Beyond theory; A philosophical disease: bioethics, culture and identity; Carl Elliott; Routledge, New York; 1999; $29.99 (paper) 195 pp. ISBN 0-415-91940-1 FIGURE 1
To grapple with Carl Elliott's important monograph, A Philosophical Disease: Bioethics, Culture and Identity, is to feel the relief of receiving a long-awaited diagnosis and the foreboding of facing an uncertain prognosis. Elliott challenges the limits of scientific and ethical theory in medical practice, including bioethics, showing how theory fails us when we reflect on everyday moral problems. As we look through his antitheoretical lens, it becomes apparent that some moral problems and moral experiences are overly circumscribed and that our responses to them are inadequate. Medical educators, bioethicists and anyone with an interest in ethical theory in health care will want to consider seriously what Elliott has to say.
This is a book that lives its message. Elliott's twin aims - exploring the institutions of medical life in the absence of agreed-upon ends and exploring the nature of bioethics in the absence of ethical theory - are (largely) achieved without recourse to the methodology he rejects. He identifies and develops his main themes by attending to and recording lived moral experience: his own, his family's and that of his philosophical and literary heroes. Ludwig Wittgenstein figures prominently, as do Walker Percy and Elliott's own father. In this manner the text, like our moral lives, becomes a tapestry of moral concepts and experiences.
For readers more accustomed to medical and philosophical authors who authoritatively take (or drag) them by the hand through a quandary of medical-moral problems, Elliott's approach may not make for easy reading. His style, though a remarkable testament to the belief that the bioethicist's role is to listen, read, and write about moral experience, risks serious disjointedness. His central chapters explore wide-ranging themes, including the role of clinical bioethicists in medical bureaucracy, the effect of illness on identity, the treatment of spiritual illness as psychiatric disease, the impact of disordered personalities on moral responsibility and the moral problem of living heart transplantation. Each of these chapters could stand alone as a useful and engaging reflection on a challenging issue, but because they are pieces of a single monograph, the reader is forced to ask: How does this fit? What is Elliott trying to say? The question of context also arises as the reader confronts Elliott's varied and unusual source material. What do Wittgenstein, Percy, Prozac, psychopathology and donating a living heart all have to tell us about the evils of theory and the responsibilities of medical practice?
The need for contextualization is not an oversight on Elliott's part but part of his point. He wants us to question context. Theories and practices, he argues, too often give context short shrift, and the moral ramifications of this are serious. The ethical issues faced by people who provide and receive care arise from and depend on the prevailing ethos of medicine, which Elliott describes as a vast, relentlessly progressive, political and economic machine. Judgements about what is "normal" and what needs to be fixed depend on how that machine envisions the world. Elliott's portrayal of lived experience suggests that our moral imagination needs to expand to accommodate the particularities of social situations and experiences. FIGURE 2
Elliott weaves these considerations of context together with considerations of identity. One's identity is formed against and changes with one's background, culture, history and relationships with others. It follows that identity cannot be understood or responded to in a meaningful way without considerations of context. Attention to contextual aspects of identity leads Elliott to question, among other things, the dominant medical understanding of autonomy, which categorizes emotional ties and moral commitments as constraints on autonomy.
Elliott's last two chapters are the most important. In chapter 7, "The point of the story," he draws attention to ways in which moral communication in medicine and bioethics is shaped by the way it is delivered. For example, despite the prevailing medical assumption that case presentations are value-neutral, Elliott shows that the manner in which a case is presented depends on the values the teller uses to interpret the world. Moreover, all use of language involves a values-based interpretation of the world. The trick is to determine which interpretations carry more moral weight.
Elliott's appreciation for narratives that honestly and comprehensively describe moral experience may explain his effective use of a confessional genre. Poignantly, he begins his book with the admission that his favourite part of Jean Jacques Rousseau's Confessions is Rousseau's description of himself as a flasher. Confessional literature closes the gap between moral description and moral experience. Medicine and bioethics must find ways to do the same.
In chapter 8, "A general antitheory of bioethics," Elliott finally pulls together his main themes while diagnosing where bioethics has gone wrong and recommending interventions that will direct it back on a healthy course. Part of the cure lies in recognizing the problem: we expect more from our ethical theories and moral concepts than they can deliver. The notion that tidy truths can be spun out of simple theories is unreasonable and inconsistent with the complexities of our moral intuitions. Values are deeply rooted in culture and life experience and, as a result, are inseparable from contexts, are not fully under our control, and cannot meet the standards of systematic ethical theory. Following Elliott, bioethicists need to understand the nature and limits of their theories and to move beyond them. We need to attend honestly to the intimate side of bioethics, to lived moral experience, and to the interweaving of moral concepts with moral life.
I thank Christy Simpson for her helpful comments on a draft of this review.