What clinicians say also signifies something a few steps back from the scene of action: their shifting relationship to the collective ethos of the work group. Eastside Services is a moralized workplace, like so many others in public sector mental health (Kirschner and Lachicotte 2001, Robins 2001). People easily endorse sentiments of responsibility and care: “You have to be a parent to the clients”. To witness a human being sliding into serious danger—Andrea barricading herself in her apartment, for example—animates clinicians’ well-intentioned perspective. Frontline staff members at this agency think of themselves as advocates whose expertise helps people avoid the worst outcomes of illness. A blockage of work or an uncontrollable crisis, therefore, threatens clinicians’ preferred self-image as well as their technical skills. By speculating about the rightness or wrongness of their conduct, clinicians take up an explicit position—perhaps for the first time—toward the pervasive but usually tacit type of self-regard in this setting.
So, everyday ethics is contextually situated, not abstract. It is indexical; it denotes near-at-hand events and relationships. Through informal reflections on the values driving their work, people discern their own commitment to collective ideals. It is also extraordinarily diverse, even in a single workplace and with a single case. People’s comments about Andrea Watkins run the gamut from matter-of-fact justifications to outright condemnations of the agency’s role. The register ranges from sarcasm to moral earnestness. Ryan’s assertion that he has Andrea at “just the right place”—medication compliant and satisfied with her housing—confidently legitimizes his actions. Neil’s shock at discovering Andrea’s lifeless body frames his work in entirely different terms. He struggles to make sense of his dual role as witness to clients’ mortality as well as insignificant cog in the municipal machinery that processes the disenfranchised. Some Eastside staff members joke nervously about trampling Andrea’s rights in order to avoid the greater harms of decompensation. Others attack the agency’s standard clinical practices as killing her spirit.
Because of this sheer diversity, ethnography must begin with the ensemble of expressions in a given workplace. Fieldwork should seek out not just the dramatic expression and the especially insightful clinician but also the ways everyone articulates (or questions) the justifications for the job. The boundaries of fieldwork obviously enclose a physical place—such as an agency or clinic—and everyone in it. But they also enclose a specific landscape of practice, the types of problems people repeatedly encounter, and the set of tools they use to meet the demands of the day. People say many things inside this boundary about right and wrong, the obligatory and the forbidden, and the legitimate use of professional power. They express it in their words, their silences, and through body language as well as emotional outbursts. Yet whatever they express emerges from the same conditions of work, and it constitutes a single, if internally diverse, repertoire.
What accounts for the range of positions that people adopt? What pushes some to champion standard practice and others to criticize it in the most radical terms? Personal biography surely explains part of the story. Religious commitments or experience with mental illness in one’s own life may well affect how someone evaluates a clinical decision or procedure. But people’s deep personal background and the psychological roots of ethical deliberation lie outside of this study. They point away from, instead of toward, the scene of work. Professional training and social position on the clinical team play a more immediate role. As medical sociologists have long shown, the competition between occupational groups often drives what later become labeled as ethical conflicts. Individuals’ structural position in the clinic helps determine how they identify ethical problems in the first place. Each health care profession, moreover, has its own ethos, so inter-professional conflict can unleash extreme rhetoric, as people defend simultaneously their own moral vision and their professional interest. Ethical debates at Eastside Services thus typically get mixed up with social competition between groups that exert unequal power and champion different visions of proper care for severe mental illness.6
ETHNOGRAPHY AND BIOETHICS: A KNOTTY CONVERSATION
Listening to Eastside Services clinicians as they pass judgment on their work reveals how they accommodate themselves to the collective ethos of the workplace and the local hierarchy of prestige and power. If the analysis stops there, however, it runs the risk of an embarrassing social science reductionism. One can legitimately regard everyday ethics as immersed in local practice, as an expression of professional ideals, and as a symptom of workplace politics. But to reduce it to any one of these levels misses what matters the most to frontline workers. It risks trivializing the passion and depth of their comments. It ignores people’s baseline propensity to evaluate how they are being treated and how they should treat others (Sayer 2010). The goal of ethnography should not be a smooth translation of insider’s ethical commentaries into one or another expert discourses in anthropology or sociology. A better goal is to open up those discourses to create a place for clinicians’ ethical sensibility, which after all carries its own penetration into the conditions of work.
The ethnography of everyday ethics, just like ethnography in general, fundamentally involves translation. Ethnographers take a fleeting moment of talk and fix it on the written page. They try to explain and generalize moments of interaction that, for the actors themselves, are self-evident and riveted to local circumstances (Ricoeur 1981, Jenkins 1994). Ethnographic translation, however, can follow several different tracks. Referring to literary texts, Walter Benjamin (1969) urges translators not to obliterate the intention of the original author; that is, not to replace it with the conventions and categories of the translator’s own language. “The language of translation,” he writes, “can—in fact must—let itself go so that it gives voice to the intentio of the original not as a reproduction, but as harmony.” In the same spirit, the ethnography of everyday ethics in health care must listen to voices from the frontline and then offer a translation that harmonizes with them. The written product should not obliterate clinicians’ own perspective (evaluative, indexical, and practical) in favor of the analytic and theory-heavy frameworks preferred by academics. It should instead complement the insiders’ perspective, so the insider’s and the ethnographer’s accounts ultimately take their place as equally provisional commentaries on the difficulties of clinical work. In the end, the language of the ethnographer-translator should be powerfully affected by the foreign tongue (to paraphrase Benjamin again). The chapters in this book document the ethical sensibility of clinicians, as expressed through their words and actions, and then frame them ethnographically in terms of the structural constraints of work. The goal is to amplify the voice of frontline workers, who have the most intimate knowledge of clients but the least influence in broader conversations about public mental health services.
A second goal is to advance the knotty and frustrating conversation between ethnography and medical ethics. So far, the cross talk between these two fields involves mostly attack, defense, and counterattack. The standard social science critique (inaugurated by Fox and Swazey 1984) claims that ethnography supplies a better translation of clinicians’ moral life than does formal bioethics. According to this argument, people engage with the ethics of medical care not by invoking abstract principles and values (autonomy, utility, care, etc.) but rather through local idioms and reflections on their immediate, practical activities. People’s moral perspective on medical treatment emerges from the concrete details of inequality and local notions of suffering, not high-order virtues or rules of conduct. Emotional experience and local institutional arrangements drive many of the social conflicts that later get formally labeled as bioethics disputes. Ethical discussions by both staff and patients are thus inseparable from their immediate life circumstances, social roles, political interests, and cultural beliefs.7
On this basis, social scientists have criticized the experience-distant language of formal bioethics for misrepresenting the way clinicians actually think about their conduct and obligations. An important stream of U.S. bioethics is committed to liberal individualism, contractual relations, and core principles such as autonomy, beneficence, nonmaleficence, and distributive justice. It prescribes rational and systematic deliberation as the proper response to moral uncertainty (Beauchamp and Childress