As Annette Baier says,
"Morality is the culturally acquired art of selecting which harms to
notice and worry about, where the worry takes the form of bad conscience or
resentment" (1983). Many of
us–especially health care workers themselves–know that Hippocrates’ ancient
injunction to "do no harm" isn’t all that clear. What counts as a harm, and who decides which
harms must be borne for some greater good, are questions continually being
examined and re-evaluated. This anthology, the inaugural volume of a new series
in Interpretive Studies in Healthcare and the Human Sciences, provides numerous
examples of harm done to patients. Its
major contribution is that it situates harm through narratives of patients’
experiences, thus providing clear case studies of the importance of
perspectivity to ethical caring.

There are five chapters in this
anthology. The first, by James
Fletcher, Mary Silva, and Jeanne Sorrell, critiques the biomedical model that
privileges professional decision-making and medical generalizations over
patients’ actual experiences and needs. The authors do this through an
examination of patients with dementia.
This chapter succeeds in making clear that patients with Alzheimer’s
must be approached from their unique perspectives and needs. The second, by
Kathryn Kavanagh, examines the experience of a woman who is both care-giver and
care-receiver. The author illuminates the struggles this woman had with role
identity when she shifted from nurse to patient and her suffering when she did
not receive the kind or quality of caring she needed. Kavanagh is quite good at making distinctions between different
kinds of care, but sometimes what her distinctions amount to isn’t clear. For
example, she seems to equate a good kind of caring as "engagement,"
but what is that exactly, and what does it look like? There is voluminous literature on the philosophical underpinnings
of care and caring, and only Nel Noddings’ work is cited; readers will learn a
lot from this chapter but will need to go elsewhere if they want a conceptual
analysis of caring well (to use Joan Tronto’s phrase [1993].) Also, while I enjoyed this article, I did
wonder who the audience is: at times, the author uses what I call
"pomo-ese." For example, she introduces a section on methodology with
this sentence: "Interpretive inquiry turns to emergent designs to
emphasize the complexity of human life in efforts to apprehend meanings in
occurrences as they are contextualized in given times and places." Such sentences are likely to be clear only
to those who are already immersed in a particular discourse and could be
alienating to the unfamiliar reader.

The third chapter, written by
Rebecca Sloan, describes the no-win situation many dialysis patients are in: if
they do not choose it, they will die, but once on such life-sustaining
technology, they experience a kind of death anyway. Sloan gives voice to many patients who suffer enormously from
being on dialysis. She shows that, for
many patients, the loss of self, experience, and embodiment amounts to loss of
existence of the "I" they were before. She also identifies ways that
medical language is experienced as harmful from the patients’ perspective. While she doesn’t offer a solution (medicine
is highly technologized, after all, and we can’t wish it away even if we wanted
to), she does prompt readers to be more sensitive to the suffering of patients
whose lives are governed by a technocratic world.

Elizabeth Smythe, in the fourth
chapter, uses a Heideggerian framework to analyze what she calls "everyday
violence." She is interested in
subjective experiences of violence and thus points out ways in which women’s
needs (in childbirth, for example) go unmet.
Her examples are poignant and memorable. They should prompt health care workers to be more aware, more
compassionate, and more sensitive. On
the other hand, I think she stops far too soon in her analysis when she leaves
the notion of violence as purely subjective.
"The violence this study seeks to illuminate is the violence that
is only known by the person receiving it." This is an unsatisfactory epistemological end point: how can we
avoid doing the kinds of things that, in her view, are "violent" if
the naming of those things is purely up to the individual? If knowledge of violence is as subjective as
Smythe says it is, then we cannot know in advance that there are certain things
that would count as violent and, thus, ought not be done. Furthermore, if violence is only a matter of
what each individual experiences as violent, then it would seem to follow that,
if a person does not experience an act as violent, then it is not violent. But that is a deeply problematic position
when it comes to women in battering relationships or children who are being
abused. Many people in long-term
violent relationships tend not to identify specific acts such as physical
assault or rape as violent (out of love or attachment or self-blame), yet their
subjective views would be, in an important sense, wrong.

The last chapter is definitely
the strongest one, and it alone is worth the cost of the book. Claire Draucker and Joanne Hessmiller provide
a clear argument and cogent analysis of the role of narrative in recovering
from sexual violence. The authors very
carefully go through the structural components of narrative, defining terms
such as "culture" and "discourse," and thoroughly apply the
analysis to the experiences of a young woman who has been raped several times. It is painful to read, but well worth it due
to the authors’ insights and clarity. (I
must say, though, that the fit with the rest of the anthology isn’t clear, even
though the authors argue that violence narratives have things in common with
illness narratives.)

In general, this anthology is a rich resource
for examples of things going wrong in the minutiae of health care. But maddeningly, it does not live up to its
promise in terms of connecting the dots from examples to concepts. The stated
purpose of the book, according to series and volume editor Nancy Diekelmann, is
to "explicate how power, oppression, and violence are implicitly embedded
in the very practices directed toward their alleviation." In most of the chapters, the authors assert
that their examples are instances of violence or oppression, but virtually
never is there an argument given to support such claims.

It is true that the foreward,
written by Kavanagh, explicitly states that "the volume mindfully avoids
imposing the conceptual burdens of restrictive definitions." Yet, one wishes the authors took conceptual
analysis more seriously and treated the fundamental concepts of the
book–violence, power, and oppression–with more rigor. Fletcher et. al. define oppression as
"associated with abusive or unreasonable use of decision-making"
which is far too broad. Marilyn Frye (1983) carefully argues that the value of
the term requires a strict application of it so that we don’t slide into the
meaningless claim that "everyone is oppressed." Oppression, as distinct from unjust actions
or coercion, involves systematic forces and barriers that mold and shape
members of a group in virtue of their group membership (Frye 1983). It isn’t at all obvious that the many claims
in this book about oppressive practices in health care genuinely are
instances of oppression. While I think that many times, the various authors are
correct in their claims about oppressive practices, I note the absence of argument. This is unfortunate, for mere assertions of
oppression will not persuade many readers.

Similar concerns may be raised
about the claims that such-and-such an act or attitude is violent. I am
sympathetic to the point Smythe expresses that "we tend to ignore violence
in its more subtle form." But if
we are to do better at identifying it, we must have a better idea of what it
is, and an ostensive definition will not suffice. Are all harms necessarily
violent? Smythe equates feelings of
hurt, waiting, being rushed, and being inappropriately reinterpreted all as
forms of violence. Therapist indifference is "an assault." What holds all these kinds of harm or hurt
together? Again, there exists a rich
body of philosophical literature on violence that the authors (and readers)
could benefit from. The term
"violence," like the term "oppression" should not be
watered down so that anything will count as violence as long as you or I say
so. For the term to be meaningful,
there must be such a thing as a wrong application of the term.

Bibliography

Baier,
Annette. 1985. Postures of the Mind: Essays on Mind and Morals.
Minneapolis: University of Minnesota Press.

Frye,
Marilyn. 1983. "Oppression." The Politics of Reality: Essays in
Feminist Theory. Freedom, California: Crossing Press.

Tronto, Joan. 1993. Moral Boundaries: A Political Argument for an
Ethic of Care. New York: Routledge.

© 2003 Nancy
Potter

Nancy Potter, Ph.D., Department
of Philosophy, University of Louisville, Kentucky.

Categories: Ethics