Conversations on the Edge: Narratives of Ethics and Illness (review)

Many academic medical centers have ethics consultation services staffed by people with training and experience in clinical ethics. Richard Zaner, a distinguished philosopher who has worked for over twenty years as an ethics consultant at Vanderbilt University Medical Center, is one of these people. In Conversations on the Edge: Narratives of Ethics and Illness, he draws on his experience to tell six stories intermixed with reflections. Five stories revolve around formal ethics consultations; Zaner describes cases, recounts discussions, reports on decisions people had to make, and reflects on his own emotional engagement. The sixth story is Zaner's account of the illness and death of his own mother. As her illness progressed, she grew concerned about the kind of person she was becoming and the burden she would be for others.

A good example of Zaner's work is the second story, "When You're Dead Anyway, What's to Live For?," about Tom, a twenty-eight-year-old patient, who was refusing dialysis. Tom told Zaner, directly and forcefully, "I know damn well what I want and don't want, and what I don't want is to be hooked up to that damn machine! Not me, no sir! I've done it, I've had it, and I've had it especially with machines and hospitals and doctors, and I've had it with folks like you" (17). An ethics consultant with a libertarian bent might make short work of this case. Competent adult, right to be left alone—end of story. But Zaner does what a good ethicist would do: he tries to figure out why Tom does not want dialysis. He succeeds because he asks good questions, listens carefully, and helps Tom construct a coherent and heartfelt narrative about his past endeavors, present problems, and future possibilities.

Tom was born with spina bifida. He endured surgeries and treatments that allowed him to live, but he never had use of his legs or control of his bladder. He did have a close relationship with his mother, a meaningful job, and a strong desire to be more independent, but recent illnesses had jeopardized his job and his quest to live independently. Without meaningful work and some hope of independence, he did not want to live. None of this was apparent to his doctors, nurses, mother, or even to Tom himself, until Zaner talked and listened to him, probed and explored, and forced everyone to confront a variety of issues. In the end, Tom chose to accept treatment because he wanted to try to get his job back and move into an apartment by himself.

When involved in a case, Zaner observes his own reactions and does not shy away from "wormy thoughts and gloomy feelings" (73). His introspections and inner dialogues often lead to reflections in which he tries to articulate what I would call the phenomenological ground of ethics. Zaner doubts that ethical life can be grounded in abstract notions of autonomy and rationality; he focuses his attention on relationships and connections. This is not new—for years feminists have critiqued legalistic notions of autonomy and focused attention on relationships. But Zaner uses this focus to illuminate work in clinical ethics. He also notes just how much ethical life is embodied in orientations, postures, attitudes, comportments, and interactions. Our encounters with one another are "saturated with values, obligations, responsibilities" (36).

Conversations on the Edge has many merits, but I want to try to articulate its limitations because these are not so apparent. First, the range of reflections is somewhat limited. Zaner often considers the phenomenological, the existential, even the metaphysical aspects of cases, but rarely the political. For example, Tom's case prompts Zaner to reflect on the orientation of ethical attention, the reflexive nature of the self, and—although he does not quite say it—the cosmic injustice of congenital accidents. The case prompted me, however, to reflect on other things, such as how many cases...