James Phelan, to name just a very, very small few in that field? Second, narrative ethics in bioethics rarely attends to the work of narrative ethics outside of bioethics (see Tony E. Adams’s “A Review of Narrative Ethics,” in Qualitative Inquiry ). There seems an odd assumption in bioethics that narrative ethics and narrative bioethics are the same thing. Both of these “broadenings” will not easily resolve the lack of coherence in this method, but they would help narrative ethicists in bioethics to build upon the work of others and also adopt a common vocabulary. • Tod S. Chambers Northwestern University DOI: 10.1002/hast.301
the author replies t Tod Chambers is so annoyed. Not only could few people discern the difference between the majority of the essays in Martha Montello’s special report on narrative ethics and the essays from the 1995 Stories and Their Limits, but, unlike utilitarianism, narrative ethics has no end of difficulty in defining itself. And why aren’t the people who use narrative approaches to bioethics better grounded in narratology, for heaven’s sake? Moreover and furthermore, don’t these people realize that there is narrative ethics outside of bioethics? It’s enough to make a man spit. Let’s take the first grievance first. Suppose, for the sake of argument, that narrative approaches to ethics constitute a moral theory, like the utilitarianism to which Chambers compares them. If so, then the demand for progress strikes me as overly optimistic. Wouldn’t Chambers have just as much trouble telling the difference between recent articles employing utilitarianism from those published fifteen years ago? But, of course, narrative approaches aren’t moral theories at all. They are instead what their name implies: approaches to ethics that employ stories in all kinds of different ways. Sometimes the stories are parables that explain what certain moral concepts amount to (“A certain man came down from Jerusalem to Jericho . . .”); sometimes they display 4 HASTIN G S C E N T E R R E P ORT
a puzzling moral situation (insert your favorite case study here); sometimes they model a paradigmatic case to which a case at hand can be compared (e.g., Cruzan v. Director, Missouri Department of Health); sometimes they serve as cautionary tales (as in Dax’s case). Because they can be put to any number of moral uses—far more than the handful of examples I’ve just given—they can’t be neatly classified into a tidy theory, although there are many theories about what stories are and what makes them good or bad stories for a given purpose. Here’s one such theory; call it an instance of narratology without the postmodernist jargon. Stories are depictive, selective in what they depict, connective both in how their internal elements are
Once we recognize that putting stories to various moral uses doesn’t constitute a unified methodology, we might better appreciate the richness and versatility of many narrative approaches to ethics. linked and in how they relate to other stories, and interpretive in offering ways of understanding a situation, person, or relationship. Because stories have these four properties, they can be very useful indeed as aids to moral reflection. To be that, though, they have to do their jobs well, where “well” usually means that their depiction is an accurate one that neither puts undue emphasis on certain features of a situation nor papers over others that are morally inconvenient and one that connects to other stories in the right way so that their interpretation of the situation is morally justified. To get all this right requires not just a basic grounding in narratology, but a certain level of moral competence—and, yes, an awareness of narrative approaches to ethics that goes beyond bioethics. I have a modest proposal that would go some way toward mollifying the
disgruntled Professor Chambers: let’s stop using the term “narrative ethics.” Because he’s right. Not only does it not name anything real, but it also sounds too much like a moral theory: care ethics, virtue ethics, Kantian ethics, narrative ethics. Once we get it out of our heads that putting stories to various moral uses constitutes a unified methodology, we might be better able to appreciate the richness and versatility of the many narrative approaches to ethics that Montello’s special report displays. • Hilde Lindemann Michigan State University DOI: 10.1002/hast.302
u From
Applied Ethics to Narrative Ethics: The Rationality and Morality of Telling Stories in Bioethics
The recent special report Narrative Ethics: The Role of Stories in Bioethics shows how narrative ethics can enlarge and enrich bioethics. Christine Mitchell, author of one of the essays in the collection, rightly attributes the popularity of narrative ethics to “the aridness of philosophical ethical theory.” Telling stories liberates morality from the constricted, philosophically grounded applied ethics that has dominated bioethics. Ethical theory is abstruse and indeterminate, and neither quality is tolerable when the people are real, the moral stakes are high, and the decision cannot be deferred. As with any emancipation, enthusiasm for narrative ethics abounds, but for its promise to be realized, the moral workings of stories need to be understood. Telling stories frees bioethics from the philosophical requirement of applying general moral principles to the facts of problems to derive demonstrably correct decisions. Stories are about the particular, the concrete, the contextual, the dynamic, the complex, the contingent. May-June 2014
They involve specific people, in specific situations, with specific problems subjected to specific constraints. Those people are finite and fallible, and they live in a world that is constantly in flux and endlessly risky. How do they make their way through that world? By learning from experience—from their own experiences but even more from the accumulated collective experiences of others. These are experiences embodied in and conveyed by stories. Telling stories is about understanding, not the justification of moral prescriptions, as Montello explains: “A narrative approach steps back from . . .
Enthusiasm for narrative ethics abounds, but for its promise to be realized, the moral workings of stories need to be understood. directiveness and instead asks people to reflect on how they got to where they are.” Telling stories is a naturalistic morality that people actually use to create, assess, and shape their lives and relationships, practices and institutions, and cultures and societies. Stories about the past provide understanding of how a person got into a predicament; stories about the present provide understanding of the dimensions of a predicament; and stories about the future provide understanding of ways of resolving a predicament. From that understanding, Montello adds, people proceed to “questions of how they want to move on from there.” For the reasoning of applied ethics, however, drawing a conclusion about how I should move on from here from an account of how I got here is a logical fallacy because you cannot derive an “ought” from an “is.” That is a truth about deduction, but it becomes a truth about morality only if moral reasoning is reduced to deduction, as happens in applied ethics. In stories, facts and values commingle May-June 2014
and enhance the understanding of one another, and stories about what happened in the past can yield insights and ideas about directions for the future. Telling stories is deliberation that culminates in judgment, as Hilde Lindemann recognizes: “When moral deliberators construct a story. . . , they come to understand the situation in a certain way, and that, in turn, guides their sense of how they should act in or with respect to it.” Judgment—a sense of what should be done—is inescapable in moral deliberation, even in applied ethics, where judgment is required to determine which principles are relevant, to interpret general terms in principles, and to resolve conflicts between principles. But when rationality is only reasoning, as it is in philosophy, and judgment is not reasoning, applied ethics cannot be rational. Narrative ethics is no better off if it cannot be rational. The rationality of moral deliberation about and with stories inheres in its process. The judgment that emanates from a deliberative process— the guidance of understanding—is rational when the process is rational, and that depends on the extent to which it involves observation, creative construction, formal and informal reasoning methods, and comprehensive critical assessment. Careful, systematic observation provides content for stories. Creative construction develops stories and innovatively adjusts and modifies them to explore options. Formal and informal reasoning methods examine components of stories such as an inductive belief in the continued efficacy of a treatment or an analogy with a friend’s response to the same disease. Comprehensive critical assessment exposes assumptions and tests conclusions, proposes counterstories, and scrutinizes the coherence and credence of stories. Engaging people in the process as contributors to and critics of stories bolsters the rationality of the process. Stories are not easy to tell. The participation of others helps to elucidate which features are relevant, how they should be represented and connected,
ON THE WEB n Bioethics Forum http://www.bioethicsforum.org Truvada: No Substitute for Responsible Sex By Richard M. Weinmeyer The availability of Truvada as [an HIV] prevention tool has led to some positing that it could be the “new condom” for gay men, while others have voiced concern that the drug will be used improperly or will only exacerbate rising rates of unsafe sex among gay men. But what is currently missing is a frank discussion about personal responsibility in gay men’s sexual health choices, and the duties all of us have . . . . De-Extinction: Could Technology Save Nature? By Gregory E. Kaebnick [O]ver the past year, some scientists and others have been declaring that the woolly rhino–last seen, oh, 10,000 years or so ago–could soon NOT be extinct. Along with a small but growing host of recently expired species, it might undergo “deextinction”: we could sequence and then synthesize its genome, and then use the genome to synthesize the animals themselves. Borderline Disorder: Medical Personnel and Law Enforcement By Dien Ho, Kenneth A. Richman, and Mark Bigney The lawsuit alleges that . . . Ms. Doe was returning from a visit in Mexico when an agent of CBP [U.S. Customs and Border Protection] informed her that she had been chosen for increased inspection and secondary screening. . . . Ms. Doe was . . . transported to University Medical Center of El Paso. There, she was handcuffed to an examination table, and instructed to ingest a laxative. New York’s Measles Outbreak: Take Off Your Shoes and Roll Up Your Sleeve By Karyn L. Boyar [A] longstanding controversy in the U.S. concerns parents who choose to not have their children vaccinated for fear that the MMR (measles, mumps, and rubella) vaccine causes autism. The most recent studies performed here and abroad have not found a link to autism. H AS TI N GS C E N TE R RE P O RT
5
and the direction in which the story is moving. A process of deliberation also has to be moral. Arthur Frank points out that “everyone involved in a patient’s care needs to know what story everyone else is telling” and that “approval of others’ stories is not necessary, but plausibility and respect are essential.” The social enterprise of moral deliberation requires transparency and respect along with values such as tolerance, humility, sincerity, and flexibility. That process should support, not disfranchise, patients and families and should produce a uniform, shared understanding of the situation and how to handle it. Most importantly, the patient’s story needs to be heard because listening to a story affirms the individuality and worthiness of the story and the person telling the story. • Barry Hoffmaster University of Western Ontario DOI: 10.1002/hast.303
u How
NarrativeBased Approaches Distort Medical Decision-Making
Several essays in Narrative Ethics: The Role of Stories in Bioethics highlighted the important role for narrative approaches in enhancing understanding of the emotional and psychological landscapes of patients and their families. These essays showed how use of narratives results in a deeper appreciation and a greater empathy for a patient’s plight and struggles. They also argued that narratives should form the basis for decisions made by patients and their surrogates when faced with the complexities of critical illness and end of life. As a physician, I worry that narrative-based approaches may actually at times promote decisions and resolutions that are at odds with the best interests of the patient. My overriding concern is that an exclusively narrative-based approach has the potential to significantly distort the medical decision-making process. I am not arguing that this is 6 HASTIN G S C E N T E R R E P ORT
unique to narrative-based approaches. Rather, it is my position that with a narrative approach, there is a greater propensity for distortions to occur. Three types of distortions are, I believe, the most concerning. As I address each of these, my intent is not to dismiss the need for and usefulness of patient’s stories but instead to provide a cautionary perspective on the use of narratives as a tool to reach medical decisions. First narrative approaches may conflict with the physician’s role and may enhance the possibility of bad decisions at the end of life. There are fundamental differences between how physicians and narrativists approach difficult medical decisions. This divergence is most evident when complex medical decisions
Since narratives may lead to decisions at odds with what is medically appropriate, “bad” decisions may occur that actually increase patient suffering and harm. are being rendered in order to define goals of care at the end of life. In this circumstance, the strict narrativist is agnostic and seeks a resolution based on the themes and arc of the patient’s story. In contrast, the physician is duty bound to not be agnostic since he or she seeks a resolution that is based on the patient’s prognosis, medical literature, professional experience, and what ultimately can be achieved realistically. Since narratives may lead to decisions at odds with what is medically appropriate, “bad” decisions may occur that actually increase patient suffering and harm. An unfortunate yet common example is ongoing aggressive care of patients with widespread metastatic cancer who die on ventilators in intensive care units because this “ending” is allegedly consistent with how the patients lived. Honoring certain narratives may thus be at the expense of beneficence.
Second, a thematic patient narrative may not exist. People’s lives are commonly fragmented; as a result, their stories may not contain clear-cut themes to guide medical decision-making. It is also the case that the complicated and rich experiences of a single person’s life may contain multiple and conflicting themes. If one believes, as many narrativists do, that a distinct narrative can be elucidated, the conception of “false” themes may thus unwittingly occur when one tries to make sense of a patient’s life story. The concern here is that this can lead to prejudiced medical decision-making. An all-too-frequent example is the claim, based on a preconceived interpretation of the narrative conveyed, that a patient is a “fighter and would never give up.” This presumed theme is then used to substantiate a physician’s own unwillingness to stop treatment. In my opinion, the creation and content of these “false” themes are motivated by the complexities and needs of a countertransference-like process, akin to what occurs in psychotherapy. While this is potentially true for all engagements with patients and their families, I worry that the relationship of the narrativist to his or her subject may be particularly prone to this type of bias. This may be the case because the interpretive literary sensibility that characterizes the narrativist has many features of the psychotherapist temperament. Finally, narratives derived from surrogates may obfuscate and cause a loss of focus on the patient. Because many patients are extremely sick, we use their surrogates to make critical decisions. Surrogates are also the source of patients’ narratives. One concerning possibility is that key decisions may be driven more by what we hear from surrogates than by what is best for the patient. No doubt, unraveling the psychological complexities of surrogates’ narratives sheds an important light on how to help families and patients cope. Without a skepticism and sensitivity to the potential insidious self-interest and harmful motives of a surrogate’s narrative, however, one could readily lose focus and misinterpret the real desires May-June 2014
the author replies t Tod Chambers is so annoyed. Not only could few people discern the difference between the majority of the essays in Martha Montello’s special report on narrative ethics and the essays from the 1995 Stories and Their Limits, but, unlike utilitarianism, narrative ethics has no end of difficulty in defining itself. And why aren’t the people who use narrative approaches to bioethics better grounded in narratology, for heaven’s sake? Moreover and furthermore, don’t these people realize that there is narrative ethics outside of bioethics? It’s enough to make a man spit. Let’s take the first grievance first. Suppose, for the sake of argument, that narrative approaches to ethics constitute a moral theory, like the utilitarianism to which Chambers compares them. If so, then the demand for progress strikes me as overly optimistic. Wouldn’t Chambers have just as much trouble telling the difference between recent articles employing utilitarianism from those published fifteen years ago? But, of course, narrative approaches aren’t moral theories at all. They are instead what their name implies: approaches to ethics that employ stories in all kinds of different ways. Sometimes the stories are parables that explain what certain moral concepts amount to (“A certain man came down from Jerusalem to Jericho . . .”); sometimes they display 4 HASTIN G S C E N T E R R E P ORT
a puzzling moral situation (insert your favorite case study here); sometimes they model a paradigmatic case to which a case at hand can be compared (e.g., Cruzan v. Director, Missouri Department of Health); sometimes they serve as cautionary tales (as in Dax’s case). Because they can be put to any number of moral uses—far more than the handful of examples I’ve just given—they can’t be neatly classified into a tidy theory, although there are many theories about what stories are and what makes them good or bad stories for a given purpose. Here’s one such theory; call it an instance of narratology without the postmodernist jargon. Stories are depictive, selective in what they depict, connective both in how their internal elements are
Once we recognize that putting stories to various moral uses doesn’t constitute a unified methodology, we might better appreciate the richness and versatility of many narrative approaches to ethics. linked and in how they relate to other stories, and interpretive in offering ways of understanding a situation, person, or relationship. Because stories have these four properties, they can be very useful indeed as aids to moral reflection. To be that, though, they have to do their jobs well, where “well” usually means that their depiction is an accurate one that neither puts undue emphasis on certain features of a situation nor papers over others that are morally inconvenient and one that connects to other stories in the right way so that their interpretation of the situation is morally justified. To get all this right requires not just a basic grounding in narratology, but a certain level of moral competence—and, yes, an awareness of narrative approaches to ethics that goes beyond bioethics. I have a modest proposal that would go some way toward mollifying the
disgruntled Professor Chambers: let’s stop using the term “narrative ethics.” Because he’s right. Not only does it not name anything real, but it also sounds too much like a moral theory: care ethics, virtue ethics, Kantian ethics, narrative ethics. Once we get it out of our heads that putting stories to various moral uses constitutes a unified methodology, we might be better able to appreciate the richness and versatility of the many narrative approaches to ethics that Montello’s special report displays. • Hilde Lindemann Michigan State University DOI: 10.1002/hast.302
u From
Applied Ethics to Narrative Ethics: The Rationality and Morality of Telling Stories in Bioethics
The recent special report Narrative Ethics: The Role of Stories in Bioethics shows how narrative ethics can enlarge and enrich bioethics. Christine Mitchell, author of one of the essays in the collection, rightly attributes the popularity of narrative ethics to “the aridness of philosophical ethical theory.” Telling stories liberates morality from the constricted, philosophically grounded applied ethics that has dominated bioethics. Ethical theory is abstruse and indeterminate, and neither quality is tolerable when the people are real, the moral stakes are high, and the decision cannot be deferred. As with any emancipation, enthusiasm for narrative ethics abounds, but for its promise to be realized, the moral workings of stories need to be understood. Telling stories frees bioethics from the philosophical requirement of applying general moral principles to the facts of problems to derive demonstrably correct decisions. Stories are about the particular, the concrete, the contextual, the dynamic, the complex, the contingent. May-June 2014
They involve specific people, in specific situations, with specific problems subjected to specific constraints. Those people are finite and fallible, and they live in a world that is constantly in flux and endlessly risky. How do they make their way through that world? By learning from experience—from their own experiences but even more from the accumulated collective experiences of others. These are experiences embodied in and conveyed by stories. Telling stories is about understanding, not the justification of moral prescriptions, as Montello explains: “A narrative approach steps back from . . .
Enthusiasm for narrative ethics abounds, but for its promise to be realized, the moral workings of stories need to be understood. directiveness and instead asks people to reflect on how they got to where they are.” Telling stories is a naturalistic morality that people actually use to create, assess, and shape their lives and relationships, practices and institutions, and cultures and societies. Stories about the past provide understanding of how a person got into a predicament; stories about the present provide understanding of the dimensions of a predicament; and stories about the future provide understanding of ways of resolving a predicament. From that understanding, Montello adds, people proceed to “questions of how they want to move on from there.” For the reasoning of applied ethics, however, drawing a conclusion about how I should move on from here from an account of how I got here is a logical fallacy because you cannot derive an “ought” from an “is.” That is a truth about deduction, but it becomes a truth about morality only if moral reasoning is reduced to deduction, as happens in applied ethics. In stories, facts and values commingle May-June 2014
and enhance the understanding of one another, and stories about what happened in the past can yield insights and ideas about directions for the future. Telling stories is deliberation that culminates in judgment, as Hilde Lindemann recognizes: “When moral deliberators construct a story. . . , they come to understand the situation in a certain way, and that, in turn, guides their sense of how they should act in or with respect to it.” Judgment—a sense of what should be done—is inescapable in moral deliberation, even in applied ethics, where judgment is required to determine which principles are relevant, to interpret general terms in principles, and to resolve conflicts between principles. But when rationality is only reasoning, as it is in philosophy, and judgment is not reasoning, applied ethics cannot be rational. Narrative ethics is no better off if it cannot be rational. The rationality of moral deliberation about and with stories inheres in its process. The judgment that emanates from a deliberative process— the guidance of understanding—is rational when the process is rational, and that depends on the extent to which it involves observation, creative construction, formal and informal reasoning methods, and comprehensive critical assessment. Careful, systematic observation provides content for stories. Creative construction develops stories and innovatively adjusts and modifies them to explore options. Formal and informal reasoning methods examine components of stories such as an inductive belief in the continued efficacy of a treatment or an analogy with a friend’s response to the same disease. Comprehensive critical assessment exposes assumptions and tests conclusions, proposes counterstories, and scrutinizes the coherence and credence of stories. Engaging people in the process as contributors to and critics of stories bolsters the rationality of the process. Stories are not easy to tell. The participation of others helps to elucidate which features are relevant, how they should be represented and connected,
ON THE WEB n Bioethics Forum http://www.bioethicsforum.org Truvada: No Substitute for Responsible Sex By Richard M. Weinmeyer The availability of Truvada as [an HIV] prevention tool has led to some positing that it could be the “new condom” for gay men, while others have voiced concern that the drug will be used improperly or will only exacerbate rising rates of unsafe sex among gay men. But what is currently missing is a frank discussion about personal responsibility in gay men’s sexual health choices, and the duties all of us have . . . . De-Extinction: Could Technology Save Nature? By Gregory E. Kaebnick [O]ver the past year, some scientists and others have been declaring that the woolly rhino–last seen, oh, 10,000 years or so ago–could soon NOT be extinct. Along with a small but growing host of recently expired species, it might undergo “deextinction”: we could sequence and then synthesize its genome, and then use the genome to synthesize the animals themselves. Borderline Disorder: Medical Personnel and Law Enforcement By Dien Ho, Kenneth A. Richman, and Mark Bigney The lawsuit alleges that . . . Ms. Doe was returning from a visit in Mexico when an agent of CBP [U.S. Customs and Border Protection] informed her that she had been chosen for increased inspection and secondary screening. . . . Ms. Doe was . . . transported to University Medical Center of El Paso. There, she was handcuffed to an examination table, and instructed to ingest a laxative. New York’s Measles Outbreak: Take Off Your Shoes and Roll Up Your Sleeve By Karyn L. Boyar [A] longstanding controversy in the U.S. concerns parents who choose to not have their children vaccinated for fear that the MMR (measles, mumps, and rubella) vaccine causes autism. The most recent studies performed here and abroad have not found a link to autism. H AS TI N GS C E N TE R RE P O RT
5
and the direction in which the story is moving. A process of deliberation also has to be moral. Arthur Frank points out that “everyone involved in a patient’s care needs to know what story everyone else is telling” and that “approval of others’ stories is not necessary, but plausibility and respect are essential.” The social enterprise of moral deliberation requires transparency and respect along with values such as tolerance, humility, sincerity, and flexibility. That process should support, not disfranchise, patients and families and should produce a uniform, shared understanding of the situation and how to handle it. Most importantly, the patient’s story needs to be heard because listening to a story affirms the individuality and worthiness of the story and the person telling the story. • Barry Hoffmaster University of Western Ontario DOI: 10.1002/hast.303
u How
NarrativeBased Approaches Distort Medical Decision-Making
Several essays in Narrative Ethics: The Role of Stories in Bioethics highlighted the important role for narrative approaches in enhancing understanding of the emotional and psychological landscapes of patients and their families. These essays showed how use of narratives results in a deeper appreciation and a greater empathy for a patient’s plight and struggles. They also argued that narratives should form the basis for decisions made by patients and their surrogates when faced with the complexities of critical illness and end of life. As a physician, I worry that narrative-based approaches may actually at times promote decisions and resolutions that are at odds with the best interests of the patient. My overriding concern is that an exclusively narrative-based approach has the potential to significantly distort the medical decision-making process. I am not arguing that this is 6 HASTIN G S C E N T E R R E P ORT
unique to narrative-based approaches. Rather, it is my position that with a narrative approach, there is a greater propensity for distortions to occur. Three types of distortions are, I believe, the most concerning. As I address each of these, my intent is not to dismiss the need for and usefulness of patient’s stories but instead to provide a cautionary perspective on the use of narratives as a tool to reach medical decisions. First narrative approaches may conflict with the physician’s role and may enhance the possibility of bad decisions at the end of life. There are fundamental differences between how physicians and narrativists approach difficult medical decisions. This divergence is most evident when complex medical decisions
Since narratives may lead to decisions at odds with what is medically appropriate, “bad” decisions may occur that actually increase patient suffering and harm. are being rendered in order to define goals of care at the end of life. In this circumstance, the strict narrativist is agnostic and seeks a resolution based on the themes and arc of the patient’s story. In contrast, the physician is duty bound to not be agnostic since he or she seeks a resolution that is based on the patient’s prognosis, medical literature, professional experience, and what ultimately can be achieved realistically. Since narratives may lead to decisions at odds with what is medically appropriate, “bad” decisions may occur that actually increase patient suffering and harm. An unfortunate yet common example is ongoing aggressive care of patients with widespread metastatic cancer who die on ventilators in intensive care units because this “ending” is allegedly consistent with how the patients lived. Honoring certain narratives may thus be at the expense of beneficence.
Second, a thematic patient narrative may not exist. People’s lives are commonly fragmented; as a result, their stories may not contain clear-cut themes to guide medical decision-making. It is also the case that the complicated and rich experiences of a single person’s life may contain multiple and conflicting themes. If one believes, as many narrativists do, that a distinct narrative can be elucidated, the conception of “false” themes may thus unwittingly occur when one tries to make sense of a patient’s life story. The concern here is that this can lead to prejudiced medical decision-making. An all-too-frequent example is the claim, based on a preconceived interpretation of the narrative conveyed, that a patient is a “fighter and would never give up.” This presumed theme is then used to substantiate a physician’s own unwillingness to stop treatment. In my opinion, the creation and content of these “false” themes are motivated by the complexities and needs of a countertransference-like process, akin to what occurs in psychotherapy. While this is potentially true for all engagements with patients and their families, I worry that the relationship of the narrativist to his or her subject may be particularly prone to this type of bias. This may be the case because the interpretive literary sensibility that characterizes the narrativist has many features of the psychotherapist temperament. Finally, narratives derived from surrogates may obfuscate and cause a loss of focus on the patient. Because many patients are extremely sick, we use their surrogates to make critical decisions. Surrogates are also the source of patients’ narratives. One concerning possibility is that key decisions may be driven more by what we hear from surrogates than by what is best for the patient. No doubt, unraveling the psychological complexities of surrogates’ narratives sheds an important light on how to help families and patients cope. Without a skepticism and sensitivity to the potential insidious self-interest and harmful motives of a surrogate’s narrative, however, one could readily lose focus and misinterpret the real desires May-June 2014
