another day. Literary theory is concerned with the complexities of such narrative representation. Story is the actual set of events, while plot is the teller's particular arrangement of those events. The plot of your colleague's narrative is not the plot of the patient's story nor of his wife's, each of which would require different information, different endings. Plot thus shapes the meaning of narrative and its effect on its audience.

This article explores the link between character and ethics. Ethics, today, tends to be thought of as a branch of philosophy. But Greek tragic poetry has an equally strong and even older claim to the transmission of ethical wisdom. In ancient Greece, it was the poets and the tragedians, rather than the philosophers, who were regarded as the primary teachers of ethics. Sophocles' Philoctetes offers us a compelling model of ethical decision-making, of the factors that shape character and lead to right decisions between persons--in this case between doctor and patient--at the intersection of their life histories. Character (ethos) in Greek drama is a specifically moral concept. The Greeks made a distinction between a person's inborn nature, which they called phusis, and his or her character, or ethos. Phusis is a more or less static concept; it is those qualities or capacities that we were born with. Ethos, though, is capable of development; it is confirmed, strengthened, and defined through the choices that we make--for better or worse. Ethos is not the vivid outward traits that make for personality, nor an individual's distinctive psychological makeup, nor the inner, often unconscious drives of the psyche--aspects of character that we expect, seek, and admire in modern literature.

This article demonstrates how deeply embedded in time are the events and choices faced by ethicists and health professionals. The relations between discourse-time and story-time are consequential, for the narrative now is established in discoursetime and alters events in story-time, whether or not the narrator realizes it. The teller gathers up great power in the course of establishing the beginning, middle, and end of his or her story, thereby framing the reader's or listener's temporal horizons. Duration is a feature of storytelling that lives deep within the relationship between teller and listener. Duration dramatically distinguishes the discourse-time from story-time in medical stories, because the professionals' view--including the bioethicist's--of what happens is restricted to such medically salient events as courses of chemotherapy or perioperative periods, while the patient is left to endure all that time between relapses and remissions, between taking the CT scan and learning its results, between the morning and evening dose of pain medicine. Once the temporal horizon, order, and duration have been established, the teller can exercise surprise and suspense, two extraordinarily important elements of time-keeping in stories.

This article examines the ways that three different literary scholars have discussed voice and consider how their ideas can illuminate the way physicians tell stories to themselves and to other health professionals. Like point of view, voice draws upon the needs and will of the speaker, but it also involves a conscious turning outward, an expressiveness that will reveal (or, at times, attempt to conceal) point of view. Nurses reporting to the physician about a patient's restlessness will give information that they have been trained to observe and interpret as nurses, but they may give more or less information given their own work demands or even their feelings about the physician asking the question. Although they are not fiction, many clinical reports take on a narrative form. Three of these forms are the case presentation, the team conference, and the medical record. In recognizing the many facets of the narrative voice, physicians and bioethicists alike can tell their own and interpret others' stories more effectively. The narrator of a novel or short story has many options in choosing a voice. A tale may be related by one of the characters in the story, by an outsider who was purportedly told he events by one of the characters, or by any one of a variety of omniscient narrators who can see into the minds and hearts of various characters to various depths.

This article argues against the theory that when ethicists work with cases, they are taking a narrative approach to clinical ethics. Judging skillfully and well in accordance with some theory involves a consideration of the economic, cultural, class, gender, and religious contexts in which the participants operate, as these social contexts might have some bearing on which principles to select and how much relative importance to assign to conflicting principles. In a narrative approach, the social contexts are important, not because they guide the selection of the principles that will be used to resolve the case, but because of what they reveal about the identities of the participants: the religious, ethnic, gender, and other contexts in which a person lives her life contribute to her own and others' sense of who she is. The story of how the participants of the case came to their present pass is precisely a story, as is the narrative of the best way to go on in the future. The backward-looking story is explanatory; the forward-looking story is action-guiding. Juridical approaches tend to move only sideways, considering context as it fleshes out the here and now. Because narrative approaches also move backward and forward, they are better suited to ethical reflection.

This article argues for an emergent theory of narrative bioethics based on two voices and two disciplines--literary theory and textual reasoning in philosophy. If literary studies have the power to inform decisions in bioethics, it is because the knowledge of the self and others entered through the serious engagement with stories in literature is pivotal in thinking about case stories in ethics. Literature's narrative ethics examines the reciprocal responsibilities incurred by the writer who encodes thoughts and feelings into language and by the reader who rescues from words their secrets. Writer and reader (or teller and listener) develop deep powers and daring intimacies as they meet in text, for the writer, however cannily or uncannily, reveals aspects of the self while the reader, with whatever skill is available, penetrates the text toward that which put it into motion. This literary brand of narrative ethics guides the textual actors toward mutual respect and comprehension while governing the potential for exploitation or expropriation whenever one opens oneself to penetration by another. Like reading stories in literature and reasoning after the book is closed, reasoning about case stories in bioethics relies on the claim--at least the provisional claim while within the text's presence--that the world of the other is true.