Narrative Reasoning in Ethical Decision Making

Original Editor - Andrea Sturm

Top Contributors - Vidya Acharya, Kim Jackson, Rachael Lowe and Esraa Mohamed Abdullzaher  

Introduction

Physiotherapy is practiced in a wide range of countries across the globe. It is at different stages of development in different countries: with base similarities and a common definition and aim of practice but with local variations and traditions that affect its practice and development. Physiotherapy practice and education has thus followed a different development processes in different countries and there are differences pertaining to local conditions in each country and distinctions can also be made between western and developing nations.

Therefore, integration of the local moral understanding in the professional ethical reasoning of physiotherapists could be very important. Jenny Wickford outlined this importance on the basis of ethics for physiotherapists in Afghanistan. The insights she provides could be adapted to any other work-setting in which the local understanding of morals differs from a physiotherapists professional understanding of obligations and duties.

• Professional ethics refers to the study and nature of ethical issues within a profession.
• Normative ethics is concerned with applying universal ethical obligations, duties, principles, values, and beliefs to particular situations or cases.
• Narrative ethics is concerned with understanding the interpretation or meaning a person or group attributes to an experience in order to both define an ethical issue and make moral judgements.

Examples from Afghanistan

Physiotherapy training in Afghanistan has been based on western teaching materials, translated into local languages, since most Afghan physiotherapists have little or no comprehension of English. This translation of normative, evidence-based practice underpinning physiotherapy, was found to be inadequate when it comes to the issue of an ethical physiotherapy practice in Afghanistan.

Two ethical tensions are identified:

1. between individualistic and communitarian understandings of ethics, and
2. between normative ethical theory and ‘local moral experience’.

Individualistic and communitarian understanding

As members of the international physiotherapy community through membership in WCPT, there are increasing obligations for the Afghan physiotherapists to set professional standards. Ethical principles commonly employed in western countries are based on a more individualistic approach. For example, informed consent of the client is an expected ethical pursuit in a collaborative approach to services. Afghan society and culture, however, is communitarian, where decision making is also subject to the wills and expectations of those around the individual. This entails an ethical tension in balancing obligations for professional ethics with what works ‘on the ground’.

A second issue relates to balancing what the Afghan physiotherapists are taught that they should do, and want to do, with the expectations placed on them from their communities leading to actions that may not follow this. Living and working in Afghanistan entails numerous challenges, not the least in terms of the moral challenges that arise in face of the huge and varied demands of clinical practice.

Local moral experience

There are numerous challenges that Afghan physiotherapists face in their practice, where the tension between normative ethics and their local moral experience is a very real part of their clinical practice. An example of such a tension was exemplified by an incident related at a workshop at the AAPT General Assembly in 2008, where the normative ethical notion of informed consent clashed with the context:

A well respected physiotherapist posed this question to his colleagues: "Do you think that therapists should tell the patient (or caregiver) the truth?"

He then went on to relate a story of a mother with a baby girl who had hydrocephalus. The mother had asked him regarding the child’s prognosis and how disabled the child was likely to be in the future.The physiotherapist related his response to the group and it sounded like a very well balanced, informative and educative explanation to the mother as what the child and the family could expect. He had been realistic, but not overly bleak or pessimistic, offering hope of a life, which, whilst probably constrained in some ways, could nevertheless see the development of a child who could be an active and loving part of the family.The next day, the baby was found early by the staff, left at the gates of the hospital.

The question was repeated: "So should I still tell the truth in the future?"

Narrative reasoning

Interpretation & reflection

Research suggests that strengthened reflective skills can help physiotherapists tackle the ethical tensions, particularly through a narrative approach through discussion of ethical dilemmas which arise in their practice. Narrative reasoning can be used by the physiotherapists both to actively strive to understand their patients and also to understand the contextual factors which influence positively or adversely ethical decision making and action in professional practice (i.e. local moral experience).

Identity, voice & power

Narrative reasoning also considers notions of ‘identity’, ‘voice’ and ‘power’, which makes it further relevant for physiotherapists who are in the process of forming their professional identity within a larger social and medical community.

Narrative ethics & stories - telling & listening

Narrative reasoning as a practice of listening and telling stories fits well within some societies, such as the strong Afghan oral tradition. Afghan physiotherapists have many personal stories to tell which illustrate the challenges involved in working as a physiotherapist in Afghanistan, but also personal experiences of what it means to live in a country ravished by war. These can be used in a collaborative effort to explore and develop ethical practice and to teach those of us (expatriates) who do not share these experiences, what it means to work in such a context. Through telling and listening to these narratives, critical reflection can be facilitated, for expatriate and Afghan physiotherapists alike.

Narrative ethics & social concern

Through narrative ethics and the telling and sharing of experiences, the decision-making process can be shifted from an individual to a more social perspective. What ethical principles mean for the particular situations can thus be explored, rather than being simply prescribed based on normative, western traditions.

Conclusion

Ethical and clinical decision making do go hand in hand. The findings of the Wickford study give an example of professional physiotherapy practice that cannot be directly applied in a new context - professional ethics cannot be copied from a western context into the Afghan one. A narrative approach can facilitate the resolution of ethical dilemmas and tensions between what the physiotherapists are expected to do as professionals, and the expectations perceived by the local community. Also, the ethical tensions between normative ethical theory and local moral experience, and between individualistic and communitarian ethical imperatives must be addressed by teachers of professional ethics.