Principlism or narrative ethics: must we choose between them?

This paper addresses a current debate in the bioethics community between principlists, who consider that principles are at the heart of moral life, and narrativists, who see communication at its core. Using a case study entitled "The forgetful mourner" to introduce the tensions between each of these positions, I go on to explain the central tenets of both principlism and narrative ethics. Rather than focus on their respective weaknesses, which many theorists do, I emphasise instead, the contribution that each approach can make to understanding moral life and the process of ethical decision making in health care situations. My ultimate aim is to identify the, sometimes overlapping, skills that both principlism and narrative ethics require on the part of health professionals who deploy them. I conclude that a good principlist has narrativist tendencies and a good narrativist is inclined toward principlism.

This paper examines and tests the parameters of a debate that has been taking place in the bioethics community in recent years. The debate is best expressed as one between those theorists who see principles at the heart of moral life and those who see communication at its core. The former position is generally described as principlism; the latter, has become known as narrative ethics. I intend to explain and assess these positions, not, however, with a view to privileging one over the other: many books and articles have already been written which point to serious weaknesses in both of them. (For some of the standard criticisms of principlism see: Clouser KD and Gert B, (1) DuBose ER, Hamel RP and O'Connell LJ, (2) and Davis RB. (3) For some of the standard criticisms of narrative ethics, see: Clouser KD, (4) and Lindemann Nelson H. (5)) Rather, I want to present each perspective in its best light, highlighting its positive features and strengths. Ultimately, my intention is to identify the skills that each of these approaches require on the part of health professionals who deploy them.

To begin my exploration of principlism and narrative ethics, I examine a case study and, in turn, a moral issue that regularly arises when caring for people with Alzheimer's disease. This case, published in the Hastings Center Report (1995), and entitled "The forgetful mourner" concerns an eighty six year old Italian American woman with moderate dementia, Mrs C. (6) She is admitted to a nursing home when her son Tony, with whom she has been living, falls ill. When, after two years, Tony dies suddenly the staff in the nursing home are especially concerned for Mrs C. In the days and weeks that follow the funeral, she continues to ask how Tony is doing as if he is still alive.

After consulting with staff, the director of the Alzheimer unit, Dr L, decides that Mrs C's questions should be answered truthfully: she should be told that Tony has died. Each time this is done, however, Mrs C becomes distraught, enduring the pain of her son's death over and over again. While everyone finds this very hard, Dr L hopes that their patience and persistence will enable Mrs C to remember what really happened. The only alternative seems to be a grave and sustained deception on the part of everyone who has a relationship with Mrs C.

As it turns out, Mrs C is told of her son's death at least fifteen times, and each time she experiences the grief of her loss anew. Then, one of the nurses, Ms F, suggests that Mrs C put on the black dress she had been wearing on the day she attended Tony's funeral. This she does and it seems to help her to remember. Even though Mrs C continues to talk about Tony, she no longer asks how he is doing.

The two commentaries that follow the case of "The forgetful mourner" take opposite views of the response of Dr L to Mrs C's bereavement. ("The forgetful mourner" is also discussed in the light of the different responses of Dr L and Ms F in Parker M and Dickenson D. (7)) The first commentary, by Tony Yang-Lewis, is sympathetic toward both Dr L and Ms F. He takes the view that, however painful it is, in this case, communicating the truth to Mrs C, in whatever fashion, is the right and respectful thing to do because it acknowledges the importance of her relationship with her son. According to Yang-Lewis, it is Mrs C's memory that is eroded, but not necessarily her sense of self--and her relationship with her son is integral to that sense of self. (8)

The second commentary, by Harry R Moody, however, takes a much harsher line and remarks: "No more poignant example of fanaticism is imaginable than the devotion to abstract principle--truth telling--revealed by this case"? Arguing that Dr L's devotion to truth telling is misguided because it ignores the anguish and pointless pain of the patient that it causes, Moody heaps praise on the experimental and imaginative approach of Ms F, which he sees as an alternative to the "philosophical faith" or "creed" of principlism. He takes the view that Ms F's action in relation to the black dress is motivated not by the principle of truth telling, but by the desire to communicate with the patient in a way that does not prejudge the outcome. The immediate effect of the black dress, for Moody, is that it validates Mrs C's sense of loss. Ultimately, it may or may not succeed in getting Mrs C to understand and accept the truth about her son. In sum, it is communication, not principlism, which is key to moral life for Moody. Note that while Moody is hostile to what he calls, "principlism", he is not completely adverse to principles because at the end of his commentary, he suggests that we should forge a "communicative ethic" which unites principles and prudence with experiment and practical imagination/ This paper hopes to contribute in some way to the development of such a position.

PRINCIPLISM

What is known as the principlist approach to ethical decision making has dominated Western bioethics for the last twenty years. It emerged with the publication of several well known texts in the 1970s and 80s. One of these was the Belmont Report which identified basic principles that would underlie and guide the regulation of research involving human subjects. (10) Three books, also published at that time, outlined and defended a principlist ethical framework, those of Tom Beauchamp and James Childress, Robert Veatch, and H Tristram Engelhardt. (11 12 13)

This paper examines the account developed by Beauchamp and Childress in their book, Principles of Biomedical Ethics. What is especially attractive about this particular principlist model (hereafter called the PBE model) is that, since its first appearance in 1979, the authors have continuously refined and honed its central elements in …