Unmaking the ethics case; The fiction of bioethics: cases as literary texts; Tod Chambers; Routledge, New York and London; 1999; 207 pp. $34.95 ISBN 0-415-91988-6 (cloth)
FIGURE 1 As philosophy stepped down from its ivory tower and into the clinic, it was perhaps inevitable that it would adopt the style of clinical discourse - the analysis of cases. Medical cases describe and work through the "real" problems of health gone awry that are confronted and resolved in the "real" world of the medical clinic. With the emergence of bioethics, ethics cases have become the preferred method for confronting and resolving problems involving transgressions of morality in clinical practice. They bring ethical theory to bear on practical moral problems and put the tools of philosophy to work in the "real" world of the clinic. Bioethicists have tended to emphasize the "realness" of their cases, but this emphasis obscures something important: ethics cases are fiction.
All ethics cases, even those drawn from actual events, are representations of reality inevitably coloured by the philosophical and other biases of their authors. The way cases are presented affects the way we understand the moral problems they raise. In The Fiction of Bioethics Tod Chambers tackles what bioethics has ignored: a critical assessment of the rhetoric of ethics cases. His work sheds light on the ideology embedded in ethics cases and offers us strategies to better develop and analyse ethics cases. It also reminds us of the value of interdisciplinary discourse. Anyone who writes or uses ethics cases will benefit by this book.
Chambers takes us through the deconstruction of ethics cases in the step-by-step fashion of literary criticism. Whole chapters are devoted to different segments of the case: point of view, issues of authorship and readership, location, the opening and closing of the case, use of character, the patient's voice, inclusion and exclusion of information, the influence of medium, the influence of gender. Chambers' analysis is brisk, with just enough detail to make his argument clear. His language is broadly accessible, and his use of well-known bioethics cases is strikingly effective, as it forces us to confront the inadequacies of our prior analyses of those very cases.
Chambers teaches us to pay attention to the narration of ethics cases. Narrators may seem to be, but are not, impartial observers, for the author of a case subtly weaves a commentary into the events narrated. We learn to listen for the patient's voice, realizing that in ethics cases patients rarely speak for themselves. We begin to question the events of the case. The author's choice of what to include or exclude - that is, the determination of what is relevant - depends on his or her philosophical point of view. For instance, Chambers contrasts different published versions of the "real" Dax Cowart case (in which a young man, badly burned, received treatment that he had refused): what is presented as fact in one version is mere point of view in another and entirely absent in others. When we are meant to see the moral problem as a tension between autonomy and beneficence, Dax's mother is not mentioned, which obscures the effect of the physician's action on her. When we are led to conclude that paternalism is justified, information is included that challenges Dax's rationality. That information is omitted when we are meant to judge that paternalism as unjustified. FIGURE 2
Other features of ethics cases ignore - and, in so doing, sometimes sustain - matters of social injustice. Most bioethics cases take place in a generalized clinical setting, which has the paradoxical effect of narrowing the reader's philosophical and theological orientations. Accordingly, they lack sufficient particularity of location for issues of social justice to be meaningful. A lack of particularity extends to character as well. Characters tend to be so poorly developed that they are not characters at all, but mere roles. Their names, often "Smith" and "Jones," might be used to convey ordinariness, but they are not neutral. They signify only those particular communities where those names are ordinary. Their use distorts the variety and complexity of moral beings and moral situations, excluding or holding at a disadvantage those who are not "ordinary." Chambers also points out how ethics cases unintentionally privilege a male world view. With the historical predominance of men in both medicine and bioethics, the style of medical presentation and male literary modes mark ethics cases with a male voice. Thus, as opposed to the plotless, nonlinear, contextual, character oriented style of female literary modes, ethics cases marked with a male voice have linear plots that climax and lack attention to experience and character. They also emphasize binary oppositions such as autonomy vs. beneficence, giving priority to male traits of self-rule and independence over female traits of caring for the well-being of others. Chambers identifies a need to understand how other aspects of social injustice related to race, class and other social factors also influence the framing of ethics cases.
The shortcomings of Chambers' analysis lic mainly in what it does not do. I found myself wanting his literary analysis to give way to ethical analysis. Each chapter ends with insightful conclusions about how ethics cases are framed, but these endings are mere beginnings for a discussion of how ethics cases should be constructed, should be used, should be read. Chambers tells us that ethics cases are "still important" but provides no argument to convince us that this is so. He argues that we must learn to read ethics cases in a manner that uncovers their rhetorical force, but is silent about whether the way we write ethics cases should change. Leaving these issues hanging may be intentional on Chambers' part. After all, his aim is only to provoke an inward turn in bioethics toward greater intellectual honesty. Having provided an analysis that does this, Chambers leaves it to the reader to finish the job.