In the Matter of Stories
This essay lays out some of the many resources that a background in literary studies has to offer bioethics. After identifying four useful characteristics of stories, it briefly discusses some kinds of moral work that stories can be put to, including countering ethically undesirable stories and modeling ethically troubling situations. Stories can be invoked in our moral reasoning, compared and parsed, and used to teach moral lessons. They can help us discern which moral concepts are operative in a specific instance. Our personal identities consist of stories, which help us understand who we and other people are. Stories can also be parodied, for political or other effect. Stories can perform these moral functions only to the extent that the persons telling or invoking or parodying them are themselves morally competent. But given that competence, a scholarly grasp of literature and narrative can greatly enhance bioethical reflection.
When I accidentally fell into the job of Associate Editor at the Hastings Center Report, I soon learned that one of my duties was to copyedit the case studies that the Report publishes on a regular basis. The Hastings Center being the kind of institution it is, as I edited the essays, I also imbibed a good deal of bioethics. I began to publish scholarly articles and coauthor a book, all under the mentorship of Dan Callahan and the Center's other associates. Joe Fins, then the [End Page 93] Associate for Medicine, patiently answered all my many questions about ethical issues surrounding the doctor-patient relationship; Susan Wolf, the Associate for Law, taught me some classic court cases, starting with Schloendorff; and Jamie Nelson, Associate for Philosophy, gave me a crash course in moral theory. I learned an immense amount there, and I still think of the Center as my alma mater.
But my first responsibility was to help edit the Report. As I worked with the case studies, I gradually noticed something: they were tales told almost exclusively by physicians or, occasionally, by other health care workers. And they almost always were told in such a way as to drive the reader toward a particular ethical conclusion. My undergraduate major was German literature, and I also had a master's degree in theatre studies. From those disciplines I had learned a thing or two about stories. For one thing, stories are depictive, they are representations of a set of actions. Second, stories are connective, linking this incident to that one in a causal chain, but also linking the story itself to other stories: The Lord of the Rings connects with Harry Potter (think about it), while Pride and Prejudice connects to Cinderella and all other young-women-coming-of-age narratives. Third, stories are selective, choosing from among many possible details the ones the teller thinks are relevant. In that way, fourth, stories are also interpretive, in that the choice and arrangement of incidents and actions gives the story its overall meaning.
Reading the case studies from this background, I came to the cynical conclusion that they were rigged. It seemed unfair, somehow, that they were always told from the health professionals' point of view. And indeed, the commentaries often suggested that more stories were needed—perhaps a tale as the patient might have told it. Or, very occasionally, as the family members might have told it.
Thinking about all this, I wondered what would happen if you took a case study apart, retelling it by including features the original story had papered over or rendered insignificant, and changing the perspective from which the story was told. It seemed to me that you could un-rig it, resisting any unsavory ethical conclusions the first story might elicit by reassembling the ingredients so that they depicted the people and events in a more detailed and accurate light. I called such stories counterstories and later wrote a book about them (Nelson 2001). While writing that book, I came to see that, no matter how well meant they were, counterstories can backfire, unintentionally (or sometimes intentionally) damaging the identity of one social group at the same time as it depicts another group as morally respectworthy. So, like all stories, they have to be scrutinized for their moral soundness. They can also be ineffective if they don't get general uptake, because it's uptake that shows people what was wrong with the original story.
Sorting out the notion of counterstories for myself, I next began to wonder what other kind of moral work stories could be put to. I came up with a handful of different uses.
If counterstories are the first possible use, the second is that stories can be used to model an ethically troublesome situation. Case studies are a prime example, but so [End Page 94] are novels such as Sophie's Choice and plays like Antigone. Such stories can be received simply, as, perhaps, pictures of the human condition, or they can reveal that something morally dubious is going on that has escaped general notice. They can also portray people in all their moral complexity, as biographies, plays, and novels do. And certainly, they can be thrown down as an ethical challenge, charging the reader to make a moral judgment or offer a solution to the ethical problem.
A third moral use for stories is to invoke them. Alasdair MacIntyre (1984) claims that reason and rationality are always characteristic of a specific historical tradition. It's the story of one's community—whether it be ancient Greece, medieval Paris, or 18th-century Edinburgh—that develops one's capacity to see things as reasonable, appropriate, valuable, and so on. Because the narrative tradition of the community subtly shapes all its members' knowing and valuing, MacIntyre argues that there is no one model of moral reasoning that can be used as a vantage point from which to pass judgment on all the many cultures within which human beings live. Nevertheless, the mythical and historical narratives of our communities explain who we are as a people and how we came to be this particular "we." These foundational narratives serve as the community's source of moral normativity, and we invoke them as a means of ethical justification. When we have run out of reasons for acting as we do, we appeal to the norms that are internal to the social practices of the community—norms that are in turn justified by the community's foundational stories. So, to take an obvious example, physicians might look to the history of medicine and the physician's traditional role in society as justification for refusing to participate in physician-assisted suicide: the norms internal to the practice of medicine forbid physicians to kill their patients, and the rightness of these norms is explained by invoking the foundational narrative of the Hippocratic tradition.
Fourth, a case study that is morally puzzling could be compared to a paradigm story or stories whose moral meaning is clear. The paradigm story, according to proponents of casuistry, displays summaries of shared moral understandings that are already embedded in our actual practices, and these summaries serve as action-guiding principles. So when we come across a new case that leaves us uncertain how to proceed, we can look to the paradigm case for guidance. The principles displayed by the paradigm case are always subject to revision in light of new cases. As subsequent cases reveal new implications of principles embedded in the paradigm case, our view of the paradigm case may shift, causing us to modify our understanding of the original principles or perhaps even to replace them with new principles altogether. As John Arras (1991) puts it, "Casuistical analysis might be summarized as a form of reasoning by means of examples that always point beyond themselves. Both the examples and the principles derived from them are always subject to reinterpretation and gradual modification in light of subsequent examples" (35–36). [End Page 95]
Fifth, stories such as fables and parables can be used to teach moral lessons. Who is my neighbor? "A man went down from Jerusalem to Jericho …" What happens if you rely too heavily on your innate ability? The tortoise wins the race. How dangerous is it to tell lies? The ravening wolf actually comes and eats Peter. These lessons are usually learned in childhood, where they point to moral principles such as "Be kind," "Pride goes before a fall," "Honesty is the best policy." The moral principles on their own, though, aren't particularly good at helping children (or adults, for that matter) develop the ability to learn how to wield such moral concepts as kindness or honesty in a given, particular instance. It's kind to help others, but not if they're breaking into somebody's car. It's honest to say what you think, but the honesty is vicious if you're thinking racist thoughts. Stories provide context to guide moral action.
To become adept at discerning which moral concepts are operative in a specific instance, you need to put stories to a sixth use. Jonathan Dancy (1993) argues that the reasons for acting in a given set of circumstances take on a specific moral "shape." That is, they cluster together in a particular way that adds up to "this is wrong," or "this is good to do," or some such moral judgment. A reason that in one configuration might count for doing something could, in another configuration, count against doing it, or count neither for nor against. Inflicting pain is usually bad—but not when your patient needs the operation. Taking pride in your work is usually good—but not if you are an axe murderer. And because considerations carry their moral import only holistically, there are no laws that govern how these reasons behave. Instead, Dancy contends, understanding the morality of an action is a matter of skill or wisdom in seeing how the moral considerations add up in the given case. And this, says Dancy, is a narrative activity: the shape can be described by a story. Suppose you and I are health-care workers, trying to figure out whether to discontinue life-sustaining measures for a seriously ill patient with no family members to help us make the decision. We can't agree, and yet we must find a solution fairly quickly. In that case, I can tell you my story of what I see—the moral markers that seem relevant here, the narrative of how we got to this point in the first place, the good-making and bad-making features of the situation. Then you fill in the story, showing me a moral reason I missed from where I was standing, the lesser importance of something I saw in the light of this other and stronger consideration. And once we reach good-enough narrative agreement, together we can create the story of where to go on from here.
Seventh, stories constitute people's identities, and so give rise to normative expectations for behavior. I take personal identities to consist of tissues of stories and fragments of stories, generated from both first- and third-person perspectives, that cluster around what we see as our own or others' most important acts, experiences, characteristics, roles, relationships, and commitments. In short, they are narrative understandings formed out of the interaction between one's self-concept and others' sense of who one is. And because stories display time passing, the [End Page 96] narratives that constitute identities can reflect the respects in which we change, as well as how we remain the same. Many of the narrative understandings forming a part of a personal identity draw on stock plots and character types that are familiar to us all. A friend betrays you, and you identify him in biblical terms: he is a Judas. A white police officer sees a black teenager driving his mother's BMW and pigeonholes him as a drug dealer or a car thief, drawing on the representations of African American youths that saturate the media. Socially shared narratives like these contribute to the identities of groups as well as individuals, and members of the group draw a part of their identity from how the group identity is narratively constructed. Other parts of the narrative tissue that constitute a personal identity consist of the localized, particular stories that pick an individual out as distinct from others in the groups to which she belongs: these are the stories that distinguish, say, your grandmother from the other members of her family, or from the class of grandmothers in general.
Both kinds of stories are morally important because they function as counters in our social transactions, in that they convey understandings of what those who bear them are expected to do. If an answer to "who are you?" is "your doctor," I expect you to try to diagnose my illnesses, give me the medical therapies you judge best, treat me with care and respect. From a first-person perspective, personal identities function in much the same way. I treat myself with contempt or respect depending on who I think I am, and out of that narratively constructed sense of myself I also establish certain expectations for how I ought to behave in the future. But the fit between my identity and my agency goes in both directions: if it's true that I act out of the tissue of stories that constitute my sense of who I am, it's just as true that I express who I am by how I act. In fact, my actions are important criteria for assessing the accuracy of my self-conception. If, for instance, I see myself as a good driver but I've received four traffic citations in the last six months, others have reason to doubt—in this respect, at any rate—that my identity-constituting stories are credible ones. There are norms governing our use of these stories. Sometimes the right thing to do is to hold someone in their identity, responding to them on the basis of the stories by which we make sense of them. Other times it's important to let go of certain aspects of their identity, replacing stories that no longer portray them accurately with stories that are a better fit and treating them accordingly (Lindemann 2014).
Eighth, stories can be parodied. Here, for example, I am thinking of the culturally dominant stories we use to construct gender in our society. Stories such as "Snow White" teach little girls that they will find fulfillment in serving men (even little men), while teenage girls learn from any number of movies, commercials, and songs how to assume the persona of the sex goddess whose business it is to make men happy. In the meantime, adolescent boys learn from the narratives in video games that women exist to serve men sexually and can be blown away at will. In Gender Trouble (1990), Judith Butler points to the practices of drag, [End Page 97] cross-dressing, and butch/femme stylizing for their ability to parody these depictions. Drag subverts the fiction of the womanly woman and the manly man, and it does it by exaggerating the dominant stories. Drag often involves cross-dressing, but not always. Butler cites Parker Tyler, who claimed that Greta Garbo "'got in drag' whenever she took some heavy glamour part, whenever she melted in or out of a man's arms, whenever she simply let that heavenly-flexed neck … bear the weight of her thrown-back head. … How resplendent seems the art of acting! It is all impersonation, whether the sex underneath is true or not" (128). By the same token, Dolly Parton has made a lifelong career out of performing drag. Parodies can perform a kind of reductio ad absurdum on stories that are less than socially desirable, and in that way they can be counterstories. But they can also be sendups of stories that are doing morally important work, so, like all the stories I've discussed here, they must be subject to ethical scrutiny.
Narrative Approaches Get a Philosophical Boost
After five years at the Hastings Center, I decided I wanted to continue working in bioethics but needed training in philosophy if I was to be the kind of bioethicist I wanted to be. Since Fordham University was right down the road, I enrolled myself in their philosophy PhD program and began working with Margaret Urban Walker, who has a brain the size of a planet and who agreed to direct my dissertation, once I got that far. First, though, I took her seminars on Wittgenstein's later writings, moral luck, and feminist theory. And, generously, when I asked her to write about moral expertise for the Hastings Center Report, she spent one summer turning herself into a bioethicist and produced a 50-page elephant that I edited down into a paper that's still widely cited: "Keeping Moral Space Open" (Walker 1993). Even more generously, she let me read each draft chapter of the book she was writing in feminist ethics. In her Moral Understandings (1998), she argued that morality wasn't a matter of moral knowledge deduced from ideal theory and applied by individual agents to a case at hand. Instead, she described it as something we do together, a social practice in which responsibilities are assigned, contested, assumed, deflected, or accepted, for those things that are worth care and attention. Socially shared moral understandings govern this practice, and as we participate in it, we express ourselves morally.
Walker also examined how the practice is rigged. Responsibilities are unfairly distributed, so people with more than their share of social privilege aren't always held accountable for the things that are their responsibilities, while people lacking this privilege are often burdened with more responsibility than is just, held to account for things they didn't do or blocked from assuming certain forms of responsibility, such as home ownership or elective office. Walker saw gender as a piece of this abusive power system: social structures and institutions are arranged to favor men's interests, wants, and preoccupations over women's. And she argued [End Page 98] that the power system is maintained by making it seem natural—by, for example, imposing the responsibility for child care on women because they have the ability to gestate and lactate. I've returned to that book again and again, and keep finding new things in it to appreciate.
It was at about this time that I read Martha Nussbaum's Love's Knowledge (1992). Aha! I thought. Here's a full-length philosophical examination of a narrative approach to ethics. By reading serious fiction, Nussbaum argues, one can make of oneself a person "on whom nothing is lost." One does this by allowing the author of the work to direct one's attention to the rich and subtle particulars of the narrative—the moral, intellectual, emotional, and social nuances. When the author has set these out with skill and imagination, overlooking no meaningful detail, the educated reader can see what is morally at issue in the narrative: she becomes, in the words Nussbaum borrows from Henry James, "finely aware and richly responsible." "Moral knowledge," Nussbaum writes, "is not simply intellectual grasp of propositions; it is not even simply intellectual grasp of particular facts; it is perception. It is seeing a complex, concrete reality in a highly lucid and richly responsive way; it is taking in what is there, with imagination and feeling" (152). Having broadened her field of vision and refined her moral perception, Nussbaum argues, the reader is in a better position to respond excellently to actual people in the world.
Not so fast, Martha. What if the moral agent, Billy, dutifully following Nussbaum's precepts, makes a mistake in choosing which novels to read? He finds a bodice-ripper at the supermarket, really likes it, and starts to form the impression that women want to be swept off their feet by manly men and enjoy being overpowered even to the point of rape. Billy knows he can't overcome his naiveté by reading only one novel, so he continues to broaden his experience with more literature of the same kind. But because he has so little experience of real women, the only fiction that rings true to him is the kind that endorses the "treat'em rough" school of thought he first encountered at the supermarket. And then we can imagine that the same holds for his personal life: the relationships with women that he finds the most satisfying are the ones that conform to his favorite depictions of sweet savage love. "The end result of the whole affair," Michael De-Paul (1993) remarks sadly, "is that Billy's moral judgments regarding appropriate relations between men and women are thoroughly fouled up" (33).
The trouble with Billy isn't just that he's sexually incompetent. He's narratively incompetent, and that might be what's gotten him into his present predicament. Narrative competence may be defined, first, as the ability to choose good literature, and second, as the ability to read good literature with care, skill, and critical judgment. It's the capacity for selecting works of fiction that are worth one's time and attention, and then reading these works shrewdly, with an awareness of the literary techniques the author employs and a sense of how the text relates to other literary texts. [End Page 99]
But is it the lack of this sort of knowledge that has fouled up Billy's relations with the opposite sex? Note that the relevant standards are primarily aesthetic ones—the ones we use for judging literature as a work of art. If I am trying to refine my moral perception, though, why should those be the right standards? Mightn't it be more important for me to learn how to choose books—even books of poor literary quality—that can improve my moral position, and then learn how to read these books in ways that make me a morally better person? If choosing and reading books for these purposes involve standards other than aesthetic ones, then attaining narrative competence won't help me become "richly responsible." What I need instead is normative competence.
Sadly, I decided Nussbaum wasn't much help.
On the other hand, Wittgenstein's Philosophical Investigations (1958) came to my assistance again and again. For example, I began to understand the voicelessness that's brought about when patients have to use clinicians' words. Early in the Investigations Wittgenstein remarks, "To imagine a language means to imagine a life-form" (§19). In this section, he develops the idea that speaking and understanding language is a part of, and specific to, a particular way of life. The words in the language mean what they do because of how they are used by those who inhabit that way of life; the inhabitants shape the language to serve their own purposes. And so it dawned on me that the language specific to the life-form of the clinic doesn't always serve the patient's purposes. It looks deceptively like the patient's language, which is why the problem goes unnoticed, but it's actually what Wittgenstein would call a suburb of that language (§18), and to most patients and their families, it's an unfamiliar suburb.
For example, Susan, a homeless woman with HIV and a heroin addiction, was brought to the emergency room because she couldn't breathe. The oxygen they gave her made her feel much better, but when the mask was removed, her blood saturation levels dropped from 94 to 50% within five minutes. She was told she must be admitted to the hospital so that the underlying infection could be treated with IV antibiotics and she could get the respiratory support she needed. She asked if she could smoke, but the resident said it would pose an immediate health risk and was absolutely out of the question. Susan was upset and started arguing, telling them she was under a death sentence anyhow. She threatened to leave, but the nurse persuaded her not to, gently explaining how fragile her condition really was. Susan seemed to take that in, but when the resident, intern, and attending physician returned to discuss admitting her to the hospital, she again asked to smoke. The physicians all said no, telling her bluntly that she would likely die if she didn't stay. Susan demanded to be discharged and left the hospital. Twenty minutes later, the paramedics responded to an emergency call. They brought Susan back in cardiac and respiratory arrest. She was pronounced dead within minutes.
Susan didn't understand the clinic's form of life. She couldn't, perhaps, find the words to ask for what she needed: to be tucked into a soft bed with crisp, clean [End Page 100] sheets and have people who cared about her take her outside for one last cigarette before she died. She didn't want them to save her life, but to abide with her as she exited it. Sadly, the clinicians didn't understand what she wanted, so they let her go, to die afraid and alone on a dirty street.
So, what kind of moral work is done by the story I just told? Well, for one thing, it illustrates a point about language-games. But the first paragraph of it also displays a moral mess, while the second paragraph is a counterstory. And that counterstory expresses something about who I am, morally. Lots of stories behave this way, filling several functions at the same time.
Have you ever noticed what people commonly do when there are no widely shared moral understandings to guide their actions in an ethically puzzling situation? They often begin by telling themselves or their interlocutors the backward-looking stories that got them into this tight spot in the first place. These are likely stories of relationship—how Susan came to lose her friends through addiction, for example, and who she is with respect to her caregivers. Then they're apt to tell the sideways-looking stories that have to do with the social practices and institutions that form the context for the situation: the hospital's inflexible no smoking rule, the social stigma attached to HIV, the fact that heroin is illegal and we don't have the methadone clinics that other countries use to keep addicts alive and safe. And finally, people tell the forward-looking stories that set the field of future action. The story Susan's professional caregivers told her was that she would die if she didn't do exactly as they said. But Susan's story, insofar as she had words for it, was that she was under a death sentence anyhow. Tragically, no attempt was made to find a story that all parties could agree on, so the situation resolved itself more unhappily than it should have.
We all live by stories. We can't do otherwise. So narrative approaches to bioethics are inevitable. But that doesn't make all stories morally acceptable. I can't tell you how often I've been asked to referee papers for bioethics journals that argue, "Stories are good." Well, actually, some are and some aren't. Some are pernicious master narratives that ought to be resisted—in the right way. Others are clichés in dire need of greater moral imagination. All require critical reflection before we accept or reject them.
Do people trained in literary disciplines have a leg up when it comes to wielding stories for moral purposes? I'm not so sure. I do know that child development psychologists report that we need to learn, at a very young age, how to tell stories if we are to flourish as adults:
Families that are more elaborative, with each family member contributing to the ongoing narrative and sharing their perspectives and opinions, have children with higher levels of self-esteem and emotional well-being. More specifically, families that are able to reminisce about highly stressful events in an emotionally expressive and explanatory fashion have children with higher levels of self-understanding and self-esteem.(Fivush 2008) [End Page 101]
Self-esteem matters morally because it's what lets us trust our own moral judgments, as well as stay open to changes of heart and mind as the occasion arises. So maybe advanced training in literary theory can, as Nussbaum asserts, make us finely aware and richly responsible.
I doubt it, though. I've met literary scholars—and moral philosophers, for that matter—who were complete and utter jerks, and so, I daresay, have you. I'm reminded of a news story I read a while ago about a dentist in Ohio who had taken to anesthetizing his female patients and raping them while they were unconscious. After he was caught and tried, the judge sentenced him not only to jail time, but also to take an ethics course. The naiveté of this kills me. The dentist didn't need an ethics course to learn that raping your patients is wrong. He knew that already. He just didn't care. And neither an ethics course nor an advanced degree in literary studies would have turned him into a decent person.
No, all ordinary adults know, in general, right from wrong. What scholarship adds to this competence is an examination of how narratives play into our practices of morality. They bear the same relationship to bioethics as grammarians bear to language: they study it, theorize it, map it out, discover the nuances. Of course, it helps a lot if they know themselves, understand their own moral weaknesses, and try hard to live kind, courageous, virtuous lives. Armed in those ways, and with that background in theatre and literary studies, they have important contributions to make to the interdisciplinary work that is bioethics.