The ethnographer’s tool kit can illuminate what provokes people into this experience and hence to speculate about the ethical stakes of their action. Think of everyday routines and their breakdown, social hierarchies and the challenges to them, scripts for interaction and unruly or resistant actors. Such ruptures push people to evaluate the immediate situation and the possible routes through it. The criteria for their evaluation are complex, and they are difficult to express. Elucidating the concepts and rationales behind spontaneous ethical comments is the job of moral philosophy. The chief tasks of ethnography are different: to document the provocations, the range of people’s ethical response, and what their responses accomplish.
Ethnographers need greater clarity about that central term—an ethical response—in order to discern it in the messy contexts of everyday clinical work. As an expression in the midst of practice, the core characteristic of an ethical response is its subjunctive tone or mood. According to the philosopher Mary Midgley, the realm of the ethical immediately impresses with its seriousness and importance (2003: 123 and passim). An ethical expression announces that in the present circumstances, we cannot just act according to our whims, habits, or the usual conventions. Following any of these routes falls short of . . . the distinctively ethical demand. If we do not know how to act, or we know but the way forward is blocked, we feel acutely the gap between this demand and our present capacities. The perceived distance between the desirable and the possible, the ideal state and the present condition, categorically defines the ethical mood.
The ethical response also engages peoples’ central purposes as they understand them (Midgley 2003: 145). Confronted by ruptures in taken-for-granted routines and social orders, people must craft a response. Sometimes they successfully answer the challenge through their technical competence, persuasive skills, or sheer ability to maneuver through complex social institutions. Their response becomes ethical, however, when it addresses not only the situation at hand but also their more diffuse orientations toward the proper way to live and to bear responsibility for others. If, in order to resolve the problem, people must revisit other deeply held priorities concerning the good, the honorable, and the obligatory, then they are entering the terrain of everyday ethics. They do not thereby renounce other ways of solving the problem—based on clinical, technical, or legal logics—that continue to provide important recipes for action. But they discover that these standard guides or algorithms ultimately fall short. Even more, their response qualifies as ethical if they have robust knowledge of the range of alternatives. Responding in a certain way just because they cannot imagine any other path seems somehow empty of any value considerations. By contrast, evaluating the situation through one criterion, while acknowledging and rejecting others, typifies a distinctly ethical choice.
To imagine ways of acting beyond those prescribed by local customs or bureaucratic rules characterizes the ethical response. Ethnography insists, however, that such imaginings are not limitless; they grow from and return to the local social context and near-at-hand contingencies. Fieldwork must ferret out the circumstances that incite people to rework their values and articulate the emergent stakes of their action. It must document the circumstances that lead people to problematize their usual routines. Certain passages from Michel Foucault help clarify the question, even though he addressed ethics more in comparative civilizational contexts than as a matter of individual reflection. To regard one’s conduct as problematic means to question its meaning, conditions, and goals (Foucault 1997). What instigates such questions? Let us narrow the question to the face-to-face circumstances of health care work. What social, political, and economic factors cause everyday clinical routines and interaction to become ethically uncertain? Tracing the history of a particular treatment apparatus will show the fault lines in its legitimacy, that is, its vulnerability to ethical critique from individual actors. Learning the history of a given health care field– its categories, institutions, and personnel—must therefore precede the ethnography of everyday ethics.
The very ability to problematize a given situation suggests another dimension of the ethical response. When clinicians are forced to think explicitly about usually routine decisions, they also start to think differently about themselves as subjects and ethical agents. Problematizing the situation, in this sense, is a practice of freedom. When a social worker or psychiatrist discovers that the usual gesture of work subverts her own ideal self-image, she inaugurates a moment of moral reflection. At the same time, it is a momentary refusal of the sedimented values of the treatment setting and its dominant recipes for action. She carves out a small zone of freedom in the midst of workplace rules and professional norms. Foucault rejects the utopian notion that freedom means acting fully outside of power; a person, he wrote, does not begin with liberty, but with the limit (see Bernauer and Mahon 1994). So, when a clinician imagines alternatives to the prescribed routines or expectations, her freedom obviously exists in tension with specific social and historical constraints (Laidlaw 2002). What she achieves, moreover, is often evanescent and insignificant, even from the standpoint of the local work group. A hallway discussion, a staff-room debate, a push to alter the standard procedures for future cases—the real-world results of everyday ethics rarely go any further.
A more substantial change occurs in her relationship to herself. That is, she partially reformulates herself as an ethical subject. To ask whether a given action is right or wrong means to choose the kind of person one wishes to become. Foucault regarded ethical reflection as a site of self-fashioning. One chooses a moral goal and then moves toward it through practice of self-cultivation: a matter of monitoring, improving, and transforming oneself (Foucault 1990, see also Davidson 1986 and Paxon 2005). His approach suggests several questions for the ethnography of everyday ethics. When do ruptures in the flow of ordinary work provoke people to reassess their ethical agency? Do the objective constraints that clinicians encounter seep into their self-regard? How do people respond both outwardly—by trying to change conditions of work—and inwardly—by articulating their value commitments or inventing new ones?
This brief discussion does not aim at advancing moral philosophy and even less at establishing the proper norms for the conduct of mental health professionals. It instead seeks a better way for ethnography to engage with bioethics. The perspectives from Midgley and Foucault—thinkers from radically different traditions—show how to make clinicians’ ethical commentaries visible during long-term qualitative research. Fieldworkers should analyze everyday ethics as a social production but also encounter it on its own terms: its compelling quality, the deep purposes that get stirred up, the self-fashioning set in motion. The ultimate goal here is not to oppose ethnography to bioethics through a sort of disciplinary combat, but instead to amplify the voices of ordinary frontline clinicians and introduce them into debates where they are typically absent. This sort of ethnography resists translating everyday expressions into abstract social science jargon. It rather follows clinicians’ lead as they mix up reflections about local practice with other norms, ideals, and personal commitments.
OUTLINE OF CHAPTERS
Chapter One offers a genealogy of Assertive Community Treatment, a necessary prelude to the details of frontline practice. Complex social and historical conditions produced both the mission and the clinical apparatus of ACT. The core task at Eastside Services is to maintain people diagnosed with severe mental illness in their own living spaces and to delay or minimize their next psychiatric crisis. This mandate emerged from the past half-century of mental health reform in the United States, and it contains all the contradictions and unfinished business of that period. The chapter summarizes the failures of deinstitutionalization and then examines the subsequent efforts to revamp the system. Reformers assembled a novel mode of treatment by trial and error at the scene of work, as well as policy-level advocacy and lobbying. Once the model was assembled, ACT advocates set about implanting it across the country. That process, however, immersed ordinary clinicians in grids of surveillance and a rigid administrative logic that undercuts their clinical skills. The tasks of ACT inherently demand improvisation, but Eastside staff are disempowered and hedged in by bureaucratic rules. The ACT blueprint, moreover, casts the psychiatrist and case manager in complementary but unequal roles. Case managers’ distinctive knowledge always risks