This paper presents an analysis of the applicability of a principalist
approach for a global, or cross-cultural, bioethics. We focus especially
on the principle of individual autonomy, a core value in ethical
discourse. We echo some long-standing criticisms of other anthropologists,
sociologists, and many medical ethicists that the individualistic approach
to autonomy is a Euro-American value and cannot be ethically applied in
all settings. As a remedy, we suggest an adaptation of Kleinman's
Explanatory Model approach to questions of decisionmaking.1
We
argue that the analysis and resolution of ethical dilemmas might also
benefit from forms of pedagogy that integrate anthropological and other
social science perspectives, and the incorporation of ethnographic
techniques in ethical practice.
We begin our discussion with a case.
Introduction to the Four Principles
Approach
The Four Principles approach in bioethics, made famous by Beauchamp
and Childress in the five editions of their classic text on biomedical
ethics, is the hallmark of the discipline, the theoretical center from
which much of the field of bioethics has grown.2
Beauchamp T, Childress J. Principles of Biomedical
Ethics, 5th ed. New York: Oxford University Press; 2001.
Although much critiqued by ethicists from diverse standpoints and by
anthropologists (e.g., physician-anthropologists Kleinman and Helman argue
cogently against assuming the relevance of Eurocentric premises in
clinical practice), these principles continue as implicit, if not
explicit, premises underlying analysis of ethical issues and
decisionmaking in clinical settings.
3 See
note 1, Kleinman 1980; Helman CG. Culture, Health and Illness,
4th ed. New York: Arnold Press; 2000.
Indeed, a cursory review of
recent scholarship immediately illustrates the enduring reliance on
Beauchamp and Childress for an ethical framework for theory and
practice.
4 Huprich SK, Fuller KM, Schneider
R. Divergent ethical perspectives on the duty-to-warn principle with HIV
patients. Ethics & Behavior 2003;13:263–78; Curlin F,
Burck R. Patient counseling and matters of conscience. Virtual
Mentor [Internet]. 2005. Available from: http://www.ama.assn.org/ama/pub/category/14980;
McKneally MF. The role of ethical principles in health care and the
implications for ethical codes. Journal of Medical Ethics
1999;25:394–8. Review 5, of Alexander Limentani's essay on
Beauchamp and Childress; Schmidt-Felzmann H. Pragmatic
principles—Methodological pragmatism in the principle-based approach
to bioethics. Journal of Medical Philosophy
2003;28(5–6):581–96; O'Neill O. Practical principles,
practical judgment. Hastings Center Report
2001;31(4):15–23; Tanenbaum S. Say the right thing: communication
and physician accountability in the era of medical outcomes. In: Boyle PJ,
ed. Getting Doctors to Listen: Ethics and Outcomes Data in
Context. Hastings Center Studies in Ethics. Washington, D.C.:
Georgetown University Press; 2000:204–25.
O'Neill, for
example, opens a discussion on “Practical Principles, Practical
Judgment”
5 See note 4, O'Neill
2001:15.
by stating that the most well-known approach to
bioethical reasoning that appeals to principles remains that of Beauchamp
and Childress.
6 See note 4, O'Neill
2001:15.
Similarly, Annas, writing in the
New England Journal
of Medicine, critiques the recent Terri Schiavo case, and emphasizes
the importance of patients' rights, as consistent with American
values and constitutional traditions.
7 Annas
GJ. “Culture of life” politics at the bedside—The case
of Terri Schiavo. New England Journal of Medicine
2005;352(16):1710–5.
He quotes the Massachusetts Supreme
Judicial Court on the sanctity of individual choice and self-determination
as fundamental constituents of life.
8 See
note 7, Annas 2005:1715.
The principle of individual autonomy as
core to ethical considerations is again reiterated.
As an ethical framework, the principles approach is an
“attempt[s] to identify and justify” a given set of
moral norms for the “guidance of and evaluation of
conduct.”9
See note 2, Beauchamp and
Childress 2001:2.
The principles are described as “four
clusters of moral principles” and include the following:
- Respect for autonomy—a norm of respecting the decisionmaking
capacities of individual persons
- Nonmaleficence—a norm of avoiding the causation of harm
- Beneficence—a group of norms for not only “doing
good” but balancing those good works against the risks and costs
associated with the effort
- Justice—a group of norms for distributing benefits, risk, and
costs fairly.10
See note 2, Beauchamp and
Childress 2001:12.
Beauchamp and Childress have settled on these principles using
assumptions about a “common morality” which they define as
“[T]he set of norms that all morally serious persons share
… [It] contains moral norms that bind all persons in all
places; no norms are more basic to moral life”11
See note 2, Beauchamp and Childress 2001:3.
and it
is “the morality that serves as our common heritage.”
12 See note 2, Beauchamp and Childress
2001:404.
To utilize these principles in practice, Beauchamp and Childress
outline several rules. They insist that, “Principles are general
norms that leave considerable room for judgment in many cases.” More
detailed “rules” and “judgments” are therefore
required and “function as precise action guides that inform us in
each circumstance how to act.”13
see
note 2, Beauchamp and Childress 2001:13.
Some of these rules
might include the following:
- Substantive Rules (truth-telling, confidentiality, privacy,
physician-assisted suicide, informed consent, and the like)
- Authority Rules (who may and should perform actions)
- Procedural Rules (rules that establish procedures to be followed,
e.g., for determining eligibility for scarce resources, for reporting
grievances).
Finally, Beauchamp and Childress introduce elements to contend with
nonuniversal norms and human idiosyncrasies—these include rights,
the idea of moral character, virtues, the greatest balances of right and
wrong, competing obligations, and even emotions. All of these are
considered vital to the theory and to practical applications, although
they are handmaidens to the Four Principles.
In our discussion, we will focus on the culturally Euro-American
reification of the Individual, which is so fundamental to the four
principles as to limit its utility for communication in ethical conflicts,
even though the U.S. legal system rests on the concept of individual
rights. The principle of justice affirms the isomorphic relationship
between a principalist approach and Euro-American jurisprudence, yet for
patients and families of any cultural or class background, the critical
meanings associated with an ethical dilemma may be situated outside the
parameters of this narrow ethical/legal domain.
What we will propose is simultaneous attention to the
individual and cultural factors in questions of autonomy, patient
rights, and the decisionmaking process.
Following Marshall and Koenig, we do not “dispute the relevance
of abstract principles in bioethics … [but direct our]
concern as anthropologists [to] the everyday practices derived
from these principles, practices that often fall short of realizing the
normative intent of the principles themselves.”14
Marshall P, Koenig B. Accounting for culture in a globalized
bioethics. Journal of Law, Medicine & Ethics
2004;32:252–66 at p. 253.
In particular, we (and they) are
troubled by the unexamined “promulgation of a Westernized bioethics
that fosters only an illusion of global consensus about the morality of
medical practice.”
15 See note 14,
Marshall and Koenig 2004:253.
As anthropologists, we suggest that the subject of medical ethics
should be the cultural construction of morality, particularly morality
surrounding health and disease. Empiricism is requisite for a just and
informed bioethics—a descriptive bioethics that grounds each case in
its cultural, historical, and political-economic contexts. There are two
main critiques we make: that the individual is so prioritized and central
as to become an unquestioned presumption of care and that the notion of a
common morality is a false, if not a culturally imperialist, idea that
justifies the devaluation of locally meaningful moralities. Were one to
explore it at a sufficiently high level of abstraction, one might be able
to identify areas of widely shared values. However, when one gets to the
specifics of when certain moral values can be imposed, then what seem in
the abstract to be morally universals quickly become culturally specific.
For example, when is it acceptable to kill? Is it ever acceptable to rape?
What constitutes child abuse?16
Korbin's 1984 volume, Child Abuse and Neglect in
Cross-Cultural Perspective, is an early classic that raised questions
concerning global variability in what is perceived to constitute abuse and
neglect (Korbin J. Child Abuse and Neglect: Cross-Cultural
Perspectives. Berkeley: University of California Press; 1984). The
on-going debate regarding female genital cutting continues this theme;
some scholars argue that FGC represents child abuse, the mutilation of a
child's body without her consent, while others contend that as a
normative cultural practice, it should not be categorized as
“abusive” (Shell-Duncan B, Hernlund Y, eds. Female
“Circumcision” in Africa. Boulder and London: Lynn Reiner
Publishers; 2000). Herdt's analysis of masculinity rituals among the
Sambia of Highland New Guinea describes the local rationale for ritualized
oral sex between older men and young boys as part of male initiations
(Herdt G. Rituals of Manhood: Male Initiation in Papua New
Guinea. Berkeley: University of California Press; 1982). This
practice is considered requisite for boys to become men, although a
Euro-American assessment might classify the tradition as coercive or a
form of pedophilia. Also in New Guinea, ethnographers have documented
“gang rape” of women who have breached a taboo and seen the
interior of the “men's house” or have witnessed rituals
at which women's presence is prohibited. This
“punishment” of women is legitimized as a response to
seriously inappropriate behavior. The concept of rape does exist, but this
particular scenario, culminating in forced sex between a group of men and
an unwilling woman, would not be defined as such.
Reification of the Individual
The reification of individual choice in the principalist approach is
evident in several places:
- in notions of the autonomy of any given individual
- in the complete preoccupation with a focal “patient,”
the single suffering individual
- and even in biomedically defined “cases” (which have a
hegemonically determined beginning and end).
These assumptions, long the target of critique by medical
anthropologists as well as by some medical ethicists, reinforce specific
cultural notions about the target of care, the definition of the patient,
and the responsibilities of various parties involved. These assumptions
are increasingly inappropriate in healthcare, where patients frequently
come from cultural backgrounds different from their doctors. Helman, a
physician and anthropologist, notes that biomedicine focuses on the
individual patient, or even the individual organ, while ignoring wider
familial, social, and economic issues that render consensus or problem
resolution difficult to achieve.17
See note
3, Helman 2000:103.
Anthropologist Patricia Marshall has suggested that, “Bioethics
practices that celebrate only autonomy, with its emphasis on choice, and
downplay social and economic constraints on individual agency, are out of
touch with health-care realities in the U.S., as well as globally. The
changed discourse—doctor becomes provider and patient becomes
consumer—reflects fundamental, systemic problems characteristic of
market-driven medicine.”18
See note
14, Marshall and Koenig 2004:255.
Marshall and Koenig argue that
conventional individual-focused bioethics practices by themselves, and
without attention to the broader context in which individual decisions are
made, may be inadequate.
Beauchamp and Childress respond to attacks leveled against the
Autonomy Principle by insisting on the individual right to determine the
form and content of care. They write:
We defend a principle of respect for autonomy with a
correlative right to choose (not a mandatory duty to
choose). (A study they describe of 800 subjects from 4 different ethnic
groups—Korean American, Mexican American, European American, and
African American—showed ethnicity to be a primary correlate with
attitudes toward disclosure and decision-making. But, they go on) …
[e]ven if the patient delegates [their decisionmaking]
right to someone else, the choice to delegate is itself autonomous.19
See note 2, Beauchamp and Childress
2001:61–2.
Patients whose cultural or family context renders them unable or
unwilling to make decisions about their own care can, according to the
principle of autonomy, choose to refuse information about their health and
direct that others will make decisions for them. How and by whom these
interactions will occur is left to guesswork. As Beauchamp and Childress
respond, the only obligation is on the physician.
There is a fundamental obligation to ensure that patients
have the right to choose, as well as the right to accept or to decline
information…. The tricky practical question is whether it is
possible to inform patients of their rights to know and to decide without
compromising their systems of belief and value or otherwise disrespecting
them.20
See note 2, Beauchamp and Childress
2001:63.
A “tricky practical question” indeed. Patient
decisionmaking has become an obligation in the lived world of hospital and
managed care and we suggest that a truly moral stance cannot ignore the
context within which ethical theories are played out and must acknowledge
the reality in which its ideals must be rooted.
That is, to propose as a theoretical principle a concept (i.e.,
non-obligatory autonomy) that is almost universally
disregarded must call into question the validity of the theory. If patient
autonomy is viewed in the vast majority of settings as not just a right
but an obligation of patients, then this problem demands both theoretical
and pragmatic remedies. The Four Principles approach offers neither.
As we have noted, Beauchamp and Childress do claim
sensitivity to the social determinants of morality and to the function of
judgment applied in individual cases. They say that the four principles
are general norms that leave “considerable room for judgment in many
cases.” In addition, they acknowledge that moral virtues, paramount
in driving decisions for each clinical case, are socially determined. Yet,
they say, we do not approach those cases tabula rasa but with norms and
assumptions informed by culture, history, and the like.
We suggest that proponents of the principles framework approach their
cases and theory with the same culturally informed assumptions. They have
built a theory that so reifies the individual that no room is left
available in cases for judgments that might contradict these fundamental
assumptions.
Common Morality
The idea of a common, universal morality is not something readily
accepted by anthropologists, and it has come under considerable attack by
bioethicists as well. Beauchamp and Childress acknowledge this when they
write:
the common morality's norms do require interpretation if
we are to have workable practical ethics. Such interpretation is often
subject to vigorous dispute in order to resolve particular problems.21
See note 2, Beauchamp and Childress
2001:4.
They acknowledge that not all people accept these norms, but that all
serious people accept them, presumably serious
Euro-Americans.
Recent conversations have attempted to align the “common
morality” with notions of basic human rights. Thus, there are basic
human rights (roughly equivalent to the notion of a common morality) and
there is community-specific morality, which takes into account local
variation in what is considered appropriate moral behavior and motivation.
This distinction is far too general to guide clinical practice.
So, to employ the Four Principles approach, we must accept that humans
share innate (i.e., universal) processes or characteristics that eventuate
in a common morality. Anthropologists, trained to be sensitive to the
diversity of human thoughts and values, typically eschew such assumptions
about innate or universal. Virtually all schools of anthropology entail an
acceptance of at least a weak form of descriptive relativism. Normative
relativism, favored by some anthropologists, goes a step further in
asserting that, because cultures judge each other according to their own
internal standards, there are no universal standards to judge between
cultures.22
Barnard A. History and
Theory in Anthropology. Cambridge: Cambridge University Press;
2000:99.
Some of the assumptions made under the banner of common morality
include: individualistic thinking—rather than communal, family, or
some other form of thought or orientation; the linearity of
time—rather than cyclical time; the universality of truth-telling;
informed consent; definitions of personhood; ownership and transplantation
of body parts; and withholding or withdrawing life-sustaining treatments
as moral virtues.23
Marshall P. Anthropology
and bioethics. Medical Anthropology Quarterly
1992;6(1):49–73 at p. 50.
Ethnographies (i.e., anthropological descriptions and analyses of
specific cultures) abound that challenge the appropriateness of these
“beliefs.” These assumptions become very apparent and, often,
problematic in end-of-life care. Barbara Koenig, for example, says that
advance directive assume an ideal patient with
- a clear understanding of the illness, prognosis, and treatment
options shared with the medical team
- a temporal orientation to the future and a desire to maintain
control over the future
- a perception of freedom of choice
- a willingness to discuss death openly.24
Koenig B. Cultural diversity in decision-making about care at
the end of life. In: Field MJ, Cassel, CK, eds. Approaching Death:
Improving Care at the End of Life. Washington, D.C.: Institute of
Medicine; 1997:363–82.
This largely represents educated, middle/upper-middle class
Americans. But Smith-Morris's research among elderly, predominantly
Anglo adults in Arizona suggests that even these privileged citizens are
ill prepared for a more likely end-of-life scenario.25
Smith-Morris C. False expectations? Expectations vs.
probabilities for dying. Omega Journal of Death & Dying
2000;41(3):157–85.
Alternatives and What Anthropology/ists
Can Offer
What principles or ethical theory could better address this plurality?
A variety of alternative theories and approaches exist now for
bioethicists to choose from, for example, casuistry, relationship-based
approaches, utilitarianism, character or virtue ethics, and
communitarianism. But few of these provide for the type and depth of
descriptive context we propose, and none address authoritative knowledge
and the power structures within which decisions about health and
healthcare are made. So if none of these options do it, what exactly can
anthropologists add? Why would ethnographic data lead to more ethical
practice?
Case 2
To explore anthropologists' potential roles in improving
bioethics, we offer a brief second case.
A young adult male is brought to the ER having swallowed a Pentium 4
computer chip. He has a history of psychotic episodes. He now has bowel
obstruction but refuses surgery, apparently wanting to keep the mechanism.
A psychiatry consult determines that he is not competent to make decisions
and he is sent to surgery.
Once there, an OR authority questions him to determine if he is
“oriented × 3.” He knows his name, the day, and the
president. The OR nurse then overrides the surgery decision, having
determined to her own satisfaction that he is competent.
In an ethics consult to discuss the decisionmaking process in this
case, the psychiatry residents mention that although the patient is mildly
retarded, this was not a factor in their determination that he
lacked the capacity to make a decision about surgery. The OR nurse then
vigorously states that if she had known he was retarded, she
would have never questioned the psychiatry decision.
So this case raises questions concerning cultural constructs of mental
illness and mental functioning that affect both popular thinking and
understandings of biomedical professionals outside psychiatry. It appears
from the discussion that the concept of “retardation” is less
contested than that of psychosis, or delusional states, even within
biomedicine.
An ethnography of nurses and doctors in different specialties and
their understandings of psychosis might provide us with information that
could then remedy some of these issues, thus leading to workshops on what
it means to be delusional, especially in relation to functioning
effectively in some domains of social life. This, in turn, could enhance
the understanding of how decisionmaking competence is determined and the
limits of individual autonomy. That is, anthropologists can add
ethnographic detail, informing ethicists and clinicians of the personal
narratives, cultural meanings, and local moralities that shape
decisionmaking. We should note that the concept of “personal
narrative” might suggest an idiosyncratic, subjective account.
However, as Kaufman cogently argues, narratives are constructed from
shared understandings of the cultural world, and as such, they identify
important cultural and structural features that shape individual moral
thought and feeling.26
Kaufman S. Clinical
narratives and ethical dilemmas in geriatrics. In: Hoffmaster B, ed.
Bioethics in Social Context. Philadelphia: Temple University
Press; 2001:12–39 at p. 17.
Authoritative Knowledge
A theory of biomedical ethics must step beyond the bounds of hegemonic
assumptions. The principalist approach re-creates and reinforces the
primacy of individualism, rationality, and a bounded temporal experience
of disease while failing to acknowledge power relations implicit in
biomedical decisionmaking. Authoritative knowledge is produced, displayed,
resisted, and challenged in social, clinical, and political interactions.
Much research, including Sargent's, demonstrates the links between
control of technology and the hierarchy of relations between specialists
and patients.27
Jordan B. Authoritative
knowledge and its construction. In: Davis-Floyd R, Sargent CF, eds.
Childbirth and Authoritative Knowledge: Cross-Cultural
Perspectives. Berkeley: University of California Press;
1997:55–80; Davis-Floyd R, Sargent CF. Childbirth and
Authoritative Knowledge: Cross-Cultural Perspectives. Berkeley:
University of California Press; 1997.
But research also shows the
possibility for interactional cooperation (alliances) and accommodation in
the clinical setting. The constitution of authoritative knowledge is an
ongoing social process; it constructs and reflects power relationships
within a community of practice. The process by which this occurs is such
that all participants tend to see the current social order as “the
way things obviously are.”
These hegemonic forces are what Beauchamp and Childress seem most
blind to. Questions of power in moral and ethical dilemmas—power
between practitioners and patients, power between different types or
fields of practitioners, power within families and cultures—are
marginalized and left unchallenged.
Many bioethicists and clinicians might argue that they have moved
beyond a rigid application of principles to resolve ethical dilemmas, and
rather, engage in flexible negotiations, indeed in a form of
therapeutic intervention in the resolution of such conflicts. We need to
ask, however, what is the ultimate objective of these negotiations? Often,
the implicit, if not explicit, goal is to convey to the patient and/or
family the preferred decision of the clinician, based presumably on
medical expertise or institutional concerns about liability.
Should we consider these “flexible negotiations” a form of
benevolent paternalism? We suggest the importance of acknowledging the
authoritative knowledge of the physician and other biomedical
practitioners. Physicians, whose moral weight and perceived scientific
expertise are linked to formidable medical technologies, are in a position
of power, and rarely in an egalitarian, collaborative interaction.28
See note 3, Helman 2000:86.
How
authoritative knowledge is produced and displayed in ethical consultations
is a question that anthropologists could usefully address.
A grounded approach to bioethics can be generated by ethnography.
Understanding the patient's explanatory model can help bioethicists
as well as biomedical practitioners explain that system to
patients/families so that they can make better informed decisions that
the system, in fact, requires them to make. For example, the
value placed on the individual in the United States creates not an
accidental correspondence between the ethics approach and the legal
protocol; the predominant ethics approach is isomorphic with the legal
system (J. Sadler, personal communication).
Do ethics consults actually do broader cultural work of furthering a
shared moral order in the context of a multicultural society? If we inform
only the system of the patient's model, we are reinforcing medicine
as a privileged domain of moral discourse. However, if we inform patients
of cultural details, power dynamics, and institutional requirements of
biomedicine, then they can ask more nuanced questions and have a better
chance of truly participating in an asymmetric therapeutic
interaction.
We propose an alternative for moving between a larger cultural,
historical, or family structure and context to the notion of an individual
as the unit of analysis. We would first redefine “the
case.”
The boundedness of the case is another unexamined assumption
fundamental in the principalist approach and closely related to, if not
produced by, the reification of individuals. Helman, for instance,
observes that biomedicine is unique in its imposition on the patient of a
linear narrative structure, the “case history.”29
See note 3, Helman 2000:96.
The clinical case—the identified patient, other relevant
decisionmakers, even the parameters in a temporal sense (when illness
began and when it ends)—is a manufactured product; a certain telling
of the story among many other possible tellings.30
Hunter KM. Doctors' Stories: The Narrative Structure
of Medical Knowledge. Princeton, N.J.: Princeton University Press;
1991.
Relegated to the background are the economic and social
contexts of the patient's life, cultural factors in the recognition
and meaning of illness, potential stigma, simultaneous (other) healing
efforts, and so forth. Even casuist and hermeneutic approaches, known for
their strident rejection of principalism, fail to expand the parameters of
the case itself.
A procedurally simple change, implemented not after or in
the midst of a crisis (as we so often see in ethics consults), but at
the initial presentation for care— that is, as part of the intake
process—would allow the alignment of patient and clinician
expectations to occur at a more natural point in the relationship. This
approach would involve eliciting the patient and family's explanatory
model. An explanatory model, as first proposed by Arthur Kleinman and
later elaborated by him with Leon Eisenberg and Byron Good, are the
notions about an episode of sickness and its treatment that are employed
by all those engaged in the clinical process. Barry Hoffmaster adds that
patient models reflect social class, cultural beliefs, education,
occupation, religious affiliation, and past experience with illness and
healthcare.31
Hoffmaster B. Bioethics in
Social Context. Philadelphia: Temple University Press; 2001.
Returning to the issue of power differentials, Helman argues that the
power invested in clinicians as a result of their training and technical
expertise often allows them to shape the patient's explanatory model
to fit the medical model, rather than allowing the patient's
perspective on illness to emerge.
32 See note
3, Helman 2000:86.
Correspondingly, Kleinman, in his
groundbreaking book on medicine as a cultural system, states that
the most difficult aspect of clinical practice to teach to
medical students, interns, and residents is how to elicit and evaluate
objectively patient beliefs and values with respect to their illnesses and
treatments and to negotiate with (or translate between) these differing
perspectives, in the same way an advisor gives expert advice to an
advisee, who retains the right to accept, alter, or reject that
advice.33
See note 1, Kleinman
1980:58.
Collecting the explanatory model can be done through a series of
questions like those in Figure 1.
Adapting this model for a more ethically neutral approach to
healthcare decisionmaking might look like the model shown in Figure 2. That is, it would begin with aspects of
decisionmaking and the values and beliefs guiding care.
An ethically neutral model.
How might ethical decisions change if cases came to be viewed as life
stories, family events, or other ongoing narrative? A grounded approach
that is informed by ethnographic information would reliably attend to the
structural, institutional, and procedural barriers that worsen—and
in many cases produce—ethical dilemmas in care. Armed with this
information, clinicians and institutions would at least have insight into
problematic arenas requiring changes.
A final case will demonstrate what we suggest.
Case 3
A doctor writes to an ethics committee requesting a discussion of
patients who behave abusively to doctors and nurses. The committee,
composed of doctors, nurses, social workers, chaplains, and community
representatives, agrees that this is an important issue. The
anthropologist present asks what is this abuse (verbal and sometimes
physical) and who are the abusers? The response from one prominent and
respected physician is “generic scumbags.” The anthropologist
suggests a survey in which when a case arises, the following information
is reported to a central source: age, sex, ethnicity of patient, medical
condition, and circumstances/context when incident occurred. Committee
members are not interested, deciding rather to ask for a consult with
psychiatry on how to manage disruptive patients. For them, a key ethical
issue is whether it is acceptable to call security for such a patient
(with exceptions made for someone with dementia or on drugs).
Management of the abusive patients, certainly a reasonable concern,
becomes the core issue of discussion. What we lack, however, are any data
on precisely who these “abusers” might be (we might speculate
on age, sex, insurance status) and in what sorts of situations abusive
behavior might emerge. Eliciting and analyzing this information might then
provide us with a means to address the fundamental, underlying causes of
disruptive behavior, and therefore to identify possible structural factors
implicated in these scenarios.
Closing
Bioethics is a field now dominated by premises of Western
philosophical thought: principles and rights-based approaches that have
reinforced a “pervasive reductionism, utilitarianism, and
ethnocentrism in the field.”34
See
note 23, Marshall 1992:49.
The original bioethics was intended to
empower patients in the context of a rights-based approach, which would
allow patients to reclaim power from biomedical expertise. It is ironic
that this effort to generate empowerment has had such mixed results.
35 For an insightful discussion of this history
see Stevens MLT. Bioethics in America: Origins and Cultural
Politics. Baltimore: The Johns Hopkins University Press;
2000.
We suggest that incorporating an ethnographic approach in ethical
analysis would challenge ethicists to pay greater attention to how moral
concepts are embedded in social practice and how biomedical practitioners
and institutional patterns shape the production and experience of ethical
dilemmas.36
Jennings B. Ethics and
ethnography in neonatal intensive care. In: Weisz G, ed. Social
Science Perspectives on Medical Ethics. Philadelphia: University of
Pennsylvania Press; 1990:261–73 at p. 269; also see note 23,
Marshall 1992:53.
Value neutrality is untenable in a “real-world” bioethics.
But anthropologists can effect change both directly (in communication with
patients and practitioners) and by advocating for structural change that
might have broader impacts: for example, decentralization of primary care
services might allow patients to develop therapeutic relationships and
alliances that would limit disruptive behavior; intake and
consent-gathering procedures that incorporate a larger network of those
invested might forestall later crises and disputes.
What we need are theories of bioethics that do not reproduce, in an
unexamined way, the assumptions of a single cultural paradigm; we would
benefit from forms of pedagogy that integrate anthropological and other
social science perspectives—and the incorporation of ethnographic
techniques in ethical practice—to situate problems in biomedical,
familial, interpersonal contexts. There are no simple and formulaic models
that can address diverse cultural differences. We are suggesting the need
for further cross-disciplinary talk about “how to talk,” with
the ultimate objective of generating informed and collaborative
negotiation of critical life issues.
