NARRATIVE

Human beings are a narrative species. We tell stories incessantly; we read and listen to them, watch them unfold on screen and stage. In making and absorbing narrative—news, gossip, fiction, drama, anecdotes, and history—we spin and untangle explanatory accounts of the way the world works and how we and our fellow human beings act in every conceivable circumstance. Memories of the past and ideas of the future are expressed in narrative accounts of how the world was and how it will, or should, become. Individual identities and self-conceptions are packaged in life stories, part (and heirs) of larger family, community, and national stories that shape the life events and choices to become the chapters that follow. There is even evidence that narrative, rather than simply a creative use human beings have found for language, is instead the motive for its acquisition: Young children learn to talk in order to give some account of occurrences in their daily lives (Bruner).

For the most part, the word narrative is used inter-changeably with story to designate a more or less coherent written, spoken, or (by extension) enacted account of occurrences, either historical or fictional. Story, however, is used more often, especially informally, to denote spoken and fictional accounts, while narrative emphasizes the inclusion of nonfiction or indicates a contrast with visual or numerical data, as in historiography or book production or computer science. Narrative tends to be used generically in literary theory, perhaps following the Russian formalist and French structuralist distinction between story and plot, where story designates the events, and plot, the ordering of those events in the literary or historical account. Thus, the story of Oedipus begins with the prophecy his parents receive before his birth; the plot of Sophocles' play begins when, years later, he learns from the same oracle that the plague that afflicts his city is punishment for the unavenged death of the old king. Narrative refers to the whole and implies, for any particular telling, the inseparability of plot and story.

As it orders events, narrative asserts or connotes some causal relation among those events and imputes character and motives to the actors (Forster). Yet, despite this linearity, conclusions are never foregone. As narrative depicts events embedded in the lives and concerns of its protagonists, circumstances unfold through time in all their contingency and complexity (Ricoeur). Whether it is the life story essential to moral understanding (Burrell and Hauerwas; MacIntyre) or the political history of a nation (White), narrative explores the way cause and effect are entangled with the variables of human character and motivation, with luck and happenstance. When moral principles or political generalizations are abstracted from events without the use of narrative, those details are left behind as inessential, even though for those involved such particulars may represent what is most valued in a life or a history. Narrative remains mired in the particulars of human experience. From its designation of certain details as relevant "facts" and certain occurrences as "events" to the use of rhetorical strategies in the representation and description of those facts and events, narrative is concerned with the construction and interpretation of meaning.

Narrative and Medical Knowledge

Because narrative is the primary way of organizing and communicating the sense human beings make of the world, the interpretive process integral to shaping and understanding a story is at the heart of human knowing. Thus, the investigation of narrative forms and practices is a fruitful way of understanding how knowledge is acquired and transmitted. To understand medical knowledge—whether the patient's illness, the physician's practice, ideas of causality, issues of medical ethics, or activities of clinical research—it is helpful to look at the historical and explanatory narratives patients and practitioners tell themselves and each other (Charon, 1986, 1994; Hunter, 1991; Miles and Hunter).

Clinical medicine is a radically uncertain field of knowledge. Based on human biology, a science more complicated and multileveled than physics or chemistry, medicine has the task of applying scientific knowledge to the care of individual human beings. Not only does the living matter of biology change—the influenza virus mutates annually, tuberculosis and gonorrhea become drug-resistant, HIV gains purchase in the human community—but even more reliably, illness, that is, the manifestation of disease in human beings, varies unpredictably from person to person. Despite the triumph of the germ theory, "disease" remains a label given to a complicated interaction of physiological phenomena—none of which need be a necessary or sufficient cause—in circumstances identified and construed culturally, socially, and personally. Much about disease can be known scientifically, if not entirely predictably; but both the patient's illness and his or her response to treatment remain complex events with multiple causes occurring in circumstances that are impossible or immoral to replicate.

Given such uncertainty, narrative in its various guises is essential to the scientific practice of medicine. Patients relate the history of their illness when they present themselves for medical attention; disease plots make up the clinical taxonomy found in textbooks; their variant subplots are stored in physicians' memories; written accounts of medical care preserved in charts fill hospital basements; case reports contribute, one by one, to clinical research. In the physician's office where patients are well known and practice is solitary, narration may dwindle to a nearly invisible minimum. But in academic medical centers where medicine is taught and research carried out—just where one might expect to find narratives banished by the ever-present concern for scientific objectivity—narrative flourishes. The clinical case is not only the record of care but the mainstay of clinical education and academic discourse. Cases are presented at morning report, at teaching rounds, patient-care conferences, grand rounds, ethics conferences, informally in halls and locker rooms, and around lunch tables. The case record is compiled in the hospital chart by several hands. When anomalies occur, the case becomes the vehicle for communication and further investigation that may lead to sustained clinical or laboratory research. As the translation and interpretation of the patient's account of illness, augmented by further investigation, the medical narrative enables clinicians to apply scientific knowledge and therapeutic judgment to the understanding and relief of illness in particular human beings.

The case thus constitutes the scientific data in the investigation and treatment of a patient's malady. Confronted with the signs and symptoms, guided by the patient's story, the physician asks questions, sorts the information into a list of possible diagnostic plots, and then sets to work to eliminate from consideration the least probable and most life-threatening and to confirm the most likely. The goals of this medical retelling of the patient's story are representational: fidelity to the clinical observation of the patient and minimalization of the observer's (and the patient's) subjectivity. To this end the conventions of the medical case are strict and almost inviolable. The narrator is all but effaced, appearing only as a signature authorizing the passive voice, while the patient's experience is subordinated to the medical retelling of illness events and physical signs, a version that resolutely ignores the fear and bewilderment, the loss of control, and the suffering that may attend the experience of illness. This is not meant to be cruel; it is meant to provide the patient with an objective gaze that is capable of establishing with some certainty what the matter is so that treatment may begin and, with luck, health may be restored.

The physician's familiarity with other cases grounds the investigation and, indeed, the whole interpretive, diagnostic circle. Whether read and heard about or, better, observed and directly experienced, these cases make up an intellectual storehouse backed by the myriad of information accumulated in publications and through consultation. Well understood and ready to hand, this body of practical knowledge enables physicians to apply physiological principles, textbook summaries, and clinical wisdom to signs and symptoms presented by individual patients, testing each particular case against those established, more abstract patterns. There are no all-encompassing laws of disease, and physicians must learn not only operative rules and their variants, but also the habits of perception that narrative enforces, habits that will stand them in good stead for a lifetime of practice in a field where knowledge and practice constantly change—and new diseases appear. The case narrative is the means by which such a store of exemplars is assembled both in formal education and in practice (Dreyfus and Dreyfus), and is the medium for the consultation, further investigation, and publication that are the hallmarks of modern academic medicine.

Narrative and Bioethics

The centrality of narrative characteristic of clinical medicine is shared with other case-based disciplines of knowledge, such as law, moral theology, and criminal detection. In these domains, knowledge is not simply a "top-down," theory-driven activity. Research must be conducted retrospectively, and knowing is interpretive, accumulated from the experienced scrutiny of many individual instances in the light of general rules. The case—a term common to them all— functions as both exemplar and test of more general formulations: legislation, ethics, criminology, and biological science. In everyday practice, "in the trenches," these generalizations are extended or refined as they are applied, and practical expertise is developed in the continual search for more nearly adequate rules.

Narrative is also central to bioethics. Not only does it provide an opportunity for imaginative moral reflection for its audience, it is equally the proving ground of moral argument. Although the contemporary study of bioethics, especially medical ethics, until recently has focused almost exclusively on principles (Beauchamp and Childress; Pellegrino), the applicability of moral principles is inevitably gauged against the particular case, and cases regularly provoke the careful study and refinement of the rules. Indeed, the rehabilitation of casuistry—dealing with questions of right and wrong—has been the work of philosophers in bioethics (Toulmin; Jonsen and Toulmin; Jonsen).

The role of narrative in moral life is well established with regard to literature (Horace; Coles; Banks). Along with history, which is also strongly narrative, fictional narrative has long been regarded as a moral teacher—especially in that most narrative of eras, the nineteenth century. Both literary theory and historiography have struggled against this assumption of moral didacticism in the twentieth century. French historians of the Annales school and American cliometricians (mathematical and statistical analysts) have attempted to reduce the narrative element in history writing in favor of numerical data—the records of glacially slow and macroscopic social change for the former, and a microanalysis of economic statistics for the latter. In literature, from the "art-for-art's-sake" movement at the turn of the last century through Dadaist experimentation to the frequently reported "death" of the novel, twentieth-century writers defied critics to draw morals from their stories. For much of the century, literary critics, too, eschewed moralism in favor of the aesthetics of "the work itself," relegating morals to a matter of folk tales. Thus, it was oddly fitting that when structuralists reanimated a critical concern with narrative it was necessary to turn to Vladimir Propp's The Morphology of the Folktale (1968; Todorov; Brooks). More recently, literary theorist Wayne Booth and philosopher Martha Nussbaum have made strong cases for literature as the medium of moral knowledge.

Literature's usefulness for moral reasoning lies not only in its themes and characters—those elements the McGuffey Readers drew upon for the "morals" that concluded their tales—but also in the interpretive reasoning it requires. As in clinical reasoning, narrative negotiates the application of general truths about human experience to the individual case. Readers know that murder is evil, but they turn to Macbeth, Crime and Punishment, or Native Son to reflect on precisely why and how. At the same time, narrative also tests such moral truths. Its representation of the particular instance asks implicitly whether circumstances can ever be extenuating; it negotiates on behalf of ethical inquiry, as it does for medical diagnostics, the imprecise and uncertain fit between general rule and particular instance.

The narrative that constitutes the bioethics case likewise plays a role in moral reasoning. The purpose of constructing and presenting a case in bioethics should not be limited to the illustration of a rule or principle any more than in medicine (Arras; Donnelly). It is rather to set out accounts of events in order to explore imaginatively their meaning for the people they affect and to determine what action should be taken. Because narrative's representation of subjective experience gives its audience access to the perception and judgment of other human beings, good ethics cases offer a means of thinking about the meaning of illness in the life of the patient, and about the role of the physician and the meaning of a patient–doctor interaction in the life of the physician. These are traditional themes of literature, and beyond literature—the themes of the unwritten stories, the gossip, and the self-revelation—that convey and test social values and give texture both to individual lives and to culture. To read and listen to stories and to watch them enacted on screen and stage is to open the understanding to the experience of other people, and to the meaning that experience has for them. Physicians do the former all the time, asking their patients about pain or the history of an illness, talking about the effects of disability or the likelihood of death. But imagining the meaning of experience for other people is very difficult and rarely undertaken (Kleinman; Waitzkin); for physicians, traditional, professional reticence and self-protection are obstacles (Katz). The desire for just this sort of understanding from another person, especially one pledged to a certain disinterested concern, informs both nostalgia for the legendary general practitioner and Anatole Broyard's request that his physician "spend five minutes thinking about my case" (1992). A longing for an interpreter who will both hear our stories in all their physical starkness and nevertheless see in us human subjects, people who create meaning in the story of our lives, may underlie the burgeoning interest in medical ethics. The public discussion of troubling cases—in the mass media, in the courts, in drama and film and autobiography, and in ethics courses—reveals a narrative hunger for meaning in the face of death. Indeed, Walter Benjamin (1936) has located in death's certainty the closure that narrative meaning requires.

As in clinical medicine, the use of narrative in bioethics is necessitated by the limits of human knowledge, and an attention to narrative enforces an awareness of these limits for both narrator and audience. Not only does the audience understand that the narrator's knowledge is limited, but, in addition, both narrator and audience know—or soon learn— that the knowability of the narrated is limited (Hunter, 1993). What happens next? Then? And then? The unfolding of narrative through time captures the contingencies of causation, the radical uncertainty of the most ordinary life, the uncontrolled variables that resist attempts to regularize and codify social knowledge. More questions may yield more information, yet uncertainty is best met not by the pursuit of every elusive clue, but by a sense of the balance of knowledge and tolerable ignorance sufficient for action. Although always accountable to social and cultural norms— indeed, these norms are operating in the framing and interpretation of narratives—moral knowledge is inevitably subjective, always open to question, discussion, elaboration, retelling, and reinterpretation.

In bioethics as in clinical medicine, narrative knowledge is always situated knowledge. Just as every malady has its patient, every tale has a teller—either the voice of an omniscient author or a character who has been witness to the events—and every narrator has an audience, imagined or real, to whom the story is addressed. Narratives are enmeshed in the circumstances of their telling, even when, as with clinical cases, the form is specially designed to extricate itself from those circumstances. Cases do not drop pure and untouched from the sky, nor do they contain a truth or essence that could be revealed if only the circumstances of their telling were stripped away. Instead, they are narratives constructed and presented by human beings who are making an effort to be understood—or to deceive, to impress an audience, or to reinterpret an event. Even stories meant to be perfectly transparent—medical cases, news reports, ethics cases—are framed by their all-but-invisible tellers and interpreted by their audience. Though the narrator may be a disinterested and impartial observer, there is nevertheless a standpoint from which the story is told (Chambers). Some things will be emphasized or privileged, others will be out of the narrator's view. While norms exist and exert their force, they do so variously and unpredictably, and determining how they do so is one of the tasks that readers and listeners undertake. Narrators are revealed to their audience, in part, by the stands they take in relation to both the norms of society and the conventions of the narrative genre. This tension between tale and teller (or tale and the untold) is always a part of the narrative.

Where the sense of events offered by a narrative is contested or where its interpretation is in doubt, the narrative itself comes under scrutiny. The reader or listener begins to ask about the narrator and the narrative frame. Who is telling the story—the physician, the patient, a family member, an ethicist? Why is it told? In what circumstances? How does the teller frame the story to include or ignore culture, history, life stories, power relations, economic conditions, the history of the present question? Because an understanding of the problem turns upon the answers to these questions, this is where the study of ethical discourse must begin (Chambers, 1994). Cases may be narratively impoverished and morally inadequate even when bioethical principles are followed and apparently right conclusions are reached.

Through narrative, bioethics partakes of an ongoing dialogue among human beings perceiving and acting in the world. This is not a theoretical but a practical activity with strong resemblances to the clinical epistemology of which medical-case narrative is a part. As in medicine, the "facts" are sometimes of uncertain relevance and the circumstances may not be replicable, but the representation of experience through time acknowledges and puts to use the inevitable subjectivity of human understanding (Ricoeur). The subjectivity and apparent relativism unavoidable in narrative openly represents one of the conditions of moral discourse. There is no neutral position or Archimedean platform beyond nature from which a narrator, cleansed of bias, may see "truth" or "reality" in all its uncluttered purity. Indeed, narrative may be most valuable as a guarantee against this positivist assumption, for an awareness of narrative and its workings is a constant reminder that there is no absolute truth, no certainty. For the most part, stories are relatively straightforward about the conditions of their acquisition and telling. They make no pretense to objectivity—or when they do, the pretense is readily apparent as yet another storytelling genre. Narratives can be questioned: The potential prejudices of the narrator's situation beg to be understood. The interpretation of narrative may be one of the few ways human beings have of seeing our customary blind spots as both narrators and interpreters. As Ernst Hans Gombrich (1960) observed about the perception of art, there is no innocent, no "naked eye." And if there is no sight without a lens, it can become second nature to inquire into the character and quality of the lens in any particular instance—and to adjust it as needed.

Narrative exists in dialogue with other narratives, other interpretations—including the principles that, distilled from accounts of good and evil, have come to represent those accounts. Stories are not a substitute for norms and principles, just as clinical medicine does not replace medical research and case law does not render legislation irrelevant. Historians know well that every story implies an answering account, one that will surely—at last!—set the record straight. If the physician tells the patient's story, no one truly believes that it is the only story that matters; nor is the patient's story sufficient; otherwise the patient would not have sought medical help. The two are in dialogue. The goal is not a synthesis or a determination of a "truth" that will swallow up other accounts, but a sustainable representation of incommensurability, a consensus that may be acted upon. Ethics is practical knowledge, forged experientially and honed on circumstance. It is practiced in the negotiation of story and teller, story and listener, story and answering story. Because, in narrative, inquiry is inseparable from explanation, narrators and audiences must test the sources of our stories, compare versions, and sustain a healthy skepticism about answers. Thus, narrative represents the conditions of moral discourse, even as it is the principal medium of that discourse.

kathryn montgomery hunter (1995)

bibliography revised

SEE ALSO: Ethics: Moral Epistemology; Health and Disease: The Experience of Health and Illness; Literature and Healthcare; Metaphor and Analogy; Value and Valuation

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