Literature, Literary Studies, and Medical Ethics: The Interdisciplinary Question

Literature has always been an important part ofethical discourse, and the discourse of medicalethics is no exception. Short stories, novels,

poems, plays, autobiographies, and films vividly repre-sent illness, disability, and dying and thus pose manyof the questions addressed by ethics and public policy.In the 1960s and 1970s, for example, plays like PeterNichol’s Joe Egg and Brian Clark’s Whose Life Is It Any-way? portrayed the human predicaments that wereside effects of medicine’s technological marvels, thesame predicaments that occasioned early debate inmedical ethics. A decade later, Larry Kramer’s TheNormal Heart and William Hoffman’s As Is were thefirst to pound home the evils of the social refusal to at-

tend to the growing AIDS epidemic. For more than aquarter century, autobiographies of illness like AudreLorde’s The Cancer Journals, Anatole Broyard’s Intoxi-cated by My Illness, and Reynolds Price’s A Whole NewLife—to say nothing of scores of others by people un-known before their diagnosis—have found a ready au-dience. Physician-authors, like Richard Selzer, JohnStone, Perri Klass, and more recently Sherwin Nu-land, Rafael Campo, and Jerome Groopman have re-vealed the texture of medical practice. Others, likeDonald Hall, Lorrie Moore, and Deborah Hoffmann,have made riveting poems or stories or films about theillness of family members.

Fiction, poetry, drama, and autobiographical essaystake up such problems not because they are central tomedical ethics but because illness, disability, and deathare part of the human condition that imaginativewriting exists to explore. This is not a recent phenom-

36 H A S T I N G S C E N T E R R E P O R T May- June 2001

How do we know what is right, or before that, how do we recognize what is morally salient? Such

matters lie deeper than can be plumbed by traditional philosophical modes of inquiry alone. Careful study of

them requires also the study of literature, with the meticulous appraisal that it encourages of the intricate,

tangled issues involved in apprehending the world, finding our way in it, and representing it to others. In this

way, the study of literature contributes to a richer and more complex perspective on moral problems, and a

more cautious view of the status and breadth of attempts to solve those problems.

LITERATURE, LITERARY STUDIES, AND

MEDICAL ETHICS:The Interdisciplinary Question

b y K A T H R Y N M O N T G O M E R Y

Kathryn Montgomery, “Literature, Literary Studies, and MedicalEthics: The Interdisciplinary Question,” Hastings Center Report 31, no.3 (2001): 36-43.

enon: Philoctetes and King Lear are asrelevant to contemporary moral dis-course as ER. But these days, withmany human ills caught in the pro-longed embrace of what LewisThomas in Lives of a Cell called “half-way technology,” medicine has be-come central to the way we thinkabout the question of meaning in ourlives. Much of contemporary litera-ture concerns not just illness but itsmedical treatment, the moral choicesthat treatment engages, and the fail-ures of human compassion that toofrequently accompanyour trust in technolo-gized care.

Literature’s contri-bution to discourseabout ethical valuesand behavior, neverthe-less, can be easily over-looked. Plays andpoems and fictionmake no explicit argu-ment; stories alwaysseem just to be there.Irony, revelation, andmeaning itself dependon what the audiencealready knows aboutthe character of humanbeings, the acts they are likely tocommit, and the justifications theyoffer for them, and much of thisknowledge has been absorbed in turnfrom stories. But we do not ordinari-ly reflect on this: stories are simplyour element. We forget that once wewere children hungry to hear storiesthat would make sense of the world.We ignore the awkward fact thatmoral lessons are often conveyed ingossip, neighborhood rumors, andtales of office politics. We take forgranted the movies and televisionshows and fiction that enable us tolook into the abyss—or soothe uspast the temptation to peer in.

The power of literature and of pa-tients’ stories has been equally over-looked in medical ethics. This essayexamines the interplay among litera-ture, medicine, literary theory, andmedical ethics; it argues for the im-portance of the kind of moral knowl-

edge that literature offers and con-cludes with an account of the narra-tological critique of medical ethicsand the prospects for dialogue be-tween literature and moral philoso-phy.

An Ethics of Reading

Almost from the beginning ofmedical ethics, literary texts have

served as powerful and effective ex-emplars of its pressing dilemmas.Early ethics teachers in medical

schools, mainlyphysicians and re-ligious studiesscholars, lookedfor realistic fictionthat would illus-trate the questionsthat then charac-terized medicalethics:1 Should thedying be told thetruth? Does mor-tal danger overridea patient’s refusalof treatment?Who in a crazyworld is insane?The texts they as-

signed have since become canonical:Leo Tolstoy’s The Death of Ivan Ilych,William Carlos Williams’s “The Useof Force,” Anton Chekhov’s WardNo. 6.

But literature offers far more thanillustrations of dilemmas. Its real con-tribution to ethics occurs farther up-stream in the very process of the read-er’s reading or the theatergoer’s view-ing. A poem or novel or play is notsimply an illustration but is moraldiscourse itself. This view dates fromHorace’s first-century description inthe Ars Poetica of literature’s two-foldpurpose—to teach and to delight—and it has been given new life and re-spectability recently by philoso-phers—even as literary scholars werestymied by the New Criticism andthe continental formalisms that heldaudience and author to be irrelevantto the text. Stanley Cavell has usedcomplex readings of literary works to

address issues of morality and publicpolicy since the Vietnam War. In TheSovereignty of Good Iris Murdoch,novelist as well as philosopher, arguedthat literature is fundamental to theeducation of moral perception.Bernard Williams in Moral Luckpoints out that literature is essentialto ethics because it supplies themeaning that universalizing ethicalsystems necessarily omit.

Such arguments go beyond view-ing literature as a source of data aboutthe human condition, merely a morevivid form of sociology. First theyposit that as human beings we under-stand our lives narratively, and thenthey locate our acquisition of moralknowledge in the act of reading orhearing those narratives. This posi-tion in no way denies that human be-ings abstract from experience, formu-late rules, and perceive new situationsin light of these abstract categories,but neither does it relegate narrativeknowledge to second place. Each is apart of human knowing. Studies incognitive psychology and artificial in-telligence support this view. JeromeBruner, following William James, dis-tinguishes narrative knowledge fromlogico-deductive knowledge, andfinds in it the motive for our earliestlanguage acquisition.2 Roger Schankmodels human learning with ma-chines using narrative scripts, the“pattern recognition” familiar tophysicians.3 Studies by Martha Nuss-baum and Wayne C. Booth have es-tablished literature as the site ofmoral argument and (even more im-portant) moral development. In TheFragility of Goodness, Nussbaum ar-gues that fourth-century Atheniansunderstood the moral life to be morethan isolated dilemmatic choices.Greek tragedy, she believes, is an es-sential part of the philosophical ex-amination of the role of chance in themoral life and a necessary comple-ment to the Socratic dialogues. Herargument is extended in Love’s Knowl-edge, a study of the novels of HenryJames, where she maintains thatmoral knowledge, including its essen-tial emotional components, is best

H A S T I N G S C E N T E R R E P O R T 37May- June 2001

We do not

ordinarily reflect

on this:

stories are

simply our

element.

image not licencedfor online use

represented in fiction.4 In The Com-pany We Keep, Booth examines themoral subtleties at work in the inter-pretive act of reading and argues thatmoral development and characterformation (for ill as well as good) arean unavoidable aspect of reading nov-els. Prompted by a young colleague’sdoubts about teaching Huck Finnto college freshmen,Booth explores how it isthat novel-reading de-velops the skills ofmoral discernment andethical judgment, andfor reasons far morecomplex than the usualones reaches the conclu-sion that his colleague’sintuition was wellfounded.5

These assertionsabout narrative knowl-edge apply with partic-ular force to medicalethics, which as a fieldhas stressed moral de-velopment and the de-velopment of ethicalskills even as it focusedon the examination ofparticular moral dilemmas. RitaCharon has argued that narrativecompetence, a skill essential forsound judgment about medical-ethi-cal problems, is cultivated by readingand interpretation.6 In the Nico-machean Ethics Aristotle observes thatthe virtue of phronesis is not normallya characteristic of the young, but nar-rative ethicists maintain that a stockof narrative and the skill their inter-pretation engenders goes far to sup-ply the deficit. This view sheds lighton the value of case-based reasoningin medical ethics as well as in clinicalmedicine generally, and it points to aneed for a more reflexive awareness ofmoral and epistemological method inboth the clinical and the ethical as-pects of medical practice. Above all, itsuggests the need for a dialogue be-tween literature and philosophy, evenfor a genuine interdisciplinarity be-tween the two.

Can We Talk?

Interdisciplinary dialogue mightbegin with a recognition that ques-

tions about the relative influence ofphilosophy and literary studies inmedical ethics are misplaced. Sincethe early 1970s, when medical ethicsgot its start, the humanities as a

whole have takenon a broader, lessformalist, moreinterdisciplinaryorientation. Gen-res have blurred7

and with themd i s c i p l i n a r yboundaries. Phys-ical science nolonger suppliesthe measure oftruth in the hu-manities or thevalues-orientedsocial sciences,and modes of rep-resentation inevery field havebecome the ob-jects of inquiry. Insuch an intellec-

tual climate, any claim to dominance,especially philosophy’s claim to be thediscipline of ultimate resort or evento supply the essential language formoral discussion,8 is not simply arro-gant but itself open to intellectualscrutiny.

Questions of disciplinary domi-nance in the medical humanities aremisplaced for a more practical reason:medicine itself has been an over-whelming extra-disciplinary influ-ence on both literary scholars andphilosophers interested in medicine.In a postmodern era, medicine re-mains a quintessentially modernistactivity. Whether in the laboratory orthe clinic, physicians and those whowork with them are flat-footed posi-tivists. Theirs is a pragmatic stance,rather like our stubborn adherence tothe conceit (no matter how well weunderstand Copernican cosmology)that the sun rises and sets. Emphasiz-ing practice over theory, medicine

militates against deconstructionismin any but the weakest sense: diseasesmay be socially constructed in thatdifferent cultures or different sensibil-ities will recognize, describe, and evenexperience them differently. But inmedicine the reality of disease is notin doubt—nor is that of the body,however socially prescribed our per-ception and experience of embodi-ment. Bodies may be understood cul-turally and historically, but for medi-cine they are palpably real. Diseasesare things, and they are fought. Pain,although it cannot be objectivelymeasured, nevertheless is reified byboth those who experience it andthose who have a duty to relieve it.This view of the world, especially inthe United States,9 encourages themedical humanities to focus on clini-cal education and practice. It hasweaned both philosophers and liter-ary scholars from the theoretical pre-occupations of their mainstream dis-ciplines and insulated us all from latetwentieth-century ideas.

The effects of this medical posi-tivism have been different in the twofields, especially in the relation ofeach to its discipline of origin. Mostphilosophers in medical ethics havebeen allied with Anglo-American an-alytic philosophy and dismissive ofdevelopments in continental philoso-phy. Allusion to the later Wittgen-stein is as wild as they get. By con-trast, the field of literature and medi-cine, isolated at first from English de-partments and from continental phi-losophy’s influence on literary theory,now has a reputation in mainstreamliterary studies as faintly trendy, apromising area for cultural studies. Itsscholars are, nevertheless, not decon-structionists, nor have they ever been.In this they more closely resemblecolleagues in medical ethics thanthose in literature departments, andliterature and medicine has been farless innovative than what might beregarded as its close cousin, literatureand science.

The pragmatic force of medicineon philosophy and literature has af-fected the focus of the medical hu-


Questions of

subjectivity and

the ethics of

representation

have been

almost entirely

neglected in

medical ethics.


manities disciplines differently aswell. Demands for answers in the realworld of clinical problems and publicpolicy—like the effect of similar de-mands on physicians in the care ofpatients—have kept most philoso-phers in medical ethics focused ontopical questions. The commodifica-tion of health care and the undimin-ished acceleration of medical technol-ogy—the human genome project,transgenic xenotransplantation,cloning—have meant that mostphilosophers in medicine, thoughmoderately radical when they departfrom mainstream philosophy to takeup real-world questions, still hold asessential and unquestioned the ana-lytic tools they learned as graduatestudents. Scholars in literature andmedicine, by contrast, have used theluxury of their perceived irrelevanceto hot ethical topics to explore theideas of the late-twentieth century.The tasks assigned to philosophers inmedical ethics thus have limited theiropenness to interdisciplinarity and tointeresting ethical issues raised by lit-erature and literary studies.

Literary Theory and theCritique of Medical Ethics

Chief among the issues raised byliterary studies has been the

value of narrative rationality in un-certain endeavors like moral know-ing. Although, as Mark Kuczewskihas argued, there is at least a de factoconsensus among philosophers aboutnarrative in medical ethics,10 the liter-ary-theoretical perspective on the sta-tus of knowledge in medical ethics isnot yet well understood. Such episte-mological questions are the persistentconcern of literary studies. Indeed,because good readings were suppliedby teachers from other disciplineswell before literary scholars were onthe scene, its critique of medicalethics may ultimately be the mostimportant contribution of literarystudies to medical ethics.

At first this critique was implicit:literature addresses ethical problems,but differently. It provides a context

for moral dilemmas, complicates de-bate about the variable force of med-ical-ethical principles, and broadensthe scope of public policy questions.This richer perspective is the all butinevitable consequence of reading lit-erature and not of any particular liter-ary theory. Texts concerned with ill-ness and doctoring compel discussionof the nature of medicine, the charac-ter of the physician, the definition ofdisease, and the existence and expla-nation of evil in the world. AntonChekhov’s Ward No. 6 is not onlyabout the slippery definition of sanityand the proper treatment of the in-sane; it also asks its readers whether itis better to accept the world stoicallyas it is or to venture small and almostcertainly futile acts in the face of in-difference and neglect. Likewise,William Carlos Williams’s “The Useof Force,” which illustrates the con-flict of ends and means created by asick and uncooperative child, is also apersonal ethics morbidity-and-mor-tality conference. The physician-nar-rator’s account of the event raisesquestions about the selfhood of aphysician, the place of anger and con-fession in a service profession, andthe buried sexuality of the patient-physician encounter.

In the 1990s the critique of med-ical ethics became more overt,spreading through the medical hu-manities. As commonly practiced,medical ethics was described as nar-row and deductivist: not just blood-less and hyperrational in tone butmistaken about the power and au-thenticity of its objective stance. NowI’m as big a fan of objectivity as thenext American. I want referees withclear sight, judges who attend to thelaw and shun bribes of even the sub-tlest kind. But where is objectivity tobe found? Where grounded? A jokeabout major-league umpires illus-trates the difficulty. Three of base-ball’s finest are sitting in a bar. Thefirst says proudly, “I calls em like Isees em.” The second, surer of him-self, takes a swig of his beer and says,“I calls em like they is.” The third sets

down his glass and says slowly, “Theyain’t nothin’ till I calls em.”

A recognition of inescapable sub-jectivity in human knowing is notrelativism: an umpire doesn’t call emarbitrarily or in a vacuum. The gamehas rules; two other umpires are onthe field; players and managers arequick to protest bad calls—to saynothing of the fans. The game isbroadcast on radio and television,and pitches and calls are commentedupon; instant replay provides retro-spection from several camera angles;tomorrow’s papers will carry an ac-count of the game. Beyond the mo-ment, there is a guild of umpires; thegame has a history; there is a historyof just such calls; this umpire has hisown record.

These are the core issues withwhich literary studies grapples: prob-lems of representation, their implica-tions for the status of knowledge, theassertion of truth or knowability, andthe contribution of the knower (herexperience, her psychology, her cul-ture) to the known. These are philo-sophical questions too, but in the sec-ond half of the twentieth centurythey did not much interest philoso-phers drawn to medical ethics. Dur-ing that time, historians, anthropolo-gists, even economists and psycholo-gists struggled with the grounds andreliability of their knowledge. Relin-quishing their claims to be sciences(or at least proto-sciences) with vary-ing degrees of regret and relief, thosedisciplines worked out satisfactorysolutions to the perceived threat ofrelativism. But questions of subjectiv-ity and the ethics of representationhave been almost entirely neglectedin medical ethics. In this it resemblesmedicine—but without medicine’smodernist, practical excuse.

The most direct challenge to med-ical ethics has come from narratologyand the rhetorical study of ethics caseconstruction. In 1994, Tod Cham-bers published the first of a series ofpapers that applied the concepts ofliterary theory to the central narrativegenre of medical ethics, the case.Heretofore, medical ethicists (and lit-


erary scholars too) tended to regardthe ethics case as a little laboratory, athink-problem in which a difficulty isanalyzed so as to determine its solu-tion. But every case, Chamberspointed out, occludes details that areas significant as those it highlights.The case is presented from a narrativestance in a distinctive voice, and thenarrator, direct or implied, inevitablymakes assumptions about the worldand the narratability of events. “Toignore the narrative characteristicsthat the medical ethics case shareswith fiction,” wrote Chambers, “is toconfuse representation with the thingit represents—to mistake the storyfor the reality—and thus to miss thetheory in the case.”11 There is nopure, objective presentation of a case,and, although there may be a culturalor national or professional consensuson the values engaged by a case andprinciples that apply to it, consensusnever forecloses further examination,reinterpretation, and retelling. Themedical ethicist’s case, far from beinga piece of reality isolated for the test-ing of assumptions and hypotheses,has been constructed from the verymaterials it purports to test.

Philosophers who mistake this cri-tique of the medical ethics case as acriticism of themselves fail to graspthe point. Subjectivity is the in-escapable condition of human know-ing; all our science and much of ourintellectual life, including philosophy,attempts to correct for it. They ask,What do you recommend? How canwe fix it? Chambers commends a nar-ratological competence for medicalethicists that resembles the narrativecompetence Charon advises forphysicians and ethicists.12 They as au-thors (and we as readers) need to beaware of the rhetorical “constructed-ness” of the case that is among theirbest tools. Such awareness is little dif-ferent from the reflexivity required ofhistorians, and indeed of any intelli-gent reader of history. Medical ethi-cists might with profit follow the leadof historiographers—and more re-cently casuists13—to ask why theirfield needs narrative in its search for

truth, what part case narrative playsin relation to its other tools of inquiryand explanation, and how it is relatedto the principles of medical ethicsand other forms of moral knowledge.

The genuine problem for bothmedical ethics and literature, indeedfor intellectual life as a whole, is howto give proper weight to subjectivity.Hilde Lindemann Nelson has askedthe important questions in her intro-duction to Stories and Their Limits:How can an ethicist honor the per-sonal without being arbitrary? If theparticulars are important, what aboutthe general?14 Or, as John Arras putsit, near the conclusion of “Nice Story,But So What? Narrative and Justifica-tion in Ethics”: “We all need to thinkmuch harder about how to acknowl-edge our individuality and situated-ness without abandoning the possi-bility of social criticism.”15 These be-come vital questions in clinical medi-cine, where a cardinal virtue is theequal treatment of all comers. Notthat this virtue is always exercised: in-jured villains might sometimes waitwhile their victims are treated in thenext emergency room cubicle. But socentral is the profession’s nonjudg-mental openness that hospitals andthird-party payers have learned toerect barriers to the examinationrooms. Once inside, a person be-comes a patient, and the physician’sbest efforts are called forth. And therelation of the individual to the gen-eral is troublesome beyond the ques-tion of access to care: Can an em-pathic practice be unbiased? Can de-cisions be made case by case withoutultimate unfairness to some group ofpatients? Such situational, interpre-tive questions have a parallel in clini-cal diagnosis. Forty-year-old women,for example, very seldom have heartdisease, but this particular forty-year-old woman is complaining of crush-ing chest pain. Does the particulartrump the general? Because medicineis a practice and not, like medicalethics, primarily a discourse, it en-courages slippage between rules andactions. In medicine as elsewhere, therule about rules is nonarbitrariness,

but the act may fudge the rule if a sit-uation warrants and circumstancesallow.

Surely for medical ethics, too, thebest solution will be a reciprocal en-gagement of both particulars and thegeneral, both the concrete details andthe abstractions. Whether it is calleda hermeneutic circle or the achieve-ment of a Rawlsian reflective equilib-rium, the point is both—and not ei-ther-or. This is Trisha Greenhalgh’ssolution to the comparable problemin clinical reasoning in her BritishMedical Journal essay, “NarrativeBased Medicine in an Evidence BasedWorld,”16 and it marks the practicalrationality that is central to clinicalmedicine and to ethical decisionmak-ing. The parallel is neither accidentalnor the consequence of Aristotle’scomparison of the two endeavors: infact, medicine properly practiced isethics enacted. Analysis is neededwhen problems arise. But narrativeand interpretive skills are essential torecognize problems, to understandthem so as to attempt a solution, andto know whether a solution has beenreached. One cannot do this as anoutsider to the culture—not becausecultures have different principles(though they often do) but becausethe meaning of the principles is de-termined in the cultural world wherepatients (and physicians and ethicists)live.

Literature and Medical Ethics

Literature and literary studies arenot a panacea for the narrowness

of medical ethics. They bear withthem various weaknesses of theirown. The first is that they do notspeak the language of philosophy ormarshal arguments in the same way.Sometimes they seem not to argue atall. Literature and literary studies aremessy, complexified unto contrari-ness. Their texts, whether in print orelsewhere, seem interminably inter-pretable, and this instability can un-dermine rule-based answers and theirjustification. Worse, the recent inter-est in narrative in the medical hu-


manities seems to encourage a senti-mental, almost pious attitude towardpatients and the patient’s story, an at-titude that short-circuits critical at-tention to the need for diagnosis (andmoral judgment) and even good nar-rative practice itself. On the whole,literature seems a suspect means ofintroducing emotion and subjectivityinto rational discourse.

Guilty as charged. But of course Isee most of these flaws as strengths.They are not a re-placement for philoso-phy as practiced inmedical ethics but itsnecessary comple-ment. For philosophyin medical ethics alsohas its weaknesses,ones well matched tothe strengths of litera-ture. These weakness-es include a reluctanceto see knowledge asinevitably situated andcontextual, a rush tojudgment on ques-tions of policy andpractice that neglectsthe opportunity to ed-ucate participants, anoccasional neglect ofthe relation of its the-ory to practice, and awidely held assump-tion that emotion isirrational. All stemfrom the too frequentprivileging of logico-mathematical rationality, a move thatrenders the use of narrative and nar-rative rationality in ethics officiallyinvisible. The result is the failure ofan intellectual (and too often a prac-tical) interdisciplinarity. These areweaknesses for which, in a genuinedialogue, literature and literary theo-ry offer some complementarystrengths.

First, literary studies is already in-terdisciplinary, almost promiscuouslyso. So too is medical ethics, but asCarl Elliott points out, practitionersignore its complexity,17 while literarystudies revels in it. No text interprets

itself, and every commentary on atext becomes available for interpreta-tion in its turn. Therefore (like thatother interpretive enterprise, the law)literary studies draws on history, phi-losophy, economics, psychology, soci-ology, anthropology, religious stud-ies—whatever comes to hand. In thecase of narrative, literary studies sim-ply borrows back what was earlierlent.

Second, knowledge in literature isrichly detailed,contextual, in-escapably situat-ed. Stories andpoems anddrama arecrammed withinformation—the color of thewallpaper!—thatwe may not thinkwe need. Mereatmosphere! But,as with the um-pire’s call, contex-tual detail guidesour interpreta-tion. The parents’shy passivity inWilliam CarlosWilliams’s storyoffers a shred ofjustification forthe narrator’s useof force; wouldhe have acted inthe same waywith another

family? These days it is fairly well ac-cepted that literature offers richer ac-counts of moral knowledge than arecustomarily found in sociology ormedical ethics cases, but the corollaryis less well understood. The moralknowledge provided by literature isnever simple, always particular, andinevitably situated in time and placeand by the rhetoric of narration. Notext lacks the subtly graded frames ofauthor, implied author, narrator, andreader and implied reader (just togive the simplest version of this Chi-nese box), and even when such sub-tleties are unfamiliar to the reader,

they work to convey the central prob-lems of knowing outside the physicalsciences: Who is telling us? How doesshe know? How is her perspectivecoloring her representation? Thepractical understanding of ethicalquestions from the point of view ofliterary studies is thus a matter of in-terpreting the accounts of the partici-pants and working out with them thebest possible next chapter. Principlesare guidelines or, better, as JohnDewey described them, hypothesesto be tried in (and by) these circum-stances.18 Other ethical approachescondemn the hit-and-run provisionof an answer without discussion withthe patient, the family, and the peo-ple who have taken care of the pa-tient, but it is literally inconceivablein narrative ethics. Ethics consulta-tion in hospitals, on this view, be-comes education. Although such anapproach may sometimes facilitateconclusions, it avoids dispensing ad-vice or rendering judgments in favorof working out clarifying narratives.

Third, literature limits abstrac-tion, generalization. Universalizabili-ty is the hallmark of a just decision,but as Herman Melville’s Billy Buddpersuades us, conclusions reachedthrough narrative are not always uni-versalizable. Rich detail and the in-escapable situatedness of all narrativemake it difficult to determine rele-vant circumstances. Like the legalprocess and casuistry generally,Melville’s novel keeps the conversa-tion open—not only about the deathpenalty but about the grounds onwhich decisions are made and theproblem of universalizability itself.

Fourth, as an aspect of this open-ness, literature always raises questionsabout the uses to which it is put, andthus literary studies offers an exampleof reflexive inquiry. Shall we teachTolstoy’s Death of Ivan Ilych as an un-alloyed presentation of how not todie? An illustration of ElisabethKubler-Ross’s five stages of dying? Anargument for truth-telling in medi-cine? A Christian tract on salvation?A demonstration of the author’smisogyny? Reading, which models


The moral

knowledge

provided by

literature is never

simple, always

particular, and

inevitably

situated in time

and place and by

the rhetoric of

narration.


the practice of interpretation, is sub-ject to theoretical scrutiny; and liter-ary theory, because it is (as CliffordGeertz might characterize it) “experi-ence near,”19 is subjected to the test ofpractice. Values may authorize thereinterpretation of a text; equally like-ly, a rereading—like a rewriting ofhistory—may call into question or ig-nore the very conclusions or valuesthat had seemed so obvious before. Acomparable attention in medicalethics to assumptions about knowl-edge and representation might be in-terestingly productive.

Fifth, literature offers its readersthe experience of a broader conceptof rationality, an alternative to themonocular focus on logico-deductiverationality prized in science, analyticphilosophy, and, too often, medicalethics. We have just begun to under-stand narrative as an alternative ratio-nality: much work remains to bedone particularly in the ethnographyof medicine, in philosophy, and, es-pecially, in neurobiology. But it is cer-tain that the account of rationalityderived from the analytic traditionnow current in medical ethics is oftentoo narrow for the unruly particulari-ties engaged by medical practice. Notthat ethicists do not use narrative:they do so frequently and effectively.But they do not acknowledge it; inspite of Tom Beauchamp and JamesChildress’s abjuration in the fourthedition of The Principles of Bioethics,deductivism remains the “gold stan-dard” of ethical rationality. Physiciansamong others find this odd. They fre-quently have the experience of, forexample, accepting a well arguedpiece on the moral equivalence ofwithholding and withdrawing treat-ment as entirely convincing, butfinding it all but useless in their prac-tice.

Sixth, literature authorizes the ra-tionality of emotion. Its representa-tion of emotion renders that suspectphenomenon available for observa-tion and analysis, and depicts it as apart of moral reasoning. SidneyCallahan long ago argued for theplace of emotion in ethical reason-

ing;20 and Martha Nussbaum ob-serves, “cognitive activity . . . central-ly involves emotional response. Wediscover what we think . . . partly bynoticing how we feel.”21 More recent-ly, Julia Connelly has described theuse of poetry to extend this attentionto the clinical encounter.22 Certainly,literature represents both patient andphysician as full human beings andallows us to imagine what it is likeboth to face death and to break thenews to a dead patient’s family. But,as David Morris and Arthur Frankhave suggested, both literature andmedicine and medical ethics mightprofit from a serious rational consid-eration of the role of emotion and ex-perience in moral knowing and ethi-cal decisionmaking.23

The Prospects forInterdisciplinarity

Adialogue between philosophyand literary studies would have

its benefits. It could produce an alter-native to the misplaced scientism ofprinciplism and recognize medicalethics as (what it must be) a multidis-ciplinary discourse about the care ofthe ill. Nothing is wrong, of course,with a good answer to a problem.Consensus is often reached on anissue in medical ethics, and in thatsense progress is made. But contraryto the view of some medical ethicists,most issues are far from settled, andsuch settlements as have been reachedare open to review and revision. Theongoing discussion of the fine pointsof informed consent or the distinc-tion between withdrawing and with-holding treatment should be a signthat such issues are situational. Everymoral problem has a history and animmediate social context that in-cludes much about the agents that wecannot know.24 In such circum-stances, principles are most usefullyregarded as hypotheses. Like diag-noses, they must be demonstratedanew each time—or at least survivethe skepticism of those investigatingthe matter. This practice, akin toDewey’s pragmatic fallibilism, blurs

the distinction between ethics as edu-cation and ethics as practice. The de-bates over ethics consultation—whois qualified and how, and how tomeasure a consultation’s success orfailure—would disappear as consulta-tive conclusions written in the chartbecame less important than the ethi-cal discussion that preceded them.The field would be genuinely open togood practitioners who, almost nec-essarily, would also be good teachers.

Medical ethics is (or ought to be)an ongoing, dialogic, socially and his-torically conditioned discourse aboutpractical decisions in our society. Ide-ally conducted, it is an inclusive,multivocal enterprise open to allcomers and to all languages of argu-ment and description. As public edu-cation and even mail delivery arehanded over by the rich or well fund-ed to private suppliers, medical care(despite horrid inequities) may beone of our most nearly democraticinstitutions. Discussion of decisionsin the medical arena may be the bestchance of sustaining a society-wideconversation about issues that matter.We close off medical ethics fromknowledge gained at the movies orfrom poems like Rafael Campo’s“Ten Patients and Another” at ourperil.

How human beings know what isright and, before that, how we recog-nize morally problematic events andsituations are matters that lie deeperthan their logical representation. Al-though logico-deductive reasoning iscomfortingly systematic and un-doubtedly useful in dealing withmoral quandaries, the recognitionand understanding of those quan-daries, like our knowledge of cultureand its values generally, are part of amore discursive, practical, and narra-tive rationality. A good physician, likeother reliable moral agents, graspsnot just the solution to an ethicaldilemma but the action appropriateto morally significant situations. Thislarger, contextual moral interest, sointegral to the practice of medicine,can be split off from medical ethics.Some might argue that this split has



so often occurred (or been called for) inrecent years that it is an implicit goal ofbioethics. But such a split ultimatelywould divide medical ethics from medi-cine as a moral practice and deprive it ofthe insights of literary theory that are itsmost interesting and powerful critique.Literature then would be (as philoso-phers continue to conceive of it) the un-theorized handmaiden of medicalethics: merely good illustrations ofmoral dilemmas that interrupt profes-sional life rather than, as it truly is, thesource and method of moral knowledgein our culture.

References

1. See, for example, the first volume of Lit-erature and Medicine (1981).

2. J. Bruner, Actual Minds, Possible Worlds(Harvard University Press, 1986); see especial-ly chapter 2, “Two Modes of Thought,” pp.11-43.

3. R.C. Schank, Tell Me a Story: A New Lookat Real and Artificial Memory (New York:Scribners, 1990). See also R.C. Schank andR.P. Abelson, Scripts, Plans, Goals and Under-standing: An Inquiry into Human Knowledge(Hillsdale, N.J.: Erlbaum, 1981).

4. M.C. Nussbaum, The Fragility of Good-ness: Luck and Ethics in Greek Tragedy and Phi-losophy (Cambridge: Cambridge UniversityPress, 1986). Her study of the moral themes inthe fiction of Henry James amplifies the argu-ment that literature is essential to addressingquestions of the moral life: Love’s Knowledge:Essays on Philosophy and Literature (New York:Oxford University Press, 1990).

5. W.C. Booth, The Company We Keep: AnEthics of Fiction (Berkeley: University of Cali-fornia, 1988).

6. R.Charon, “Narrative Contributions toMedical Ethics: Recognition, Formulation, In-terpretation, and Validation in the Practice ofthe Ethicist,” in A Matter of Principles? Fermentin US Bioethics, ed. E.R. DuBose, R. Hamel,L.J. O’Connell (Valley Forge, Penn.: TrinityPress International, 1994), pp. 260-83.

7. C. Geertz, “Blurred Genres: The Refigu-ration of Social Thought,” in Local Knowledge:Further Essays in Interpretive Anthropology(New York: Basic Books, 1983), pp. 19-35.

8. K.D. Clouser makes this argument in“Literature and Medical Ethics,” Journal ofMedicine and Philosophy 21, no. 3 (1996):323-24.

9. Medical ethics in Europe is more open toother philosophical approaches and almost in-evitably more aware of national variation indisease labels and therapy; see H. ten Have,“Principlism: A Western European Appraisal,”in A Matter of Principles? Ferment in USBioethics, ed. E.R. DuBose, R. Hamel, L.J.O’Connell, pp. 101-20.

10. M. Kuczewski , “Bioethics’ Consensuson Method: Who Could Ask for AnythingMore?” in Stories and Their Limits: NarrativeApproaches to Bioethics, ed. H.L. Nelson (NewYork: Routledge, 1997), pp. 134-49. The con-sensus is seldom acknowledged. Like prose,that wonderful thing Moliere’s Bourgeois Gen-tilhomme discovers he has been speaking allalong, narrative in ethics has been invisible,“natural,” and till recently unanalyzed.

11. T. Chambers, “From the Ethicist’s Pointof View: The Literary Nature of Ethical In-quiry,” Hastings Center Report 26 (1996): 25-32; see also “The Bioethicist as Author: TheMedical Ethics Case as Rhetorical Device,”Literature and Medicine 13 (1994): 60-78, andThe Fiction of Bioethics (New York: Routledge,1999).

12. R. Charon, “Narrative Contributions,”pp. 275-76, and T. Chambers, “What to Ex-pect from an Ethics Case (and What It Expectsfrom You),” both in Stories and Their Limits,ed. Nelson, pp. 171-84.

13. See J.D. Arras, “Principles and Particu-larities: The Roles of Cases in Bioethics,” Indi-ana Law Journal 69 (1994), 983-1014.Howard Brody has addressed these questionsfor “ethical medicine”; see The Healer’s Power(New Haven: Yale, 1992).

14. H.L. Nelson, “Introduction: How toDo Things with Stories,” in Stories and TheirLimits, ed. Nelson, pp. vii-xx.

15. J. Arras, “Nice Story, But So What?Narrative and Justification in Ethics,” in Storiesand Their Limits, ed. Nelson, p. 84.

16. T. Greenhalgh, “Narrative Based Medi-cine in an Evidence Based World,” in Narra-tive Based Medicine: Dialogue and Discourse inClinical Practice, ed. T. Greenhalgh and B.Hurwitz (London: BMJ Books, 1999), pp.247-65.

17. C. Elliott, “Where Ethics Comes Fromand What to Do About It,” Hastings CenterReport 22, no. 4, (1992): 28-35; a later versionappears as chapter 8, “A General Antitheory ofBioethics,” in A Philosophical Disease: Bioethics,Culture and Identity (New York: Routledge,1999), pp. 141-64.

18. J. Dewey, “The Nature of Principles,”Human Nature and Conduct [1922] in TheMiddle Works, 1899-1924, vol. 14 (Carbon-dale: Southern Illinois Press, 1988), pp. 164-70.

19. C. Geertz, Local Knowledge: Further Es-says in Interpretative Anthropology cite (NewYork: Basic Books, 1983), pp.56-58. He bor-rows the terms from Heinz Kohut.

20. S. Callahan, “The Role of Emotion inEthical Decisionmaking,” Hastings Center Re-port 18, no. 3 (1988): 9-14.

21. See ref. 4., Nussbaum, The Fragility ofGoodness, pp. 15-16.

22. J. Connelly, “Being in the Present Mo-ment: Developing the Capacity for Mindful-ness in Medicine,” Academic Medicine 74(1999): 420-24.

23. D.B. Morris, Illness and Meaning in thePostmodern Age (Berkeley: University of Cali-fornia, 1998); A.W. Frank, The Wounded Sto-ryteller (Chicago: University of Chicago Press,1995).

24. See T. Chambers, “Voices”; S. Miles,“Ms. Lubell’s Complaint”; and K. Mont-gomery Hunter, “The Whole Story,” SecondOpinion 19, no. 2 (1993): 81-103.

Documents

Literature, Literary Studies, and Medical Ethics: The Interdisciplinary Question