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Journal of Applied Communication Research

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The Applicability of Narrative Ethics

Teresa L. Thompson Published online: 08 May 2009.

To cite this article: Teresa L. Thompson (2009) The Applicability of Narrative Ethics, Journal of Applied Communication Research, 37:2, 188-195, DOI: 10.1080/00909880902792305 To link to this article: http://dx.doi.org/10.1080/00909880902792305

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Journal of Applied Communication Research Vol. 37, No. 2, May 2009, pp. 188195

The Applicability of Narrative Ethics

Teresa L. Thompson

Keywords: Narrative Communication

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Medicine;

Ethics;

DoctorPatient

Interaction;

Health

I was not fortunate enough to be able to be at the program at the National Communication Association (NCA) at which the papers included within this issue were presented. I had planned to be there*I was to chair the panel*but a medical narrative led to replotting. My sister-in-law was suddenly diagnosed with rather advanced cancer in several parts of the body, and I was needed to care for her at the time. The moral, ethical decision was a straightforward one, and I was happy to be able to be with her. As I read the e-mail correspondence that was shared amongst members of that panel following the conference, it became obvious that I had missed a very special panel. I attended my first professional conference 35 years ago, and never have I experienced the sharing of emotions and passion*the depth and sincerity of response*about a scholarly panel that I did when reading the responses to the panel discussing and honoring Dr. Charons work. The reactions were similar to those I had experienced as I read her books Stories Matter (Charon & Montello, 2002b) and Narrative Medicine (Charon, 2006). Dr. Charons perspective describes medicine as it should be practiced. It describes ethics as they should be enacted. It describes the power of narratives in the health communication process. The same can be said of Dr. Zaners compelling narrative in this issue (2009), and of the work of Dr. Anderson described in Harters essay in this issue (2009). Ive been studying and writing about health communication for at least 26 years* longer if one includes my early work on disability. Most scholars in this area of study showed no recognition of the role of narrative in the health communication process when I began to survey the literature, with Barbara Sharf and David Smith being notable exceptions. Over the years, however, the examination of narrative has become an important one within this area of study, as it has in the field of communication as
Teresa L. Thompson is a Professor in the Department of Communication at the University of Dayton. Correspondence to: Teresa L. Thompson, Department of Communication, University of Dayton, Dayton, OH 45469-1410, USA. E-mail: thompson@udayton.edu Editors Note: This manuscript is one of many in a special issue of the Journal of Applied Communication Research on Health as Narrative, volume 37, issue 2.
ISSN 0090-9882 (print)/ISSN 1479-5752 (online) # 2009 National Communication Association DOI: 10.1080/00909880902792305

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a whole (Arnett, 1987). Arnetts review of the writing on communication ethics prior to 1986 already showed narrative ethics as a salient paradigm. Medicine came to the narrative table somewhat later (Charon & Montello, 2002a). Much of the most interesting work that has been done in the health communication area in the 20' years that Ive been editing the journal Health Communication is narratively based. Nonetheless, very little of it has explicitly dealt with ethical concerns. Ethical and moral concerns are implicit in much of that work, including my own writing about narratives, but have not been developed in the ways that are apparent in Dr. Charons work. The strength of Dr. Charons work is this melding of an astute understanding of ethical considerations, the intelligence and compassion of a fine healthcare provider, a sophisticated understanding of narrative, and an overriding focus on human relationships as created through communication. Her work thrills and inspires. Indeed, it extends far beyond conceptualizations of narrative medicine and ethics and substantially furthers our understanding of bioethics and ethics in health communication in general. The implications for all ethical considerations are also obvious. As I approached the composition of this essay, I originally envisioned writing a health narrative or writing about the emerging directions evident in the health communication research that focuses on narrative. Instead, I found myself stuck on an issue, and before long saw that I was writing about it. In the process of this, however, I have found that I will tell a story. My story comes about in reaction to the wonder that I find in the work on narrative medicine and narrative ethics. That wonder, however, leaves me with one hesitation. What about all of the healthcare providers who do not have the empathic abilities and interpersonal sensitivity to perceive what is not stated, to put their work and words into the context of a familys life, and to live up to the moral duties enshrined in ethical principles with sensitivity and compassion (Robinson, 2002, p. 103)? All of the writing that we do on narrative and narrative ethics seems to ignore them. What about the care providers who lack those basic cognitive/emotional capacities? These are not skills that everyone has. This skill set is a precious and rare one. Certainly, all of us would wish for a care provider like Dr. Charon*a care provider with the cognitive capacity to perceive what is not stated. And certainly all care providers could become better care givers by learning to take a narrative stance. But how over-idealistic is the presentation by many of us who write about narratives and narrative ethics, as we describe what a care provider should do? Im not raising questions of taking the time to do this*thats not an argument that Ill buy. Im raising the questions of capacities and competence. Let me now share a story with you. Our protagonists name is Bob. Ive known him since he was an undergraduate. Hes great at math and science. He had great grades and test scores. He sailed into and through medical school. He struggled with his internship and residency, but hes now a practicing physician. But, bright as he is in many ways, his cognitive and emotional capacities in other ways are limited. His ability to take the perspective of the other is particularly limited. Ive often accused him of being stubborn, and of just refusing to take the perspective of the other. But I think that Ive been wrong about that. He tells me you give me more credit than

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I deserve. I just cant think about things like that. Ive known him long enough that I think such a capacity would indeed have shown its face now and then if it were there. I think, as Ive seen him mature as a person and grow intellectually, that the capacities to perceive what is not stated would have in some way become evident to me if they were there. And Ive yet to see them. Ive known him for years, and in a variety of different contexts. Ive tried to reach him through example, conversations, nagging, and giving him readings. Ive told stories to him. Ive created stories with him. Medical curricula also attempt to reach people such as Bob, sometimes more successfully and sometimes less successfully. Dr. Charon could probably reach him, but how many Dr. Charons are there? What can we as writers about narrative and narrative ethics offer for someone like Bob? How can he use this sophisticated, compassionate perspective to become a better doctor? Do we just give up on him? Im aware that the same kinds of questions could be raised about much of the writing on bioethics and the practice of medicine*some people are going to be better and more astute than others. But Ive never felt that lack of applicability of a perspective as deeply as I do when I read about the power and passion of narrative medicine and contrast that with this technically good but empathically limited physician. I struggle with the notion of how to use a narrative approach and narrative ethics to help Bob become a better doctor and a better person. I dont think that weve addressed that issue. Narrative competence is something at which not everyone excels. Spiro (1993), for instance, discusses physicians who are alexithymic*not in touch with their own emotions, let alone those of their patients. There is considerable evidence that empathy, which is required for the utilization of a narrative perspective and understanding narrative ethics (Chambers & Montgomery, 2002; Jones, 2002), is an individual difference, trait-like variable (Mehrabian, Young, & Sato, 1988; Wiesenfeld, Whitman, & Malatesta, 1984), although it is also state-related and developmental (Haviland-Jones, Gebelt, & Stapley, 1997). There is a genetic component to empathy (Rushton, Fulker, Neale, Nias, & Eysenck, 1986) but it is also strongly influenced by both previous experiences (Jones, 2002) and temperament (Mehrabian et al., 1988). It is related to moral reasoning (Eisenberg, 1977; Eisenberg-Berg & Mussen, 1978; Kalliopuska, 1983); more empathic individuals make higher level moral decisions. Importantly, Salovey and Mayers (1990) review of relevant research noted that, there has been a centurylong tradition among clinicians recognizing that people differ in the capacity to understand and express emotions (p. 191). They then go on to describe it as a dispositional variable (p. 195). Dr. Charon (2006, p. 133) cites the definition provided by Roy Schafer of empathy: Generative empathy may be defined as the inner experience of sharing in and comprehending the momentary psychological state of another person. One of the more thorough theories of empathy, Zillmans (2006) three-factor theory, is based on the data indicating that:

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Narrative Ethics
emphatic ability tends to be treated as an enduring disposition or trait. People are presumed to have it to varying degrees; that is, to have this trait in moderation or abundance or to be deficient in it. No doubt empathic ability differs greatly among people and should be treated as an individual-difference variable of consequence. (p. 151)

191

Zillman directly relates empathy to narrative. He argues that storytelling of any kind is a principal forum of empathic reactivity (p. 152). However, his review of the empathy research makes clear that, in addition to being an individual-difference variable, how a responder looks at the person with whom he or she is attempting to empathize will color empathic responses or their lack. He notes that all impetus for attending revelations of the characters fate would be lost if we were not lovingly disposed to care for them, or, for that matter, if we were not disposed by disdain to wish harm upon them. The empathy concept can thus be considered pivotal to any interest in and, likely, any gratification from, storytelling via the media of communication (p. 152). Participants demonstrated empathy . . . only under conditions of positive affective dispositions . . .. Under conditions of negative affective dispositions, empathy was not only absent, but discordant affect was observed (Zillman, 2006, p. 169). Further, Zillman argues that three factors must interact to lead to the development of empathy: dispositional, excitatory, and experiential factors. He adds that excitatory preparation is largely independent of cognitive mediation and, in fact, eludes volitional cognitive intervention to a high degree (p. 163) and that unqualified liking constitutes the optimal condition for the development of empathic reactivity; unqualified disliking for the development of callousness necessary for counterempathic responses (p. 176). Similarly, Charon (2006) discusses one of her students, who explicitly describes his intense anger at and inability to empathize with a patient: For me to imagine myself in his shoes, I basically have to imagine myself to be someone I hate (p. 165), although he then goes on to describe the subsequent pity he learned to feel for the patient. With (a) empathy necessary for the practice of narrative medicine and narrative ethics, (b) empathic ability varying amongst individuals, and (c) empathic responses varying based on degree of liking for the other interactant, it seems that narrative ethics and narrative medicine might be limited in their usefulness for some medical care providers. What does the narrative perspective offer to us for someone who is incredibly low in empathic ability? Do we tell him to give up his hope of being a good doctor? The inspiration I feel when I read and think about narrative medicine is shadowed by the despair I experience when I think about care providers such as Bob and their lack of empathy, which will impact their abilities to understand narratives and narrative ethics. And if Bob cant reach the empathic level necessary for an understanding of others narratives, what hope has he (or we for him) of going beyond that to the disidentification advocated by Langellier in this issue (2009)? Its one thing to talk about all the problems in medicine and providerpatient interactions on a global level. Its something else to look at a particular doctor and

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192 T. L. Thompson

the struggle he experiences to try to achieve the kind of IThou relationship (Buber, 1958) made possible by a narrative approach to medicine. Some of the writing on narrative does indeed address the difficulty of the concept and the sophistication involved in using it (Childress, 2002; Jones, 2002), including Langelliers essay (this issue 2009). It is also obvious that Dr. Charon is well aware of this difficulty and requisite sophistication. She writes, sophisticated knowledge of how stories work is not attained without considerable effort and commitment (2006, p. ix) and, in describing a particular cardiologist, that This doctor is not equipped with the imagination, the ability to see from anothers point of view, the knowledge of human fears and hopes, and the ear for language and silence necessary to grasp fully the predicament of his patient and his patients wife (p. 20). Langellier, for instance, identifies the multitudinous factors involved in narrative competence; she discusses unresolvable tensions (p. 153). Childress, writing in Stories Matter (Charon & Montello, 2002b), uses such terms as highly skilled (2002, p. 119) and notes that seldom, if at all, are students and residents taught the sorts of interpretive precepts and skills of close reading that will help them to make the most of the narratives that they hear and, in turn, construct (p. 120). She closes with the caution, if thinking with stories is to contribute substantively to ethical ways of doctoring, physicians need considerable self-awareness as tellers and hearers of stories. They also need good interpretive skills with which to understand the myriad stories that fill their practice life (p. 125). Similarly, Jones (2002) provides a long list of the skills that are sequentially necessary for the development of narrative competence; she describes a narratively complex skill (p. 161). In addition to the areas of expertise that she itemizes, she points out that narrative medicine requires an existential witnessing of patients suffering that goes beyond the often-task oriented medical encounter (p. 161). Although she discusses the value of learning to read literature, she reminds us that narrative competence can be achieved only if students develop the interpretive skills that are also required in narrative ethics (p. 162). But, indeed, isnt that what ethics is all about*the ought in the world, rather than the is? Bob is a doctor. Bob ought to be better at reading and participating in narratives. But hes not. Bob can, however, relate to principalist ethics. Theyre deductive. Bob can learn the principles and learn to apply them to particular cases. He wont be as good a doctor as he could be if he could look at ethics and medicine from a narrative perspective, but hell be better than he would be if he ignored ethics completely. Thus, we see the need for the argument offered by Morris (2002) that we must incorporate both principalist and narrative ethics into our medical curriculum. Let me also make clear at this juncture that the conceptualization of empathy offered by and implicit in Dr. Charons work is highly dialogic and dyadically constructed. It is not a simplistic trait, which is the conceptualization that is inherent in some of the psychological writing on empathy. All of that said, however, there is no doubt about the value of narrative ethics and the practice of narrative medicine for those who have the requisite abilities to practice

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it, or for those who are able to develop those skill sets. Donald Spence (1982) put it appropriately when he noted:
Freud made us aware of the persuasive power of a coherent narrative*in particular, of the ways in which an aptly chosen reconstruction can fill the gap between two apparently unrelated events, and in the process, make sense out of non-sense. There seems no doubt but that a well-constructed story possesses a kind of narrative truth that is real and immediate and carries an important significance for the process of therapeutic change. (p. 21)

Closing Thoughts One of the many things that delights and inspires me as I read and think about narrative medicine and ethics is how this view of medicine gives the lie to an argument that I never bought anyway*that care providers have to maintain emotional distance in order to be good providers and to maintain their sanity. I raised the question of the validity of that argument at a health communication panel at the annual conference of the International Communication Association way back in 1985 and was completely disregarded by the remainder of the panelists and audience. Ive never been presented with data in support of that assertion. One of the many strengths of the narrative ethics view is that it shows us that emotional distancing is not necessary for either effective healthcare provision or for the emotional stability of the care provider. This perspective enables us to see that creating shared narratives and the closeness that this brings lead to better care provision than the oft-prescribed distancing. This argument is echoed by scholars such as Howard Spiro (1993), who has discussed at length the responses he has received to his writing on empathy from doctors who are tired of detachment and equanimity (p. 2). This notion of distancing relates to issues of power. One of the many values of narrative ethics and narrative medicine is some minimization of the power differences that have seemed so inherent to the practice of medicine (Charon, 2006). Rubin (2002) writes, One of the outgrowths of the narrative approach is that it entails the sharing of power: the power of telling the story, commenting on it, revising it, and concluding with it. Closure comes out of the collective hearing and telling and responding to one another (p. 112). As we think about narrative ethics and their relation to power, then, it also seems appropriate to incorporate considerations from feminist ethics and virtue ethics. In particular, for instance, Im thinking about the revised feminist ethic of care as grounded in standpoint theories (OBrien Hallstein, 1999) and virtue ethics as they go well beyond Aristotles original conceptualizations and build on the writing of such scholars as MacIntyre (1984), who is cited briefly by Charon (2006). Both narrative ethics and the ethic of care are founded on similar assumptions. They focus on the role of relationships and caring. Their complementarity is apparent. Virtue ethics provides a corresponding perspective that is especially relevant in the medical context, in which decisions must sometimes be made incredibly quickly with little

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time for ethical consideration. A care provider who has developed the habits of virtue advocated by much of this writing does not have to ponder decisions in such emergencies. These three perspectives*narrative ethics, a feminist ethics of care, and virtue ethics*meld together nicely within the medical setting (Thompson & Guttman, in press). I close with a quote from Polkinghorne (1988, p. 14), borrowed from an unpublished manuscript by Roland Barthes in 1966. Barthes argues that the history of narrative begins with the history of mankind [sic]; there does not exist, and never has existed, a people without narratives. Powerful, indeed. I thank Dr. Charon for her work; she teaches us much about narratives beyond their application in medicine.

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