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by Nancy L. Diekelmann (editor)
University of Wisconsin Press, 2002
Review by Nancy Potter, Ph.D. on Feb 17th 2003

First, Do No Harm

As Annette Baier says, "Morality is the culturally acquired art of selecting which harms to notice and worry about, where the worry takes the form of bad conscience or resentment" (1983). Many of us--especially health care workers themselves--know that Hippocrates' ancient injunction to "do no harm" isn't all that clear. What counts as a harm, and who decides which harms must be borne for some greater good, are questions continually being examined and re-evaluated. This anthology, the inaugural volume of a new series in Interpretive Studies in Healthcare and the Human Sciences, provides numerous examples of harm done to patients. Its major contribution is that it situates harm through narratives of patients' experiences, thus providing clear case studies of the importance of perspectivity to ethical caring.

There are five chapters in this anthology. The first, by James Fletcher, Mary Silva, and Jeanne Sorrell, critiques the biomedical model that privileges professional decision-making and medical generalizations over patients' actual experiences and needs. The authors do this through an examination of patients with dementia. This chapter succeeds in making clear that patients with Alzheimer's must be approached from their unique perspectives and needs. The second, by Kathryn Kavanagh, examines the experience of a woman who is both care-giver and care-receiver. The author illuminates the struggles this woman had with role identity when she shifted from nurse to patient and her suffering when she did not receive the kind or quality of caring she needed. Kavanagh is quite good at making distinctions between different kinds of care, but sometimes what her distinctions amount to isn't clear. For example, she seems to equate a good kind of caring as "engagement," but what is that exactly, and what does it look like? There is voluminous literature on the philosophical underpinnings of care and caring, and only Nel Noddings' work is cited; readers will learn a lot from this chapter but will need to go elsewhere if they want a conceptual analysis of caring well (to use Joan Tronto's phrase [1993].) Also, while I enjoyed this article, I did wonder who the audience is: at times, the author uses what I call "pomo-ese." For example, she introduces a section on methodology with this sentence: "Interpretive inquiry turns to emergent designs to emphasize the complexity of human life in efforts to apprehend meanings in occurrences as they are contextualized in given times and places." Such sentences are likely to be clear only to those who are already immersed in a particular discourse and could be alienating to the unfamiliar reader.

The third chapter, written by Rebecca Sloan, describes the no-win situation many dialysis patients are in: if they do not choose it, they will die, but once on such life-sustaining technology, they experience a kind of death anyway. Sloan gives voice to many patients who suffer enormously from being on dialysis. She shows that, for many patients, the loss of self, experience, and embodiment amounts to loss of existence of the "I" they were before. She also identifies ways that medical language is experienced as harmful from the patients' perspective. While she doesn't offer a solution (medicine is highly technologized, after all, and we can't wish it away even if we wanted to), she does prompt readers to be more sensitive to the suffering of patients whose lives are governed by a technocratic world.

Elizabeth Smythe, in the fourth chapter, uses a Heideggerian framework to analyze what she calls "everyday violence." She is interested in subjective experiences of violence and thus points out ways in which women's needs (in childbirth, for example) go unmet. Her examples are poignant and memorable. They should prompt health care workers to be more aware, more compassionate, and more sensitive. On the other hand, I think she stops far too soon in her analysis when she leaves the notion of violence as purely subjective. "The violence this study seeks to illuminate is the violence that is only known by the person receiving it." This is an unsatisfactory epistemological end point: how can we avoid doing the kinds of things that, in her view, are "violent" if the naming of those things is purely up to the individual? If knowledge of violence is as subjective as Smythe says it is, then we cannot know in advance that there are certain things that would count as violent and, thus, ought not be done. Furthermore, if violence is only a matter of what each individual experiences as violent, then it would seem to follow that, if a person does not experience an act as violent, then it is not violent. But that is a deeply problematic position when it comes to women in battering relationships or children who are being abused. Many people in long-term violent relationships tend not to identify specific acts such as physical assault or rape as violent (out of love or attachment or self-blame), yet their subjective views would be, in an important sense, wrong.

The last chapter is definitely the strongest one, and it alone is worth the cost of the book. Claire Draucker and Joanne Hessmiller provide a clear argument and cogent analysis of the role of narrative in recovering from sexual violence. The authors very carefully go through the structural components of narrative, defining terms such as "culture" and "discourse," and thoroughly apply the analysis to the experiences of a young woman who has been raped several times. It is painful to read, but well worth it due to the authors' insights and clarity. (I must say, though, that the fit with the rest of the anthology isn't clear, even though the authors argue that violence narratives have things in common with illness narratives.)

In general, this anthology is a rich resource for examples of things going wrong in the minutiae of health care. But maddeningly, it does not live up to its promise in terms of connecting the dots from examples to concepts. The stated purpose of the book, according to series and volume editor Nancy Diekelmann, is to "explicate how power, oppression, and violence are implicitly embedded in the very practices directed toward their alleviation." In most of the chapters, the authors assert that their examples are instances of violence or oppression, but virtually never is there an argument given to support such claims.

It is true that the foreward, written by Kavanagh, explicitly states that "the volume mindfully avoids imposing the conceptual burdens of restrictive definitions." Yet, one wishes the authors took conceptual analysis more seriously and treated the fundamental concepts of the book--violence, power, and oppression--with more rigor. Fletcher et. al. define oppression as "associated with abusive or unreasonable use of decision-making" which is far too broad. Marilyn Frye (1983) carefully argues that the value of the term requires a strict application of it so that we don't slide into the meaningless claim that "everyone is oppressed." Oppression, as distinct from unjust actions or coercion, involves systematic forces and barriers that mold and shape members of a group in virtue of their group membership (Frye 1983). It isn't at all obvious that the many claims in this book about oppressive practices in health care genuinely are instances of oppression. While I think that many times, the various authors are correct in their claims about oppressive practices, I note the absence of argument. This is unfortunate, for mere assertions of oppression will not persuade many readers.

Similar concerns may be raised about the claims that such-and-such an act or attitude is violent. I am sympathetic to the point Smythe expresses that "we tend to ignore violence in its more subtle form." But if we are to do better at identifying it, we must have a better idea of what it is, and an ostensive definition will not suffice. Are all harms necessarily violent? Smythe equates feelings of hurt, waiting, being rushed, and being inappropriately reinterpreted all as forms of violence. Therapist indifference is "an assault." What holds all these kinds of harm or hurt together? Again, there exists a rich body of philosophical literature on violence that the authors (and readers) could benefit from. The term "violence," like the term "oppression" should not be watered down so that anything will count as violence as long as you or I say so. For the term to be meaningful, there must be such a thing as a wrong application of the term.

 

 

Bibliography

Baier, Annette. 1985. Postures of the Mind: Essays on Mind and Morals. Minneapolis: University of Minnesota Press.

Frye, Marilyn. 1983. "Oppression." The Politics of Reality: Essays in Feminist Theory. Freedom, California: Crossing Press.

Tronto, Joan. 1993. Moral Boundaries: A Political Argument for an Ethic of Care. New York: Routledge.

 

© 2003 Nancy Potter

 

Nancy Potter, Ph.D., Department of Philosophy, University of Louisville, Kentucky.