Abstract
This paper critically discusses the role narrative accounts of the self might play in surrogate decision-making. Medical cases in which patients are not or no longer able to express their interests and also have not given a prior account of them present us with the question of how to respect their autonomy, i.e. how the patient would probably want to be treated, were he or she able to decide for him- or herself. In such situations it seems natural to refer to a notion of the person’s identity or self, for based on this we might extrapolate how the person would decide in an authentic manner. In this regard, narrative theories of the self seem to be able to provide a reasonable answer. Knowing a person’s life story seems to suggest a simple and convincing way to determine her authentic interests based on how her story, i.e. her narrative identity, would continue in a plausible and coherent way. However, I claim that narrative accounts of the self inherently fail to provide a simple and convincing answer in such cases. After distinguishing between mere expressive narrative accounts and constitutive narrative accounts, I argue that expressive narrative accounts do not present an independent analysis of the constitution of the self to begin with and are at best a helpful epistemic tool to find out what the patient’s autonomous preference likely would be. Yet, even this only holds under the contestable assumption that the patient’s self remains stable. Constitutive narrative accounts, on the other hand, while indeed presenting an independent account of the constitution of the self, either revert back to an expressive narrative account if the idea of one’s free authorship of one’s life story is rejected, or they fail to provide any reason for why one should choose a certain version of the patient’s life story as the newly to be constructed one. Instead, I conclude that a person’s life story remains in a constant state of flux, which is why also constitutive narrative accounts are unable to provide surrogate decision-makers with a well-justified answer which treatment option to choose in order to respect the patient’s autonomy based on who he or she is.
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Notes
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With the only exception of cases of hard paternalism if one concedes that such acts can ever be ethically justified. See in this regard, for instance, Beauchamp and Childress 2013, 221–23.
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For an overview, see Jaworska 2017.
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Throughout my paper I use the term ‘self’ interchangeably with a person’s ‘identity’ (as this term is usually understood in the social sciences), ‘personality,’ or ‘character,’ i.e. in general in terms of an answer to the everyday question who a person is and to spell out the criterion of authenticity within the notion of personal autonomy.
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To avoid a possible misunderstanding, I do not argue against either expressive or constitutive narrative accounts per se, i.e. in terms of such accounts being implausible analyses of the (constitution of) the self. I merely argue that neither of these accounts, convincing as they may be per se, is able to provide us with a solution to surrogate decision-making in medical ethics.
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Blustein 1999, 21.
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Kuczewski 1999, 33.
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Blustein 1999, 22.
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Although Schechtman’s term for her view is obviously straightforward enough in claiming that a person’s narrative is constitutive of her identity or self, the constraints she introduces seem to indicate that one’s narrative may very well be conceived of as merely an adequate expression of an underlying content (cp. again Schechtman 1996, 114–30). Cp. also Kuczewski 1994, 43f., 1999, 33; Blustein 1999, 24–26; and DeGrazia 2005, 80.
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This problem essentially mirrors the similar problem with referring to a patient’s advance directives, as one can never be sure that the patient’s expressed preference in it may still be considered valid and has not changed since then.
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Blustein actually admits this presupposition of stability explicitly (cp. Blustein 1999, 22).
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On a critical note, Galen Strawson has prominently pointed out that putting aspects and situations of a person’s life in a meaningful order does not necessarily mean telling a canonized form of story (cp. Strawson 2004, 439–43). Weaker versions of constitutive narrative accounts, thus, only comprise the claim that some form of meaningful order has to be established with regard to the aspects and situations in question. While this may be done in form of a canonized story, it does not have to be. In contrast, stronger versions of constitutive narrative accounts, like Ricœur’s, claim just that. We need canonized forms of storytelling in order to construe a meaningful self. Moreover, we also need an adequate social context in which this may be done and from which the canonized forms of storytelling stem. Be that as it may, the crucial point for my discussion here is that both weaker and stronger versions of constitutive narrative accounts include the claim that at least some form of meaningful order needs to be construed in order to render single events or decisions intelligible within a coherent frame of reference.
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This holds at least partially if the impact of social conditions on what may count as successful storytelling and which versions of a story a person comes to think of in the first place is taken into account.
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DeGrazia 2005, 107.
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Of course, much more needs to be said about whether an existentialist approach to the constitution of the self is really untenable. For a concise overview of existentialism in general, see Crowell 2017, and for an existentialist approach to the constitution of the self in particular, see Kühler and Jelinek 2013, xif. and xviii–xx. For the purpose of my paper, however, I can leave this question open.
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Schechtman’s discussion of the articulation constraint and reality constraint remains rather vague in this regard. If there are, indeed, any decisive criteria upon which one’s self-narrative can be judged as being adequate or not, this would imply that one’s life story has to track underlying and given content of one’s life and character. However, if there are no such decisive criteria, this would imply that the constraints Schechtman advocates cannot plausibly go beyond simple descriptive coherence with reality, e.g. one’s whereabouts at a certain time. Cp. Schechtman 1996, 115–19 and 125–30.
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Kühler, M. (2020). Narratives in Flux. Why Patients’ Life Stories Do Not Provide Decisive Instructions in Cases of Surrogate Decision-Making. In: Kühler, M., Mitrović, V.L. (eds) Theories of the Self and Autonomy in Medical Ethics. The International Library of Bioethics, vol 83. Springer, Cham. https://doi.org/10.1007/978-3-030-56703-3_5
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