Community as Healing: Pragmatist Ethics in Medical Encounters (review)

In Community as Healing: Pragmatist Ethics in Medical Encounters, Micah Hester achieves the near impossible—offering a book on bioethical methodology that combines critical virtuosity with accessibility to nonbioethicists. Emphasizing the teachings of pragmatist philosophers John Dewey, William James, and George Herbert Mead, Community as Healing offers an elegant summary of the development and operation of personal intelligence, a scathing (if at times exaggerated) critique of bioethical principlism, and (best of all) a cogent and engaging prescription for cultivating communities of healing. This book is necessary reading for academic bioethicists who wish to keep abreast of the best and most innovative thinking in their field. Perhaps more importantly, it is ideal for undergraduate and graduate students of bioethics or American philosophy. There is, I believe, no better introduction to Deweyan methodology in bioethics.

In the initial chapter, Hester examines practices and persons. He notes that practice is a function of habit (5) and then distinguishes between rigid, dogmatic habits (habituations) and dynamic, flexible habits (intelligent habits). Because practices are socially embedded, and because social relations (especially medical ones) are transmutable and often transient, the acquisition of good habits requires a high degree of social responsiveness. Good medicine is a form of moral artistry, insofar as effective practitioners must cultivate just the right mix of sociality, flexibility, and critical acumen.

Further, Hester confirms that those who seek care should be viewed as persons rather than as disease receptacles. They seek help because their lives have been disrupted. Healing generally requires that these disruptions be understood in their proper context—as interruptions in the processes by which individuals constitute themselves as contributing members of various communities. In order to be healed, individuals must be restored to active participation within their chosen communities (17). On the basis of such considerations, in combination with the Deweyan insight that it is best to refrain whenever possible from enacting a means-end duality, Hester concludes:

Healthy living is the common participation in, with, and by community. It is the significant, meaningful engagement in one's pursuits within a social context. Therefore, living significantly in community should be both the end and means of most medical encounters. (17)

Hester assails the traditional bioethical principlism of Beauchamp and Childress and the deontological libertarianism of H. Tristram Engelhardt because they provide no room, and no stimulus, for the morally imaginative clinical encounter. Instead, these thinkers focus on the doctrine of informed consent, derived abstractly from a higher order principle of autonomy. Hester shows us how this kind of thinking begets mechanical medical encounters, in which clinicians recommend a certain intervention and then, after reciting a list of risks, burdens, benefits, and alternatives, conclude their discussion by obtaining the patient's signature on a prototype consent form. In autonomy-based bioethics, Hester concludes, moral artistry gives way to lifeless routine. Hester adroitly challenges Beauchamp and Childress by exposing the inherent limitations of a top-down methodology that begins with principles, and admonishes Engelhardt both for his too-facile division of humanity into moral friends and moral strangers and for the sterility of his notion of community.

Hester concludes his brief treatise in Chapter 4 and a short epilogue, where he utilizes his pragmatic approach to construct a new model for clinical medicine. Like his fellow pragmatic bioethicists, Hester is keen to insist that not just clinicians, but patients and all other contributors as well, should be members of the health care community (75). Hester also joins certain nonpragmatist bioethicists such as Howard Brody by insisting on the narrative structure of the social self (54-60). Each clinical encounter is part of an ongoing narrative, constructed by clinicians and patients alike. Optimally, Hester holds that these narratives should be constructed mutually and collaboratively, and that they should encompass as many related narratives...