applicability of narrative ethics

7/27/2019 Applicability of Narrative Ethics

1/9

This article was downloaded by: [Yonsei University]On: 14 October 2013, At: 03:54Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Applied Communication

ResearchPublication details, including instructions for authors and

subscription information:

http://www.tandfonline.com/loi/rjac20

The Applicability of Narrative EthicsTeresa 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

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the

Content) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views ofor endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to orarising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
http://dx.doi.org/10.1080/00909880902792305http://www.tandfonline.com/action/showCitFormats?doi=10.1080/00909880902792305http://www.tandfonline.com/loi/rjac20http://www.tandfonline.com/loi/rjac20http://www.tandfonline.com/page/terms-and-conditionshttp://www.tandfonline.com/page/terms-and-conditionshttp://dx.doi.org/10.1080/00909880902792305http://www.tandfonline.com/action/showCitFormats?doi=10.1080/00909880902792305http://www.tandfonline.com/loi/rjac20


2/9

The Applicability of Narrative EthicsTeresa L. Thompson

Keywords: Narrative Medicine; Ethics; DoctorPatient Interaction; Health

Communication

I was not fortunate enough to be able to be at the program at the NationalCommunication 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: [email protected]

Editors Note: This manuscript is one of many in a special issue of the Journal of Applied Communication

Researchon Health as Narrative, volume 37, issue 2.

ISSN 0090-9882 (print)/ISSN 1479-5752 (online) # 2009 National Communication Association

DOI: 10.1080/00909880902792305

Journal of Applied Communication Research

Vol. 37, No. 2, May 2009, pp. 188195


3/9

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 commu-nication 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 myselfstuck 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 workand 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 narrativesand 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. I ve often accused

him of being stubborn, and of just refusing to take the perspective of the other. ButI think that Ive been wrong about that. He tells me you give me more credit than

Narrative Ethics 189


4/9

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 ofmedicine*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 century-

long 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:

190 T. L. Thompson


5/9

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)

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 ofcommunication (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 counter-

empathic 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 providerpatientinteractions on a global level. Its something else to look at a particular doctor and



6/9

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 ofthis 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) andnotes 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 narrativelycomplex 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 andthe practice of narrative medicine for those who have the requisite abilities to practice

192 T. L. Thompson


7/9

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*inparticular, 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 ofnon-sense. There seems no doubt but that a well-constructed story possesses a kindof narrative truth that is real and immediate and carries an important significancefor 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 scholarssuch 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 andtelling 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 medicalcontext, in which decisions must sometimes be made incredibly quickly with little



8/9

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.

References

Arnett, R. (1987). The status of communication ethics scholarship in speech communicationjournals from 1915 to 1985. Central States Speech Journal, 38, 4461.

Buber, M. (1958). I and thou (2nd ed). New York: Charles Scribners Sons.

Chambers, T., & Montgomery, K. (2002). Plot: Framing contingency and choice in bioethics. In

R. Charon & M. Montello (Eds.), Stories matter: The role of narratives in medical ethics (pp.

7784). New York: Routledge.

Charon, R. (2006). Narrative medicine: Honoring the stories of illness. New York and Oxford: Oxford

University Press.

Charon, R., & Montello, M. (2002a). Memory and anticipation: The practice of narrative ethics. In

R. Charon & M. Montello (Eds.), Stories matter: The role of narratives in medical ethics (pp.

ixxii). New York: Routledge.

Charon, R., & Montello, M. (2002b). Stories matter: The role of narratives in medical ethics. NewYork: Routledge.

Childress, M. D. (2002). Of symbols and silence: Using narrative and its interpretation to foster

physician understanding. In R. Charon & M. Montello (Eds.), Stories matter: The role of

narratives in medical ethics (pp. 119125). New York: Routledge.

Eisenberg, N. (1977). The development of prosocial moral judgement and its correlates. Dissertation

Abstracts International, 37, 4735B.

Eisenberg-Berg, N., & Mussen, P. (1978). Empathy and moral development in adolescence.

Developmental Psychology, 14, 185186.

Harter, L. M. (2009). Narratives as dialogic, contested, and aesthetic performances. Journal of

Applied Communication Research, 37, 140150.

Haviland-Jones, J., Gebelt, J. L., & Stapley, J. C. (1997). The questions of development in emotion.In P. Salovey & D. J. Sluyter (Eds.), Emotional development and emotional intelligence (pp.

233253). New York: Basic Books.

Jones, A. H. (2002). The color of the wallpaper: Training for narrative ethics. In R. Charon &

M. Montello (Eds.), Stories matter: The role of narratives in medical ethics (pp. 160170).

New York: Routledge.

Kalliopuska, M. (1983). Relationship between moral judgement and empathy. Psychological Reports,

53, 575578.

Langellier, K. M. (2009). Performing narrative medicine. Journal of Applied Communication

Research, 37, 151158.

MacIntyre, A. (1984). After virtue: A study in moral theory (2nd ed.). Notre Dame, IN: Notre Dame

University Press.

Mehrabian, A., Young, A. L., & Sato, S. (1988). Emotional empathy and associated individual

differences. Current Psychology, 7, 221240.

194 T. L. Thompson


9/9

Morris, D. B. (2002). Narrative, ethics, and pain: Thinking with stories. In: R. Charon &

M. Montello (Eds.), Stories matter: The role of narratives in medical ethics (pp. 196218).

New York: Routledge.

OBrien Hallstein, D. L. (1999). A postmodern caring: Feminist standpoint theories, revisioned

caring, and communication ethics. Western Journal of Communication, 63, 3256.

Polkinghorne, D. E. (1988). Narrative knowing and the human sciences. Albany, NY: State Universityof New York Press.

Robinson, W. M. (2002). The narrative of rescue in pediatric practice. In R. Charon & M. Montello

(Eds.), Stories matter: The role of narratives in medical ethics (pp. 97108). New York:

Routledge.

Rubin, S. B. (2002). Beyond the authoritative voice: Casting a wide net in ethics consultation. In

R. Charon & M. Montello (Eds.), Stories matter: The role of narratives in medical ethics

(pp. 109118). New York: Routledge.

Rushton, J. P., Fulker, D. W., Neale, M. C., Nias, D. K. B., & Eysenck, H. J. (1986). Altruism and

aggression: The heritability of individual differences. Journal of Personality and Social

Psychology, 50, 11921198.

Salovey, P., & Mayer, J. D. (1990). Emotional intelligence. Imagination. Cognition and Personality,9, 186211.

Spence, D. (1982). Narrative truth and historical truth: Meaning and interpretation in psychoanalysis.

New York: W. W. Norton.

Spiro, H. M. (1993). Empathy and the practice of medicine. New Haven, CT: Yale University Press.

Thompson, T. L., & Guttman, N. (in press). Ethics in health communication. In S. May, G. Cheney,

& D. Munshi (Eds.), Handbook of communication ethics. Mahwah, NJ: Lawrence Erlbaum

Associates, Inc.

Wiesenfeld, A. R., Whitman, P. B., & Malatesta, C. Z. (1984). Individual differences among adult

women in sensitivity to infants: Evidence in support of an empathy concept. Journal of

Personality and Social Psychology, 46, 118124.

Zaner, R. M. (2009). Narrative and decision. Journal of Applied Communication Research, 37,174187.

Zillman, D. (2006). Empathy: Affective reactivity to others emotional experiences. In J. Bryant &

P. Vorderer (Eds.), Psychology of entertainment (pp. 151182). Mahwah, NJ: Lawrence

Erlbaum Associates, Inc.


applicability of narrative ethics

Documents