Interplays of Reflection and Text: Telling the Case

The patient is an 84-year-old white female admitted nine days ago for uterine suspension and bladder repair.

Mrs. C, an 84-year-old white woman, was admitted nine days ago in order to undergo a uterine suspension and bladder repair.

This patient had been hospitalized for nine days prior to her sons' request for ethics consultation. She was 84 years old and had been admitted to the hospital to undergo a uterine suspension and bladder repair.

The beginning of this consultation had two features that were unusual. First, I received a call from one of the executive secretaries in the administrative suites at the hospital requesting my assistance. The other significant feature was that the request for ethics consultation had originated from the patient's son.

The phone rings, I pick it up, saying as I always do, "Hello, medical ethics." "Hello, Dr. Monk?" the voice says. "Are you the ethicist on service? We need some assistance with a situation."

The five fragments above represent five opening lines for five "cases" that, without too much imagination, may be seen as addressing a single set of circumstances. Which of these might be the best to utilize for capturing complex moments of ethical significance in clinical situations is a crucial question, the question that most concerns Chambers in The Fiction of Bioethics (1999). In his précis of this work (2001), Chambers presents the foundational point for such an exploration of genre, namely that how a case is told—that is, the form of narrative utilized—is as important a feature for understanding the ethical issues or considerations presented by the case as what the case actually states. In part, we offer the five opening lines above as a means of amplifying this point and showing our sympathy with Chambers' project. But these five opening lines are meant to do much more.

As Chambers explicitly notes, his concern is with the relation between narrative form and ethical theory as such is instantiated in a "case." The relevance of this relation is paramount when a case is taken to be a report or description of what occurs in a situation or conversation. But the rich diversity of literature that addresses medical themes—Campo's poetry (1996), Selzer's stories (1979), Edson's play (1999)—is itself indicative of the fact that writing "about" medical situations and circumstances that evoke ethical consideration need not always be understood as mere reporting. Indeed, as there are many different voices found within the clinical context, there are many different aims available when writing a case.

Accordingly, through his work, Chambers is inviting each of us to reflect on the ways in which a case not only reveals and conceals, but also shapes, our understanding of "ethics." Not only do we endorse such critical self-reflection, but we further believe this is crucial for those of us who occupy the role of "ethics consultant" and venture into clinical contexts under the aegis of that role. The reason is this: whatever theoretical perspective informs one's understanding of ethics, and thus "ethics consultation," nothing can, in the end, substitute for the actual experience of being in the role of ethics consultant within clinical circumstances. Accordingly, an account of ethics consultation—the kind that one might find in an ethics case, for example—must be able to account for the meanings and values embedded in both the role of ethics consultation and the activities (including reflection) one performs when enacting that role.

Along with our colleague Richard Zaner, we have been exploring these concerns for some time now, most recently in a special volume (Zaner 1999). As part of this exploration, we have come to take seriously the notion that a case may in fact serve primarily to evoke the moral complexity and ethical significance of actual clinical experience as experienced...