Narrative versus Principle-Based Bioethics

05 Sep


The field of bioethics addresses moral questions in the areas of medical practice and policy, as well the life sciences. Although there are many different methods of approaching bioethical issues, two in particular are currently very influential and often thought to be in tension.  The first, often called principlism, looks to certain basic principles as its central guide.  These principles of autonomy, non-maleficence, beneficence, and justice are held to be objective and universal, the set of norms that all morally serious persons share.  A course of action is morally justified if it is consistent with the principles.  The work of ethical decision-making consists in bringing these principles to bear on the particular situation at hand.   The principles are weighed, tested, and revised in response to the specific context involved.


While principlism has long dominated the bioethical landscape, in the last twenty years, an increasing number of theorists have turned their attention to alternative approaches.  One such alternative approach is narrative ethics, which incorporates narrative concepts and methodologies drawn from literary criticism and philosophy.  According to bioethicist Joan McCarthy, narrative ethics holds that “every moral situation is unique and unrepeatable and its meaning cannot be fully captured by appealing to universal principles.  In any given health care situation, any decision or course of action is justified in terms of its fit with the individual life story of the patient,” not with how closely it follows universal moral principles.  The objective of narrative ethics is “not necessarily to unify moral beliefs and commitments, but to open up dialogue, challenge received views and norms, and explore tensions between individual and shared meanings.”


McCarthy sees principlism and narrative ethics as each having their own respective strengths.  Principlism “provides a clear method and vocabulary for identifying ethical concerns in health care situations and for negotiating moral ideas and arguments.” It is also a “particularly useful means of drawing the parameters of moral relationships between strangers.” Since “the four principles are considered to be binding on all moral persons irrespective of culture or creed,” principlism is “a particularly important tool for legislators and public policy makers, whose task is to regulate the conduct of various individuals, groups, and institutions with different backgrounds and agendas.” “The strength of narrative ethics, on the other hand, is that it provides a method and vocabulary for interpreting and respecting the unique and personal stories of individuals.”


In considering McCarthy’s descriptions and analysis of principlism and narrative ethics, it seems to me that the two theories function as complementary partners in the process of ethical decision-making.  Narrative ethics acts as a check on the tendency of principlism to lose sight of the particularities of the stories involved in a moral situation.  In applying moral principles to a situation it is crucial that we have an accurate portrayal of the stories that constitute that situation.  We must have a correct diagnosis (the story) before we can apply the cure (the moral principles).  Arriving at such an accurate portrayal is more challenging, painstaking work than some ethicists applying principles to a situation might at first appreciate.  Rather than a god’s-eyed view of the situation, a tapestry of narratives is sometimes the most we can expect to obtain. 


But the stories that make up a moral situation do not themselves supply the values and principles that guide moral action.  For example, McCarthy describes how a narrative approach has “contributed to discussion and debate in relation to end of life decisions.” The U.S. Council on Ethical and Judicial Affairs suggests when making decisions for an incompetent patients, one the decision-maker’s tasks is to consider “how the patient constructed his or her identity or life-story.” In this way, the surrogate decision-maker can act in a way that continues the patient’s life-story “in a manner that is meaningful and consistent with the patient’s self-conception.” Here it seems to me the principle of autonomy is being implicitly applied.  That a person constructed a certain identify or life-story does not bind the surrogate decision-maker to make a decision in continuity with that life-story.  The surrogate decision-maker’s values might conflict with the patient’s, leading to a decision that is contrary to the patient’s will.  For example, a surrogate decision-maker who values the continuation of life at all costs might disagree with the living will of a patient who opposes any “heroic measures.”  It is principle of autonomy—respecting the patient’s agency—that instructs the surrogate decision –maker to nevertheless act in continuity with the patient’s life-story.


Narrative ethicists might respond that we do not need values or principles to guide moral decision-making.  Even without reference to any moral principles, sharing and hearing the stories that constitute a moral situation enriches our understanding and generates a better appreciation of the courses of action we might take.  But what is the use of arriving at a better understanding of our moral options unless there is some real moral standard to which we want our choices to conform?    While “opening up dialogue, challenging received views and norms, and exploring tensions between individual and shared meanings” are intrinsically valuable activities, aren’t they ultimately driven by question, “what is the truly right thing to do?”  To answer that question, we need criteria or principles for what constitutes right action.  Positing, as some narrative ethicists seem to do, that “right action is what best fits the story” is smuggling in such a moral principle.

Even as I don’t see narrative ethics as supplanting the principle-based approach to bioethics, it nonetheless is making important contributions to the field and to health care in general.  Here is an interesting article about the movement.


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Posted by on September 5, 2013 in Uncategorized


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