Moral experience and ethical reflection: Can ethnography reconcile them? A quandary for "The new bioethics"

Daedalus

Volumn 128, Issue 4, 1999, Pages 69-97

  Kleinman, Arthur ^a,b  

^a HARVARD MEDICAL SCHOOL   (United States)

^b HARVARD UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANALYTICAL APPROACH; ANTHROPOLOGY; ARTICLE; BIOETHICS; BIOETHICS AND PROFESSIONAL ETHICS; CONSUMER; CULTURAL ANTHROPOLOGY; DECISION MAKING; DEVELOPING COUNTRY; EMPIRICAL RESEARCH; ETHICIST; ETHICS; HUMAN; HUMAN RIGHTS; INTERDISCIPLINARY COMMUNICATION; INTERNATIONAL COOPERATION; MEDICAL ETHICS; MORALITY; PROFESSIONAL COMPETENCE; PUBLIC RELATIONS; RESEARCH; SOCIAL PROBLEM; SOCIAL PSYCHOLOGY; SOCIOECONOMICS; SOCIOLOGY; TECHNIQUE; VERBAL COMMUNICATION;

ANALYTICAL APPROACH; BIOETHICS AND PROFESSIONAL ETHICS;

ANTHROPOLOGY; BIOETHICAL ISSUES; BIOETHICS; CONSUMER PARTICIPATION; CULTURAL DIVERSITY; DECISION MAKING; DEVELOPING COUNTRIES; EMPIRICAL RESEARCH; ETHICAL RELATIVISM; ETHICISTS; ETHICS; ETHICS, MEDICAL; HUMAN RIGHTS; HUMANS; INTERDISCIPLINARY COMMUNICATION; INTERNATIONAL COOPERATION; INTERNATIONALITY; INTERPROFESSIONAL RELATIONS; METHODS; MORALS; NARRATION; PROFESSIONAL COMPETENCE; RESEARCH; SOCIAL PROBLEMS; SOCIAL SCIENCES; SOCIAL VALUES; SOCIOECONOMIC FACTORS;

EID: 0033187389     PISSN: 00115266     EISSN: 15486192     Source Type: Journal    
DOI: None     Document Type: Article

References (71)

1. See Arthur Kleinman, Writing at the Margin: Discourse Between Anthropology and Medicine (Los Angeles and London: University of California Press, 1995), 41-67.
2. For example, consider these recent contributions: Ronald Carson and Chester Burns, eds., Philosophy of Medicine and Bioethics (Dordrecht, Boston, and London: Kluwer, 1997);
3. Raymond DeVries and Janardin Sabede, eds., Bioethics and Society: Constructing the Ethical Enterprise (Upper Saddle River, N.J.: Prentice Hall, 1998);
4. Carl Elliott, A Philosophical Disease: Bioethics, Culture and Identity (New York and London: Routledge, 1999);
5. Barry Hoffmaster, "Can Ethnography Save the Life of Medical Ethics?" Social Science and Medicine 35 (12) (1992): 1421-1432;
6. Hilde Lindemann Nelson, ed., Stories and their Limits: Narrative Approaches to Bioethics (New York and London: Routledge, 1997);
7. Michelle Moody-Adams, Fieldwork in Familiar Places: Morality, Culture and Philosophy (Cambridge, Mass.: Harvard University Press, 1997). This last, strictly speaking, is not a work in bioethics, but a general contribution to moral theory. That is my point - the new bioethics overlaps with some of the most original approaches to moral theory in general.
8. That this question has been present from the beginning of the contemporary bioethics movement in the 1960s can be seen in a paper by one of the early formative figures in the field: James Gustafson, "Context versus Principles," Harvard Theological Review 58 (1965): 191.
9. That bioethicists still routinely are unable to provide useful answers can readily be seen in Ruth Macklin, Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine (New York: Oxford University Press, 1999). Macklin, while acknowledging cultural diversity, treats it as the anthropologist's source of unacceptable relativism, and then clears the field by making the search for universal ethical principles the only serious and supportable moral procedure. This bit of sophistry - which stereotypes and stigmatizes contextual perspectives - simply declares the problem resolved by denying that there is one. This is not an encouraging sign that bioethicists coming out of an analytic philosophy background are making much progress on this core dilemma.
10. These aspects of moral processes as social processes in local worlds are developed more fully in several of my recent publications. See Arthur Kleinman, "Everything that Really Matters: Social Suffering, Subjectivity, and the Remaking of Human Experience in a Disordering World," Harvard Theological Review 90 (3) (1997): 315-326;
11. Arthur Kleinman, "Experience and its Moral Modes: Culture, Human Conditions, and Disorder," in Grethe B. Peterson, ed., The Tanner Lectures on Human Values, vol. 20 (Salt Lake City: University of Utah Press, 1999), 355-420.
12. For example, higher-order, abstract, ethical principles like beneficence and justice tell us almost nothing about the actual moral content of most patient-doctor interactions in American society, even ones among poor patients for whom there is an unjust social distribution of health and health-care resources that precedes people's access to the clinics. These principles are simply too remote from the local grounds of experience to be of much service in actual cases, and yet at the level of the national regulatory system of policies and programs, they are obviously important.
13. Philip Gourevitch, We Wish to Inform You that Tomorrow We Will be Killed With Our Families: Stories from Rwanda (New York: Farrar, Straus & Giroux, 1998), describes communities in Rwanda where all Hutus took part in the killing of their Tutsi neighbors and relatives; there was no internal criticism or resistance. Hence, here a translocal perspective is crucial.
14. See Edvard Westermarck, Ethical Relativity (London: K. Paul Trench, Trabner and Co. Ltd., 1932);
15. Kleinman, "Experience and its Moral Modes";
16. Tzvetan Todorov, On Human Diversity in French Thought (Cambridge, Mass.: Harvard University Press, 1993), 3, 24, 61;
17. C. A. J. Coady, Testimony: A Philosophical Study (Oxford: Clarendon Press, 1992). During the nineteenth century, the idea of human nature, which Foucault claimed received its modern form in the eighteenth century, got taken up in the wave of cultural representations of natural history. This lent to the idea of human nature its currently accepted biological significance, as in the nature and natural history of plants, animals, and diseases.
18. See N. Jardine et al., eds., Culture of Natural History (Cambridge and New York: Cambridge University Press, 1996).
19. The most immodest of claims for a biological basis of human nature and ethics is made by the influential sociobiologist E. O. Wilson in "The Biological Bases of Morality," The Atlantic Monthly 28 (4) (1998): 53-70.
20. See also the account of E. O. Wilson in "From Ants to Ethics: A Biologist Dreams of Unity of Knowledge," New York Times, 12 May 1998, C1. Only vaporous dreams and romantic rhetoric can match the science that is cited to the claims about the biology of morality.
21. See Kleinman, "Experience and its Moral Modes,"
22. Arthur Kleinman, The Illness Narratives (New York: Basic Books, 1988), chap. 15.
23. Hoffmaster, "Can Ethnography Save the Life of Medical Ethics?"
24. Many methodologists have written about the postmodernist turn in ethnography, by its proponents and critics, in debating change. See, for example, James Clifford and George Marcus, Writing Culture: The Poetics and Politics of Ethnography (Berkeley: University of California Press, 1986);
25. James Clifford, The Predicament of Culture: Twentieth-Century Ethnography, Literature and Art (Cambridge, Mass.: Harvard University Press, 1988);
26. George Marcus and Michael Fischer, Anthropology as Cultural Critique: An Experimental Moment in the Human Sciences (Chicago: University of Chicago Press, 1986). I am not certain, however, that this diverse literature of essays on ethnography does justice to what ethnography can achieve and how it makes its contribution. Even more recent collections that also illustrate important ties between theory and ethnography, although important theoretical statements, do not get at what I take to be most central in ethnography: namely, its engagement with experience.
27. See, for example, Akhil Gupta and James Ferguson, eds., Culture, Power, Place: Exploration in Critical Anthropology (Durham, N.C.: Duke University Press, 1997).
28. Rather critical readings into experience-near ethnographies themselves provide a sounder introduction to the field. In this regard, a few illustrative works, drawn from a potentially very large list, might include: Nancy Scheper-Hughes, Death Without Weeping (Berkeley: University of California Press, 1992);
29. Anna Tsing, In the Realm of the Diamond Queen (Princeton, N.J.: Princeton University Press, 1993);
30. Veena Das, Critical Events: An Anthropological Perspective on Contemporary India (Delhi: Oxford University Press, 1995);
31. Michael Jackson, ed., Things as They Are: New Directions in Phenomenological Anthropology (Bloomington, Ind.: Indiana University Press, 1996);
32. Mary Steedley, Hanging Without A Rope: Narrative Experience in Colonial and Post Colonial Karoland (Berkeley: University of California Press, 1993);
33. Paul Farmer, AIDS and Accusation (Berkeley: University of California Press, 1992);
34. Lawrence Cohen, No Aging in India (Berkeley: University of California Press, 1999);
35. Phillipe Bourgois, In Search of Respect: Selling Crack in El Barrio (Cambridge: Cambridge University Press, 1995);
36. Rayna Rapp, Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America (New York: Routledge, 1999);
37. Tanya Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry (New York: Knopf, forthcoming);
38. Maya Todeschini, "Bittersweet Crossroads: Women of Hiroshima and Nagasaki," Ph.D. dissertation, Department of Anthropology, Harvard University, 1999.
39. A new journal devoted to these issues is Ethnography (Sage Publications).
40. Consider the writings of Barbara Koenig and Patricia Marshall, among others. For example, Patricia Marshall and Barbara Koenig, "Bioethics in Anthropology: Perspectives on Culture, Medicine and Morality," in C. F. Sargent and T. Johnson, eds., Medical Anthropology (Westport, Conn.: Praeger, 1996), 349-373;
41. Barbara Koenig, "Organ Transplantation Reexamined?" Medical Anthropology Quarterly 9 (3) (1995): 393-397;
42. Patricia Marshall et al., "Ethical Issues in Immigrant Health Care and Clinical Research," in S. Love, ed., Handbook on Immigrant Health (New York: Plenum, 1998).
43. Other works by anthropologist-ethnographers in bioethics include Linda Hunt, "Moral Reasoning and the Meaning of Cancer," Medical Anthropology Quarterly 12 (3) (1998): 298-318;
44. Gelya Frank et al., "A Discourse of Relationships in Bioethics," Medical Anthropology Quarterly 12 (4) (1998): 403-423;
45. Don Seeman, "One People, One Blood: Public Health, Political Violence and HIV in an Ethiopian-Israeli Setting," Culture, Medicine and Psychiatry 23 (2) (1999): 159-195;
46. as well as the contributions by Lawrence Cohen, Veena Das, and Mary-Jo Good in this issue of Dædalus.
47. See the experience-near ethnographic works listed in note 11.
48. See Yunxiang Yan, The Flow of Gifts (Stanford: Stanford University Press, 1996).
49. Of course, ethnographers will show that ethical formulations are ultimately also grounded in the categories and commitments of a local place, so that the claims to universality for bioethics need to be understood in a more modest sense of a quest and aspiration for translocal values.
50. Nancy Scheper-Hughes, Death Without Weeping: The Violence of Everyday Life in Brazil (Berkeley: University of California Press, 1993).
51. Das's ethnographic contribution to medical ethics is found in several of her works: "Moral Orientations to Suffering," in L. C. Chen, A. Kleinman, and N. C. Ware, eds., Health and Social Change in International Perspective (Cambridge, Mass.: Harvard University Press, 1994);
52. "Language and Body: Transactions in the Construction of Pain," Dædalus 125 (1) (Winter 1996): 67-92;
53. Critical Events: An Anthropological Perspective on Contemporary India (Delhi: Oxford University Press, 1995).
54. Das is presently editing a volume, Rebuilding A World (Berkeley: University of California Press, forthcoming), in which young ethnographers working in communities with extreme political violence come up against the same barriers.
55. John Borneman, Settling Accounts: Violence, Justice, and Accountability in Post-Socialist Europe (Princeton, N.J.: Princeton University Press, 1997), examining serious wrongs perpetrated by socialist governments in East and Central Europe, argues for the crucial role of accountability for past abuses in legitimizing current democratic procedures in these countries. He holds up legal procedures of retributive justice as the way to undo moral injury. But Borneman does not deal with the way that such procedures have remade victims' suffering into a new object of professional appropriation that removes the moral heart of the matter, a subject about which Veena Das provides perhaps the most telling criticism.
56. See Das, "Moral Orientations to Suffering."
57. Martha Minow calls attention to the same problem in Between Vengeance and Forgiveness: Facing History after Genocide and Mass Violence (Boston: Beacon Press, 1998), where she makes the point that, after massive social violence, trials, truth commissions, and reparations all have their limitations. Both authors demonstrate that moral accountability and legal accountability are not the same thing, that acknowledgment of the significance of the former is not necessarily accomplished by the procedures pertinent to the latter, even though they may be all that can be accomplished in given cases.
58. Paul Farmer, Infections and Inequalities (Berkeley: University of California Press, 1999).
59. Salmaan Keshavjee, Sheri Weiser, and Arthur Kleinman, "AIDS and Hemophilia Testimonies: A Collective Experience of Illness and Suffering," unpublished manuscript.
60. See Arthur Kleinman, Writing at the Margin: Discourse between Anthropology and Medicine (Berkeley: University of California Press, 1995).
61. Rayna Rapp, Testing Women: Testing the Fetus (New York: Routledge, forthcoming).
62. For studies undertaken from an anthropological perspective, see Ruth Behar, Translated Woman: Crossing the Border with Esperanza's Story (Boston: Beacon Press, 1993);
63. Kamala Visweswaran, Fictions of Feminist Ethnography (Minneapolis: University of Minnesota Press, 1994).
64. Jing Bao Nie, "Voices Behind the Silence: Chinese Moral Views and Experiences of Abortion," Ph.D. dissertation, Institute of the Medical Humanities, University of Texas Graduate School of Biomedical Sciences at Galveston, 1998.
65. Kleinman, The Illness Narratives, chap. 15.
66. The next two paragraphs are drawn from Kleinman, "Experience and its Moral Modes."
67. See, for example, Robert Desjarlais et al., eds., World Mental Health: Policies and Priorities in Low-Income Countries (New York: Oxford University Press, 1995);
68. Farmer, Infections and Inequalities;
69. Veena Das, "Introduction," Rebuilding a World.
70. This is modified from Arthur Kleinman, "Ethics and Experience," presented to the Workshops on Health Equity, Harvard Center for Population and Development, Harvard School of Public Health: Working Paper Series, No. 99.04, March 1999.
71. In closing, I had hoped to review the relationship of moral processes and ethical deliberation to religion, which also can be understood as social process (i.e., ritual and ordinary devotional practices) and institutionalized discourse (i.e., theology), and which has in the past and can in the future play a clearly crucial role in bioethics. But this proved too much for a short paper to support and so will be the subject of another essay.