Annals of Long Term Care

Introduction

Narrative ethics provides a framework for ethical decision making. This framework informs healthcare practitioners that to make an ethical decision regarding the life and well-being of an individual, one must view that individual’s stories, history, and character as a key component of the decision-making process. It should complement and enhance the usual approach to ethical decision making, which is often based on the foundational principles of autonomy, beneficence, non-maleficence, and justice.

In the clinical setting, narrative ethics is applied through understanding the stories and characteristics that comprise the identity and well-being of both patients and practitioners to assure ethical treatment, communication, and decision making. This article provides a case scenario to illustrate the relevance and importance of narrative ethics in the clinical setting, and to highlight the potential and real beneficial effects of narrative through exploring the various means of its application in the care of patients.

The Case

Mr. H was 82 years old. I (author MG) knew him for about six years while he lived in the affiliated retirement home. I had been asked to see him because he was in chronic renal failure and had refused dialysis. “I’m old. I have no one left in the world. What reason is there to live?” Those were the answers he gave explaining why he had declined dialysis. He was a Hungarian immigrant, widower, and childless, as the children he had from his first marriage perished in the Holocaust. Without dialysis he would die.

With very little prodding, Mr. H continued his explanation as to why he had refused the treatment. “You know that I lost all of my family in the Holocaust. I had a wife and two children who were seven and five at the time that they were taken from me. I remarried after the war to a Canadian woman who came from my town in Hungary, but before the war. We did not have any children, and she died more than 15 years ago. I have been alone ever since. I worked as a bookkeeper but could not continue, and within five years of her death I stopped working, living on a modest pension and some reparations from Germany. The only person left is a distant cousin who lives in London, Ontario, whom I haven’t seen in four years, and she is quite ill herself.”
As Mr. H revealed more and more personal reflections about his own values, beliefs, and memories, woven into a fairly coherent narrative spanning several decades, there was a sacred space opened between us, and a different kind of knowing, for both of us, became possible. He was not simply a “nephrology patient” but a human being with layers of stories, memories, and meaningful experiences important for me to know something about.

The nurses and the attending physician had referred Mr. H to me to see if I could “convince” him to agree to dialysis, as I had known him since the time he moved into the retirement home. It was I who had referred him to the nephrologists some years before. After a psychiatric consultation, which indicated that he was not clinically depressed, the feeling was that he was mentally capable of making his own decision to forgo dialysis. He appeared to understand the potential benefits of treatment and the risks associated. While the healthcare workers may have actually wanted me to try to convince Mr. H to have treatment, they and I knew that we are not in the business of trying to coerce people to undergo treatment just because we think they should. It would be important to understand their “stories” about why they think Mr. H ought to be convinced to do something that seems to be counter to what he actually wishes. My sense is that they too felt that there were additional pieces of experience and knowledge missing from their scanty version of Mr. H’s accounting to them that required an opportunity to be voiced. After all, the consequences of missing relevant pieces of Mr.