Listening to the Whispers is the fifth book in a series called Interpretive Studies in Healthcare and the Human Sciences.  Edited by Christine Sorrell Dinkins and Jeanne Merkle Sorrell, this book treats the subject of medical ethics from several different points of view.  Philosophers, medical anthropologists, physical therapists, and nurses offer their understanding of the current state of America's healthcare system and the position of ethics in that system.  One result of this gathering of viewpoints is a collection of essays that broadens the reader's appreciation of the ethical issues in healthcare by giving voice to some oft-ignored members of the healthcare community (oft-ignored, that is, in "traditional" biomedical philosophy).  Another result is that the book's appeal is widened to embrace not only philosophers, but also members of the medical and healthcare communities, as well as anybody with an interest in the real-world application of ethics.

There are five essays in this book.  Each is followed by a response from the editors.  The first is an ethnography, a case study of one home care facility's transition from public to private institution.  As the study recounts, corporatization (or privatization) carries with the risk of depersonalization.  Due to the pressures of business (productivity, regulatory paperwork, bureaucracy, regulations), nurses begin to feel like cogs in a machine rather than care-providers.  And because of the shift in focus from patients to productivity, patients end up being treated less as people and more as objects.  When care is no longer the main focus of an institution, but is relegated to one of many concerns, tasks compete for nurses' time.  Inevitably, the harsh realities of business force nurses to spend more time attending to the bottom line than to the needs of their patients.  One lesson of this exposé is that insofar as corporatization is here to stay, we ought to do everything in our power to not let healthcare-providers become buried under jobs that take them away from their most important role.  Listening to and heeding the concerns of nurses and others in healthcare institutions will help ensure that this loss of personhood does not occur.

The second essay continues along these lines, dealing with the question of how a healthcare organization can maintain its ethical identity.  Along with privatization, pluralization can be a major obstacle to ethical conduct and effective care and, in the context of the institution discussed, training.  In particular, this question arises: how can a Catholic healthcare organization maintain its religious and moral values while at the same time developing as a business?  It seems that when an institution has a sufficiently long and rich history, it is possible for the individuals within that institution to hold on to tradition while succeeding in business.  This, I take it, is intended as a message to other healthcare institutions: "Articulate your values, healthcare institutions, so that you might maintain your integrity."

The third essay offers the reader a lesson in ethical theory while advocating one approach to biomedical ethics above others.  Two modern theories, Consequentialism and Deontology, are presented as constituting a dichotomy.  Depending on which one a person accepts will determine whether, for example, the act of taking a patient off of life-support will be vindicated or condemned.  A better approach to such ethical questions as 'is it morally acceptable to remove life-support from a terminally ill patient' is not a modern one; it is an ancient one.  Aristotle's teleological approach, with its account of the human good, is a better guide through the dense forest of issues in medical ethics.  The editors, in their response, offer a nice illustration of the superiority of the Aristotelian approach over Consequentialism and (Kantian) Deontology.  Imagine you are an emergency room nurse.  A family has been in an auto accident, and you are treating the father.  You learn that the other family members have not survived the accident.  When the father then asks you how the rest of his family is doing, what do you say?  The deontologist (Kant) would have you tell the truth, while the consequentialist would have you lie.  If these seem like unsatisfying and extreme recommendations, consider the Aristotelian answer: aim between the extremes.  In the case at hand, that might mean telling the father to concentrate on getting better (or some such helpful platitude).  But Aristotle's ethic is not as rigid as some others.  It does not tell us never to lie.  Instead, it tells us to act based on consideration of each situation we face, along with our experience and our moral character.  This ancient theory has a lot to offer today's healthcare system.

The fourth essay in this collection illustrates some of the points made in the previous essay.  A look into the world of the physical therapist reveals a struggle between codes of ethics (moral duties) and patient care.  How does one determine one's actual duty when facing many competing (and conflicting) prima facie duties?  To what extent is a physical therapist (or any other care-provider, for that matter) expected to respect a patient's autonomy, knowing that in some cases a patient will make choices inconsistent with her health interests?  Because the moral codes of the healthcare system impose constraints on the moral conduct of physical therapists, each must rely on core values, emotional sensitivity, and "moral imagination".  These allow care-providers to cope with the rigid moral codes that healthcare facilities adopt, helping therapists bend the rules in the interest of patients.

The fifth essay sketches the state of healthcare and ethics in today's society.  This piece seems to offer both a warning and a suggestion.  The former involves the way individuals in modern society currently relate to one another.  We tend now to exist alongside one another, never striving to understand what it must be like to be somebody else.  We experience the world through our own set of lenses and through nobody else's.  If this continues to describe the state of society (and of the healthcare system), the ethical problems we face will never go away.  The suggestion this essay makes involves our seeing the world as others do.  Humans are essentially relational.  As such, we need to find ways to experience our shared world in more than one way.  In doing so, we foster an environment in which healthcare and ethics can happily coexist.

The editors have contributed the following concluding thoughts: We are at a point in time when the status quo of healthcare can be seen to be inadequate.  We need to recognize the diversity that exists in our world and listen to the many voices that have not to date been heard.  These voices inform us of varied viewpoints and experiences, and allow us to redefine 'care'.  And according to the editors, the result of this rethinking will be a more effective healthcare system, one plagued with fewer dilemmas and failures.

My training is in what you might call traditional analytic philosophy.  Consequently, I faced some difficulty when trying to read some of the essays in Listening to the Whispers.  My lack of familiarity with some of the anthropological jargon used resulted in my having to work a bit to understand when (and if) arguments were being presented in support of theses.  But despite my shortcomings in the social sciences, I found the exercise of comprehending this book to be quite rewarding.  No doubt, those comfortable with the style and terminology of an anthropology essay will be rewarded even more than I have been.  Listening to the Whispers does a very nice job of calling attention to the problems that exist right now in the healthcare system.  And although it is primarily a work of sociology or anthropology (i.e., highly descriptive), it presents a compelling and prescriptive case.  It describes the world in such a way that pushes one to begin the arduous but essential task of rethinking ethics in healthcare.

© 2007 Andrew Brei

Andrew Brei is working on a dissertation entitled "Our Right to Health and Our Duty to Nature," and expects to receive his Ph.D. in philosophy in 2007.  In the meantime, he teaches ethics at Purdue University.

Categories: Ethics