The narrative approach has not assumed the features of an autonomous methodology in biomedical ethics. Nonetheless, it has much to contribute in the way of guiding decision-making. It is a peculiar approach, as it does not have an argumentative form. However, in spite of this, it allows one to justify practical judgments. In this paper, I intend to demonstrate the way in which such narrative justification is possible, probing whether there is a specific means of using narrative that does more than merely complement current methodologies. To this end, I focus not on actions but on their subject-actors, first as historical beings and then as dramaturgical characters.

Argumentation, authority, or narrative in biomedical ethics

One might define argumentation as a particular way of using language characterized by the necessity to provide reasons for defending or fighting against a specific claim [1, p. 109]. That claim may be theoretical, but it can also be practical. In order to differentiate between the two types of claims, I refer to the latter type as practical judgment. It is this latter type of judgment that is at issue here. Thus, drawing on the above definition, I begin with the following twin assertions: not every rational practical judgment needs to be argued, and not every argued practical judgment is rational.

The above statement is based on the assumption that it is possible to rationally differentiate between good and evil—an assumption whose justification is beyond the scope of this work. If this assumption is accepted, then the second part of the statement (i.e., that not every argued practical judgment is rational) is easy to understand. It is not difficult to think of situations in which a set of arguments, or (pseudo-)reasons, would be provided to persuade someone of the necessity to perpetrate evil. For example, one might assert that it is necessary to torture a criminal because torture is the most efficient means of procuring a confession. The first part of the above sentence (i.e., that not every practical judgment needs to be argued) is not difficult to capture either, given the observation that, in many contexts, it is licit for certain people to make decisions without having to provide reasons for said decisions. In such cases, the indicated context supplies the justification. For example, although it may be convenient to do so, parents do not always need to provide reasons before asking their children to perform a specific task. Sometimes the reason “because I said so” may be valid. In this kind of situation, one might assert that parental judgment (fair or rational) is justified not by arguments or reasons but by the parent’s position in the parent–child relationship. In this way, the justice of a judgment (its rationality) is one thing, and its justification is another. The latter can be reached through argumentation (providing reasons), or it may derive from the authoritative position of the person making the practical judgment.

When this outline is moved to the field of biomedical ethics, the following options emerge for justifying practical judgment:

  1. a.

    Justification by argumentation. In the field of biomedical ethics, one engages in argumentation when one follows, for instance, the paths outlined by two of the main bioethical methodologies—principlism and casuistry. Many different kinds of reasons can be put forth within the scope of these respective methodologies. With typical reasons, one invokes principles under the former approach, while observing similarities under the latter. However, the rationale and argumentative scheme in both cases are one and the same. One needs to correlate facts and norms if one intends to justify a practical judgment.

  2. b.

    Justification from authority. In light of the above discussion, a practical judgment—assuming that it is rational—may be justified without the need for argumentation when the one taking the relevant position does so from a position of authority. In the field of biomedicine, the model of the parent figure has been extrapolated literally, amounting to what is known as medical paternalism. Paternalism is the practice of deciding on behalf of another for the other’s own sake. It is characterized by the presence of two features in the parental figure: beneficence and legitimate authority [2, p. 63]. Medical paternalism vests doctors with authority over patients. In recognizing that—due to their illness or infirmity and (likely) lack of medical education—patients are not guaranteed to be in a position to make rational medical decisions, paternalism makes such decision-making the responsibility of the physician. It has been a very common practice for physicians to implement little-argued decisions, in the sense that the reasons underlying them are not made explicit (not that these reasons do not exist).

  3. c.

    Justification through narrative. Beyond argumentation and authoritative status, there is a third means of justifying practical judgment—one of particular interest to my project here—namely, recourse to narrative. This justification can be done either by preparing an ad hoc narrative or by consulting a premade narrative. And the narrative can be real or figurative. Justifying practical judgment through narrative is very common in ordinary life, and it also has a place in the clinical setting. This practice is exemplified when someone who intends to justify a practical judgment, rather than arguing, says something along the lines of “I’ll tell you a story,” leaving the listener (or reader) to draw her own conclusions about what must be done after the narrative has culminated. In the field of biomedical ethics, autobiographies by patients who explain their experiences with disease from a first-person perspective have made quite an impact (e.g., [3, 4]). Some authors call this kind of literature “pathography” [5, pp. 323–324], although the role of the narrative is not limited to this specific class of stories.

For narrative to be consequential from the viewpoint of decision-making, it is necessary that stories have some type of practical effectiveness. For this, two things are needed.

On the one hand, it is necessary to arrange the facts in such a way that they speak for themselves (res ipsae loquuntur). In effect, argumentation revolves around a normative element that is already given: the principle in the abstract or the principle applied to a paradigmatic case. But in the narrative approach, typically principles must be abstracted from stories. Therefore, the facts have to be especially eloquent. For example, in the teleplay Wit [6], which assumes the perspective of an English professor who is dying of ovarian cancer, the performance of the protagonist’s medical team is especially significant, bringing any viewer to the conclusion that biomedical research should not be prioritized above the well-being and dignity of the patient.

On the other hand, if a normative conclusion is to be drawn, then it is necessary for the facts to form a coherent textual unit of global meaning, and this cohesion can be achieved only by way of some kind of norm, which may or may not be invoked explicitly. The entire sequence of events carries the mark of this norm. Just as salt, invisibly and ambiently, gives flavor to food after its component parts have been prepared, so too do norms, concurrently and implicitly, accord practical consequences to stories after their constituent facts have been elaborated. In the above example of Wit, if the viewer reaches the conclusion that biomedical research should not come before the well-being and dignity of the patient, then she does so by virtue of the playwright and film scriptwriter’s having preselected and prearranged the facts in light of this principle.

Drawing normative consequences from a text is a circular process, as has already been highlighted in the field of law. As Arthur Kaufmann points out, norms can be applied to cases only when their concordance of meaning is elaborated [7, p. 130]. In other words, the rules of a case are selected and interpreted in light of the narration of its facts, and the narration of its facts is presented and arranged in light of the relevant legal norms—all through the historical subjectivity of the interpreter. In reality, gross facts do not exist, but rather must be constructed in the form of a coherent narrative that can be subsumed under some particular norm. This construction is not made in the abstract, but in view of this norm. In turn, the selection, and interpretation, of the applicable norm depends on the narration that comprises the facts. Perhaps, this mechanism is better characterized not as a circular process but as a spiral movement, since the normative selection and the construction of the facts, far from being invariable, continuously adapt as the interpreter becomes better acquainted with the case. In a legal case, each party constructs the facts in its own way, but the judge’s account has ultimate authority, and the facts that she gathers in her sentence are considered the procedural truth.

In the field of biomedical ethics, there is no version of a story that holds the same authority as the judicial account; thus, the facts contained by a medical narrative must be especially plausible and eloquent for the addressee to accept the principle that gives them meaning.

The narrative approach as a complement to current methodologies: challenges to its methodological autonomy

In view of the previous section, the narrative approach would seem an ideal complement to current methodologies. On the one hand, attention to narrative could enrich these methodologies by expanding their temporal purview to include the moral history of the patient. On the other hand, such methodologies could bolster the narrative approach by endowing it with the bioethical principles needed to accord the story a practical role.

Indeed, Rita Charon considers the narrative approach to contribute greater precision and functional efficiency to existing methods, but without constituting an independent method in its own right. While Charon considers narrative complementary to principlism [8, p. 277], Kathryn Hunter, in turn, configures it as an enrichment of casuistry [9, p. 316]. Moreover, James Childress concludes that medical cases are, in effect, “mini-narratives” [10, p. 255] in a dialectical relationship with principles [10, p. 261]. Commenting on the case of Dax Cowart, he affirms concretely that the dual issues of beneficence and respect for human beings arise in the same capacity at the level of narrative as they do at the level of concrete decision-making [10, p. 263]. Regardless of whether one starts with norms or with narratives, the one will end up referring to the other. In Childress’s view, the two perspectives are both necessary and mutually enriching—with the former oriented toward the general and the latter oriented toward the particular [10, p. 268]. Finally, rounding out this line of thought, Lydia Feito argues that the narrative approach complements the modern model of rationalist, decisionist, and principlist ethics by providing a perspective informed by relationships and contexts, one that minds the particulars of each case and attends to the emotional and affective factors that influence decision-making [11, p. 84].

While all this is true, it remains unclear why the narrative approach must lack the substantive autonomy that would enable it to play a role independent from current methodologies. Affording narrative substantive autonomy does not entail that it be understood as a distinct method. In fact, there is no definitive technique for formulating a story—storytelling is more artistic than it is strictly technical. A story cannot be created linearly by following a sequence of steps, since the final product does not exist a priori. At most, the author of a story deals with a rudimentary scheme or idea, which takes on a definite form as it is deployed throughout the unfolding story.

At its origins, the narrative approach bears a close association with the notion of practical reason. According to David Burrell and Stanley Hauerwas, narrative constitutes, in effect, “the form that does justice to the kind of objectivity proper to practical reason” [12, p. 112]. However, this way of conceptualizing the role of narrative has been relatively unsuccessful. In reality, there are two factors that bear heavily on the narrative approach, and these factors work together to limit its scope as an autonomous source of normativity. The first factor relates to the relative subjectivity of historical narrative—for formal methodological purposes, constructing a historical narrative is much more subjective, given the number of elements to be combined, than narrating the facts of a specific case. The second factor consists in the lack of an authoritative source that would confer special value on one particular account, especially when multiple versions come into conflict.

The combination of subjectivity and lack of authority presents a daunting obstacle for the narrative approach, but, as shown later on, this obstacle is not impossible to overcome. Traditionally, doctors have held authoritative status, such that their reports could be understood as a sort of procedural truth. One might conceive of a doctor’s report as a narrative that is schematically outlined, for instance, in the medical history of a patient. But, as mentioned above, recent decades have seen a strong rise in autonomism within medicine, as spurred by liberal cultural influences. From the assumption that nobody has authority over the patient (save when she or he is disabled), it follows that only the patient may make decisions regarding the patient’s life and health. From a narrative point of view, this implies that the normative consequences that need to be considered are those resulting from the patient’s story. However, this liberal model has been questioned from a postmodern perspective (e.g., [13]). Under the postmodern view, there can be no justification for the existence of privileged narratives.

While in the legal field, power (at least, institutional power) may be something good and necessary, in the field of biomedical ethics, which lacks institutionality, any position of power (in this case, moral power) comes under suspicion from a postmodern perspective. As Howard Brody has written, medical practice is a political act, and, as such, it must be justified or not in its own political terms, not as a result of an alleged natural or divine law [14, p. 22]. In his view, the root of this notion lies in the idea that the world has no objective knowledge, just privileged interpretations. Given this assumption, it does not make sense to elevate the position of doctors based on their purportedly better access to objective reality. The practical effect of Brody’s stance is that whatever trust people may have placed in doctors before is now called into question insofar as any privileged position is suspected of concealing a certain power. Though, from the standpoint of moral objectivity, authority may be a positive value, the postmodern view casts authority as a mere corollary of power, which is a negative value.

With respect to narrative, this postmodern principle applies not only to doctors’ narratives, dispossessing them of their primacy, but also to patients’ narratives, which do not necessarily fare better than doctors’ narratives. Elsewhere, Brody contends that no narrative is privileged or more important than others. There is no reason why the doctor’s perspective on the case should be better than that of the nurse or the patient’s family. However, the patient’s view is not the most important one either. According to Brody, often the best input comes from people who are typically marginalized in the decision-making process. The above-mentioned film Wit offers good evidence of this. Although both the story of the primary doctor and the story of the patient characterize the patient as a person who is absolutely committed to the investigation of her disease, in the light of the facts, it is clear that their stories are no better than that of the nurse, who truly understands the patient’s dramatic situation. In this sense, Brody is right to assert that incorporating others’ points of view both enriches the ethical discussion by embodying new perspectives in the original narrative and helps to democratize decision-making in the scope of healthcare [15, p. 49].

The problem is that democracy is not the same as consensus. Some authors suggest mediation in the sense of transforming “opposing conflict stories into a richer mutual story that legitimizes the perspectives of both parties” [16, p. 504]. However, in order for this richer mutual story to be confected, all parties must be committed to the search for a solution and willing to engage in narrative compromise by sacrificing parts of their own story. Such compromise does not always occur. Moreover, if the postmodern point of view is on the right track and the practice of medicine is indeed an act of power, then each party would naturally be inclined to place itself in the dominant position. The only logic in power is its own increase. Adopting this disposition gives rise not to consensus but to conflict—with the imposition of one’s own narrative seen as the most desirable end—and then, eventually, to violence. The postmodern approach does not explain why peace is better than violence. If violence is eschewed as a means of enforcing practical judgments, one can turn to providing reasons (arguments) or stirring emotions (persuasion). Of course, these categories are not watertight; they can be combined.

The narrative approach lends more weight to persuasive than to argumentative means, and, if posed improperly, narrative is more apt to perpetuate the alleged positions of power to which the postmodern approach is so sensitive. With respect to argumentation, such perpetuation of power would instead involve exploiting eristics and making abusive use of rhetoric [17]. Forgoing the manipulative capacities afforded by these resources makes sense only if there is some kind of ethical imperative that transcends the interests at stake. But if one such imperative on ethical behavior does exist, then it is also possible to assign different degrees of value to the eventually coincident stories. To claim that all stories are of equal worth engenders confusion in the event that the stories at stake show courses of action that are incompatible with one another. This confusion does not arise under the original two models—the first based on the authority of the doctor and the second based on the freedom of the patient. Both are highly executable. The consequences of either the doctor’s story or the patient’s story are applied accordingly. Nonetheless, if no stories are privileged, then one is ostensibly doomed to irresolution.

At this crossroads, there are three possible directions that one may take. As stated above, a story that has normative consequences results from a circular process of interweaving a series of facts with a set of principles (usually implicit) and feeding this assemblage through the subjectivity of an interpreter. Therefore, one has the option to focus on the principles, on the facts, or on the subject-actors. In turn, this third route bifurcates into two paths—the first focusing on the historical nature of the subject-actor who delivers or selects the narration (i.e., the teller) and the second focusing on the moral nature of the subject-actors that take part in the narration (i.e., the characters). In the remainder of this section, I consider the first three roads, reserving the fourth road for the next section.

Option 1: focus on principles

Brody agrees with those who, like Charon, combine the narrative approach with other approaches. In this sense, he believes that it is possible to resort to principles, which must be specified in each case in a coherent way. Starting from the so-called “wide reflective equilibrium” of Rawls—which combines abstract principles of justice, considered judgments on particular cases or issues, and basic theories about human nature—Brody proposes what he calls a “deep reflective equilibrium,” extending the picture to a fourth element, formed through a set of narratives based on personal experience [14, p. 28].

As I have shown elsewhere [18, pp. 66–70], one of the problematic points faced by those who operate with principles consists in the concretion of these principles. Indeed, each principle can be specified in an indefinite number of ways. Likewise, each principle may conflict with other principles in an indefinite number of ways. Those who assume that it is possible to discriminate between different specifications based on consistency with a particular set of principles or values forget that coherence is not an ethical value in and of itself—the doctor in the aforementioned film is consistent in holding research as a value, though it cannot be said that such consistency is good in an ethical sense. Likewise, the correction that entails considering different ethical theories cannot be reached except in the light of one’s own prejudices. So subjectivism is not avoided. In fact, the principlism of Beauchamp and Childress, which assumes wide equilibrium, has been labeled as colonial and North American [19, p. 51].

Option 2: focus on facts

Feito and Tomás Domingo, in Narrative Bioethics, suggest a procedure for overcoming the conflict of interpretations, and this procedure presents two steps [20, pp. 166–167]. First, one needs to determine if the discrepancy is due to different data handling. If this is the case, then it is necessary to provide the parties in conflict with the same information. Second, if the discrepancy persists after one confirms that both parties have the same information, then it becomes an issue of determining the critical point of departure supporting the different interpretations (e.g., different values). This point, they assert, needs to be properly reviewed in order to either reach agreement or achieve compatibility between the differing interpretations. A oft-invoked means of dealing with values is the deliberative method advanced by Diego Gracia [21, pp. 120–150]. When agreement is not possible, according to Feito and Domingo, the deliberative procedure should, at least, enable a deeper grasp of one’s own view and the views of others, contributing to mutual understanding and inviting each party to question its own position. To the authors, narrative plurality is a good thing—hence their defense of a so-called narrative cosmopolitanism [20, p. 164].

However, it might be noted that just as coherence is not a value in itself, so too is plurality not a value in itself—the different points of view that concur in plurality need to have some added value beyond their mere concurrency. At the same time, if conflict between narratives invites one to question one’s own prejudices, then it does so because of some kind of moral objectivity. Without such objectivity, there would be no basis for questioning one’s own prejudices except on the realization that these prejudices are dissimilar from the opinions and prejudices of others—and that itself is not a very sound reason. In contrast, as Hans-Georg Gadamer has written, dialogue is important, but as a means of approaching truth through reciprocal questioning of prejudices [22, p. 556; 23, pp. 257–258].

Option 3: focus on the historical nature of the subject as teller

Rather than focusing on normative elements or facts, one can instead look at one’s very way of looking, as the story’s teller, understanding that this role, as well as the perspective that accompanies it, is ultimately conditioned by the context of telling. As modern philosophic hermeneutics has shown, there is no judgment without prejudice [22, p. 361ff]. This factum has been interpreted from a postmodern point of view to mean that access to the truth is not possible. As David Gibson writes, when this postmodern notion is applied to biomedical ethics, it “invites healthcare practitioners to recognize that the guidelines they work under, the knowledge that guides practice and the protocols they follow have been developed in the light of particular theories, at a particular time in history and within a particular setting” [13, p. 177].

The admission that there is no moral objectivity does not constitute an exit for the problem at hand—namely, how to resolve conflicting narratives. If, in accordance with the postmodern perspective, no interpretations should be privileged, then one should assume, as Brody does, that all interpretations (and stories) have the same value. There are two problems with this approach. First, such an assumption eventuates in perplexity or irresolution. Second, this formulation is radically incapable of explaining why equality is a value per se. Indeed, all three models—that in which the doctor prevails, that in which the patient prevails, and that in which both subjects are on a par—are all equally interpretive.

For this reason, Gadamer steers his theory on the right track when he specifies that understanding is not as much a matter of reliving the psychological process of a text’s author as much as it is a matter of reaching agreement on reality itself. To Gadamer, language is the means by which such agreement is reached, but consensus is assembled upon a foundation of concrete reality [22, p. 462]. Interpretation is certainly subjective, but truth is the condition of possibility for hermeneutics itself.

Nonetheless, the concept of truth is elusive. From a theoretical standpoint, it can be asserted that truth entails a certain correspondence between reason and facts, a correspondence that is never complete. From a practical standpoint, this concept is more difficult to capture and assume. One might think that truth entails a certain correspondence between actions and rules, yet this correspondence has more to do with the concept of correction than it has to do with truth. Regardless, capturing this elusive concept is critical to a proper understanding of what the narrative approach contributes to bioethics. To get at the heart of this question, it is necessary to look at the historical subject to assess not as much its historicity as its morality.

Story beyond history: toward an autonomous conception of the narrative approach

It is paradoxical that in order to find the thread of a particular kind of objectivity, certainly a peculiar kind of objectivity, one must enter into the labyrinth of subjectivity by way of the apparently subjective moral character. History is change and contingency, and subjects are factually immersed in it. Human life might be compared to a river, but such a comparison would be imprecise—if everything were in constant flux, then personality would become disintegrated. On the opposite end, though, comparing human life to a pond would be equally imprecise, since personality formation is historical and continues to play out over time. In the end, human life may be best compared to a pool within a river: the river water, while never ceasing to flow, tends to accumulate in the pool and gain in potential force, just as the human personality, while never ceasing to change, tends to stabilize and gain in deepness, force, and richness (though this is not always the case).

In his Poetics, Aristotle points to six elements of tragedy that are also present in each narrative (Poet. 1450a9–10, in [24, p. 1450]). Here I mention two elements in particular, which complement the ideas expressed above. The first is plot (mythos), or the web of facts without which there would be no tragedy. In the bioethical field, Tod Chambers and Kathryn Montgomery have argued that there is no story without a plot, positing that every narrator arranges the elements of the plot with a particular orientation that conditions the audience’s ethical judgment [25]. No matter how much she tries to maintain objectivity, then, the narrator necessarily engages in “persuading listeners to take a particular position by shaping the telling of the events in a particular way” [25, p. 81]. Thus, in their view, the plot should be seen as a rhetorical construction. However, rhetoric is not incompatible with objectivity. The second element that Aristotle points to is characterization (ethos)—namely, the process guiding the formation of each character. This element correlates with the notion that each person forges a particular personality through history. Here is where I now turn my focus.

For any given text, to characterize characters means to assign them a determined personality. This personality is not assigned by way of description, but rather develops through the role that the character plays. It depends fundamentally on his actions. In turn, the role of the character needs to be coherent. This requirement of coherence is not merely rhetorical, intended to make the character more credible; rather, if the character is more credible, then the requirement is essentially ontological. For a character to be coherent implies that his actions correspond to his personality. Thus, a circular process presents itself. On the one hand, the character’s actions define and shape his personality. On the other hand, the character’s personality determines and governs his actions. This narrative circle cannot be ignored, just as the hermeneutic circle formulated by Gadamer—inspired, in part, by Aristotle [22, p. 396]—cannot be ignored.

Studying character personality can be useful not only from a rhetorical point of view, but also from an ethical point of view. The former point of view is broader, subsuming the latter. In Rhetoric, Aristotle studies personality with a psychological bent, so as to gain a descriptive understanding of human action [26]. Such an approach is especially useful for lawyers, since they must understand all the psychical mechanisms that contribute to actions in order to form competent theories and informed judgments. On Aristotle’s view, personality embodies innate factors (e.g., temperament) as well as acquired factors. Among the second group is one’s moral character—the object of Aristotle’s Nicomachean Ethics [27].

Aristotle recognizes that actions cannot be morally qualified outside of the subject by which they are carried out, just as one cannot say that an arrowshot is dexterous only by virtue of its having hit a target. To Aristotle, a good action is a practically wise action—that is, one resulting from the virtue of phronesis (i.e., practical wisdom). Practical wisdom is not an ideal that can be perceived intuitively a priori; rather, it is a way of being that is embodied in the phronimos, or the practically wise moral expert. For this reason, as Aristotle observes, in order to understand the meaning of practical wisdom, one must attune to the actions of those whom one considers to be practically wise (Nic. Eth. 1140a22–25, in [27, p. 273]).

In this way, practical wisdom is not a value that can be weighed in the abstract; it is a value embodied in actual, tangible, effective, and historical human life—though if not for its highly historical nature, human life ceases to make intrinsic rational sense. Hence the narrative approach is particularly well suited for an ethical perspective. The phronimos is characterized by an exemplary life, and the stories he incarnates are precisely exemplary lives (i.e., examples through which to seek practical wisdom). This reflexive effect reveals the narrative approach’s main contribution to bioethics. The approach harmonizes well with what Ian Kidd calls “exemplarism,” a proposal connecting narrative with the eudaimonic concept of the good life [5, p. 323]. Ultimately, the narrative approach can acquire its own identity if it is conceived not just in descriptive terms, but in terms of representative models of conduct. However, for the approach to be formulated in this way, narrative must be taken as a symbol or allegory for human life, and human life must have some normative sense of its own—namely, in the form of the good life.

The proposal that I have laid out above has nothing to do with creating optimistic or hyper-positive stories in the sense that some authors have criticized (e.g., [28, pp. 53–57]). I am talking not about psychology but about ethics. Neither is my focus here on phenomenology, though this topic has been taken on by Havi Carel [29], who puts forward the narrative approach—quite rightly, in my view—as a tool through which the patient can better understand her illness against the backdrop of her very existence. From this phenomenological angle, disease is seen as an opportunity to reconsider, in a narrative manner, the way in which the patient is in the world. But this point of view is strictly descriptive [29, pp. 100, 110]. The human being is regarded as a possibility, not as a normative behavioral model. For this reason, under Carel’s approach, the contradictions that may arise between narratives expressing different understandings of disease need not be solved [29, p. 110].

While phenomenology sits at a descriptive level distinct from that of ethics, Carel’s writing introduces some points of tangency. For example, in discussing the difficulties that patients encounter when adapting to their ill bodies and to the world around them, Carel explains: “Finding a new way of performing an old task given an altered set of capacities is challenging; successful performance leads to a sense of achievement” [29, p. 106]. It is this dimension of achievement—which phenomenology detects but is limited to pointing at—that an eudaimonic ethic, such as the Aristotelian one, can explain thoroughly. This kind of ethics is proposed not according to a subsumptive norm–facts scheme, in which the only thing that matters is the correction of concrete action, but according to a scheme of means–ends adaptation, the point of which is to equip the subject with the ability to make a right deliberation—one through which reason is capable of reaching, in the midst of contingent circumstances, the good sought by the will.

The key notion that brings together both the deliberative elements and the volitional and affective elements is that of practical wisdom. But practical wisdom is exercised throughout an entire lifetime. The narrative approach has the advantage of compressing its characters’ lives into a story format, highlighting with more or less success some of the features that allow the level of practical wisdom espoused by them to be calibrated. This way, the audience can differentiate between the various characters, deciding whether to be receptive to them or to reject their behavioral patterns. One of the most important prospective applications of the narrative approach is therefore in the ethical training of health professionals. As Feito points out, the narrative approach contributes to the development of an ability to perceive the particular, a sensitivity generated by certain processes of identification through stories offering an education in moral attitudes [11, p. 84]. The film Wit, with its broad range of characters, offers a good example of such moral education in action. Another valuable example attesting to the efficacy of the narrative approach involves stories based on experiences of surrogate pregnancy, in which it is typical to expressly highlight the altruistic character of the pregnant woman [30, p. 10]. However, it is perhaps more interesting to reconstruct the moral character of the stories’ protagonists: the clients. Doing so yields much richer and more complete practical conclusions.

As pointed out above, for the narrative approach to contribute to decision-making, it must have both a guiding nature and a normative nature. With regard to the former, I observe that the narrative approach cannot be based merely in the principles expressed or tacitly embodied, since framing the approach as such would render it no different than principlism or casuistry. With regard to the latter, I show that if no figure has the capacity to formulate authorized stories (like a judge in law), then normativity is put at risk when practically incompatible stories co-occur.

Nevertheless, when the narrative approach is considered with a focus on the moral character, then both problems are overcome. On the one hand, with regard to its guiding nature, the story takes the form of a standard or behavioral pattern. On the other hand, with regard to its normative nature, every conduct model has an ontological root in the phronimos figure, which embodies a real and historical exemplar of the right way toward good. Virtue ethics finds in the narrative approach its most perfect expression. The good life and history are intrinsically interrelated.

Robert Coles recounts the story that a black woman from the Mississippi Delta told about her general practitioner, who gave preferential treatment to white patients (especially wealthy white patients) while being especially dismissive and inconsiderate to black patients. This woman’s speech is highly illustrative of the narrative approach advanced here. Schematically, it contrasts the moral character of the doctor with the ideal type of a wise man, inviting the doctor to look at himself and meditate on whether he is really living his life in the best way that he can [31, p. 444].

Final remarks

It is one thing for a judgment to be fair or just (i.e., rational), and it is another thing for that judgment to be justified. The standard means of justifying practical judgment involves providing a set of reasons in support of said judgment. In some contexts, it may be licit to omit explicit argumentation when the subject that performs the practical judgment has a status of authority. In the biomedical field, this status and its accompanying responsibilities have traditionally fallen on the doctor, but in recent decades this status quo has been critically reassessed and labeled as paternalistic. However, a third means of justifying practical judgment exists, one that shirks both argumentation and traditional power roles—namely, framing justification in a narrative context.

After conducting a comparative analysis between the fields of biomedicine and law, I conclude that in order for a story or narrative to have practical effectiveness with respect to justifying specific practical judgments, it is necessary to frame the facts as a unit of meaning under the banner of some kind of norm, which may be implicit or explicit.

However, this framing does not present a significant point of departure between the narrative approach and current methodologies, such as principlism or casuistry—thus consigning narrative to serve as a methodological complement, aimed at enriching the point of view of the subject-actor performing the practical judgment with a historical perspective. Moreover, the fact that the preparation of a narrative is an artistic rather than strictly technical enterprise confounds the elaboration of an autonomous narrative method of decision-making. However, this complexity does not detract from the value of narrative as a primordial form for expressing practical reason, as understood in the Aristotelian sense.

In the elaboration of a new story, or in the selection of a prefabricated story, there is a great deal of subjectivity. Postmodernists are correct to deny that a story has authority simply by virtue of its coming from a subject who holds a privileged position. However, this postmodern perspective is (a) insufficient: it does not explain why there must not be privileged positions; (b) incongruent: since the logic of power is precisely its own increase, it entails that parties would attempt to superimpose their own stories over the stories of others; and (c) impractical: it results in perplexity when concurrent stories come into conflict with one another on the basis of their practical consequences.

In the myth of the Cretan Minotaur, Theseus is able to locate the exit of the maze using a spool of thread, which he uncoils as he makes his way into the heart of the labyrinth. The exit from the labyrinth of perplexity through which postmodernism leads us is similarly connected to a kind of thread, one formed through the characters within stories—to the extent that such characters in their (real or fictive) historicity are or are not authentic, summary, and specific manifestations of the Aristotelian phronimos. Thus, the narrative approach highlights the normative dimension of human life that can be captured but not explained from a phenomenological point of view. Ultimately, when understood in terms of its dramatic essence, the narrative approach reveals itself to be a highly serious and relevant methodology in biomedical ethics, one that is no less autonomous and no less practicable than principlism or casuistry.