The ethnographic critique of bioethics relies on a categorical division between “moral talk” and “ethics.” For the above authors, moral talk is utilized by ordinary frontline practitioners as they handle particular illness episodes. Ethics, by contrast, is the codified, reflective language of elite experts, located far from the scene of clinical action (Kleinman 1999)9. Moral talk addresses everyday experience and gets expressed idiomatically in the midst of ongoing social life. Ethics is based on the human capacity for reasoning and gets expressed through formal systematic theory (see Hoffmaster 1992, Jennings 1990). The categorical division itself sums up the central argument. Conventional bioethics offers an inadequate and misleading representation of the ordinary moral experience of practitioners. Ethnographic research, by contrast, is uniquely fitted to the task.
The critique successfully carves out a space for the prime anthropological method in a terrain otherwise monopolized by law and moral philosophy. It nonetheless has several shortcomings. First of all, bioethicists themselves have responded to the ethnographic critique point by point (Turner 2009, Hoeyer 2006, and DeVries et al. 2007). They point out that it misconstrues the internal diversity of contemporary bioethics. For decades, mainstream bioethicists have argued against formal inductive methods (see Dubose et al. 1994). Some privilege the cultural and institutional contexts of moral deliberation (Churchill 1997). Others draw from narrative theory and philosophical pragmatism to explore how ordinary people make (and represent) ethical decisions (Chambers 1999, McGee 2003). The ethnographic critique mistakenly loads all the abstraction on one side (formal bioethics), and all the concrete details of history, practice, and structural constraints on the other (ethnography). That false dichotomy in turn fuels the call for ethicists to become more like empirical social scientists. Raymond DeVries sensibly responds that the two fields are not obliged to agree with each other or use the same methods. They should instead regard their distinctiveness as a source of strength, because, after all, they have legitimately different endpoints. The contextualizing and often debunking style of social science aims at something quite different than the normative analysis, advice giving, and regulatory activities of bioethics professionals.
Even on empirical grounds, the sharp divide between disciplinary bioethics and everyday moral commentary starts to break down. Routine clinical work is deeply infused with the categories and instruments of formal bioethics, as illustrated by the above vignette from Eastside Services. The paperwork required to commit someone, for example, is mandated by the state mental health code, which itself arose decades ago out of explicit debates about patient autonomy and the obligation to treat (explored in Chapters Two and Six). Efforts to reform the inhumane state hospital system of the 1950s and to protect patients’ rights once dominated newspaper headlines and courtrooms, but they never quite went away. They instead became sedimented into everyday routines about commitment and many other basic clinical gestures. Even mundane bureaucratic procedures bear the marks of prior ethical debates. Eastside case managers, for example, must show people a paper labeled “patient’s bill of rights” when they get admitted to the program. Clients must sign a written consent form every year in order to receive services. Techniques to hold back people’s money and to write the treatment plan involve similar paperwork and have embedded in them similar ethical rationales, explored later in this book. These forms of regulation continue to shape daily work, whether or not clinicians acknowledge them. In the end, spontaneous commentaries about right and wrong are coproduced by high-order mandates as well as the local context of practice. To set up a categorical division between abstract normative ethics and everyday moral talk obscures this reality (see also Brodwin 2008).
According to the standard ethnographic critique, universalizing ethical frameworks are irrelevant to frontline workers. But this claim seriously mischaracterizes the moral life of clinicians. Listen again to Neil Hansen commenting on Andrea Watkins: “[She] manages never to be trained by the ringmaster. Why kill that? . . . We kill the spirit chemically or sociologically. And to do that to another human being is so unethical.” Neil Hansen, a low-level case manager, refuses outright the norms and standard practices endorsed by his agency. In fact, he uses the word unethical precisely because in colloquial English it enacts a blanket condemnation. He engages with the rightness or wrongness of his job by distancing himself from the local context and usual justifications. His reaction suggests that people socialized in a given setting—as small as a clinic or as large as a “culture”—do not necessarily respect the moral walls that surround them (Moody-Adams 1997). The walls are not impenetrable. Insiders actually find ways to criticize standard practices and assumptions, often by reference to high-order virtues and universal imperatives. To make sense of how frontline clinicians struggle through their work, thick description is necessary, but not sufficient. Ethnography must also ask how they manage to wrench themselves free, if only for a moment, from the near-at-hand warrants for action and the local moral worlds (see Kleinman 2006).
To drown clinicians’ ethical voice in layers of social context is a mistranslation—even a betrayal. The notion of everyday ethics seeks an alternative. It takes seriously people’s ability to evaluate their actions and express concern about their world, using criteria not already present in the immediate context. For this alternative method to succeed, it needs a firm concept of the ethical as an aspect of social life. One of the first books about the anthropology of ethics distinguished between ethics wide and ethics narrow (Edel and Edel 2000 [1968]). The former term refers to broad values and ideals, along with the means to realize them available in a given society. This notion fits all too well with an old and now discredited anthropological notion of culture. It is overly general and assumes a false uniformity of attitudes within bounded social wholes (Howell 1997). Ethics narrow is conceptually stronger and provides a clearer guide for ethnography. The latter term privileges obligations and duties: the subset of values that people feel compelled to realize. It gets expressed in language that enjoins and prescribes, approves and prohibits, praises and blames. The premise of everyday ethics begins with this simple model of ethics narrow. It then applies the model to the realities of clinical practice: short-term decisions and trains of action calibrated to local constraints and also the imperative to intervene in episodes of illness. It extends the register beyond the verbal and into people’s lived engagements. Clinicians’ sense of right and wrong and the way they figure their responsibility for particular others constitute the realm of ethics narrow. The realm becomes visible to ethnography not only through words but also through nonverbal expressions and action. The values that people feel compelled to realize become evident in the way they enact, evade, or modify the mandates for work.
To theorize the ethical as an aspect of social life, hence amenable to ethnography, presupposes that all humans experience “contemplative moments of moral reflexivity” (Parkin 1985, see also Sayer 2011). During such moments, people are influenced by ideals (about obligation and duty, for example) that aspire to universal application. But transcendent ideals are constantly questioned and modified through the give and flow of face-to-face encounters. As an element in social life, high-order principles, virtues, and norms are always already relational. They get mobilized only when people start to figure their responsibility, and hence their proper conduct, in concrete circumstances. Indeed, some argue that ethical experience as such occurs only when people criticize local circumstances by invoking values that extend beyond the local (see Kleinman 2006). This process becomes visible especially when they feel a mismatch between the inherited ideals and what the immediate situation demands. Such moments prove that people are not social automatons or simple vehicles for the reproduction of existing arrangements and ideologies. Parkin’s moment of moral reflexivity is the baseline experience