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Moral Experience and Ethical Reflection: Can Ethnography Reconcile Them? a Quandary for "The New Bioethics" Author(S): Arthur Kleinman Source: Daedalus, Vol

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Moral Experience and Ethical Reflection: Can Ethnography Reconcile Them? a Quandary for Moral Experience and Ethical Reflection: Can Ethnography Reconcile Them? A Quandary for "The New Bioethics" Author(s): Arthur Kleinman Source: Daedalus, Vol. 128, No. 4, Bioethics and Beyond (Fall, 1999), pp. 69-97 Published by: The MIT Press on behalf of American Academy of Arts & Sciences Stable URL: http://www.jstor.org/stable/20027589 . Accessed: 23/04/2014 17:01 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. The MIT Press and American Academy of Arts & Sciences are collaborating with JSTOR to digitize, preserve and extend access to Daedalus. http://www.jstor.org This content downloaded from 128.103.149.52 on Wed, 23 Apr 2014 17:01:18 PM All use subject to JSTOR Terms and Conditions Arthur Kleinman Moral Experience and Ethical Reflection: Can Ethnography Reconcile Them? A Quandary for "The New Bioethics" REMAKING THE CASE FOR BIOETHICS ITH hastening pace, bioethics in America is moving in manifold ways to deal with serious problems in its modus operandi. These problems have become so w well known they are by now clich?s. In previous studies I have attempted to characterize them by means of three "isms": ethnocentrism, medicocentrism, psychocentrism.1 By this awk ward-sounding trio I meant to encompass past criticism of on bioethics account of its Eurocentric orientation and grudg ingly limited engagement with non-Western and ethnic value orientations. I also meant to conjure its tendency to prioritize often esoteric professional formulations over ordinary, commonsensical patient and family perspectives, as well as to critique the way ethicists psychologize moral issues that in are more everyday life often expressed by ordinary people via religious, social, and somatic idioms. Others have so flayed the principle-based methodology still in command today that this Arthur Kleinman is Maude and Lillian Presley Professor of Medical Anthropology and Psychiatry in the department of social medicine at Harvard Medical School and professor of social anthropology in the department of anthropology at Harvard University. 69 This content downloaded from 128.103.149.52 on Wed, 23 Apr 2014 17:01:18 PM All use subject to JSTOR Terms and Conditions 70 Arthur Kleinman mode of criticism would be pointless were it not for the persis tence a narrow of rather Anglo-American analytic philosophy as the discipline's canon. The discipline itself has made many moves (at least in America) to apply, or respond to, survey research, clinical epidemiology, ethnography, cultural studies, narratology, feminist theory, and still other contextual methods of analysis and engagement. And neopragmatism and continen tal philosophy are making some, if limited, headway, even if a social theory is still held at distance. So much is changing so fast that we might well speak of "the new bioethics": more inclusive of alternative approaches, seemingly more willing to employ a broader variety of perspectives, more empirical, and even sense experimental?in the of trying out, albeit gingerly, new methods of inquiry.2 One must recognize, of course, that this is not (at least not yet) the dominant stream of bioethics, that it is "new" only in the sense that ideas that have been around for some time are now being more widely embraced. For all these efforts at repair and reform, however, bioethics is confronted with an extraordinarily difficult quandary: how to reconcile the clearly immense differences in the social and personal realities of moral life with the need to apply a univer sal standard to those fragments of experience that can foster not only comparison and evaluation but also action.3 For phi losophers, the gulf between the universal and the particular may be regarded as an irksome and a perennial barrier; but bioethicists, like clinicians and policy implementers, simply cannot function without finding a way of relating ethical deliberation to local contexts. The issue can be put in other terms. For almost all of us, everyday life experience in communities and networks?no matter how influenced we are by global forces of communica tion, commerce, and the flow of people?centers on what is locally at stake. What matters most in the mundane and ex traordinary transpersonal details that bind and define us through relationships, work, and the close politics of a particular place is the overwhelmingly pragmatic orientation of men and women everywhere. Even the quest for transcendent meaning needs to be understood in this light. The "local" nowadays may be better understood as more like a network than a neighborhood; This content downloaded from 128.103.149.52 on Wed, 23 Apr 2014 17:01:18 PM All use subject to JSTOR Terms and Conditions Moral Experience and Ethical Reflection 71 yet its power to engage us in what matters continues to define human affairs. There is great diversity in what is valued, to be sure; but that ordinary people, even the marginalized, are stake holders in local worlds is what social life is about. Status, material resources, relationships of exchange, survival, iden tity, and transcendence are examples of the things that are sought collectively and individually. What is at stake may differ, but the human experience of pursuing such goals is empirically describable. And that is the point: empirical re can search provide knowledge about local worlds of experi ence?knowledge that is useful, even essential, for bioethics. There simply is no getting around the great influence of these local moral processes. Why moral? Because they consist of the contestations and compromises that actualize values both for collectives and for individuals. Indeed, the individual-collective dichotomy is overdone; within these social processes values are negotiated and reworked among others in a space that is thor oughly intersubjective.4 Think of the adult children of a father with Alzheimer's Disease whose dementia is so severe that he cannot remember the content of his children's statements about the question of his placement in a nursing home. The experience as of suffering is lodged much in the emotions (sadness, grief, frustration) of the children as in those of their father; indeed, these emotions build on each other. The responses that lead to decisions about when and where to be institutionalized are moral engagements within this family's relationships. They are part of ongoing conversations and exchanges that began even were before these adult children born, developed in ways in separable from their own trajectories, bled into their actual a situations at particular time, and will without question go on not after their father's death. It is individuals as isolated beings who make the choice to place a parent in a nursing home, pace scene the primal and somewhat atomistic favored by analytic philosophers. It is rather the person as part of a network of relations, memories, current pressures, and uncertain prospects, and constrained by interconnections and shared fate, who is the locus of moral experience. Hence moral experience is about the local processes (collective, interpersonal, subjective) that real ize (enact) values in ordinary living. These processes cross the This content downloaded from 128.103.149.52 on Wed, 23 Apr 2014 17:01:18 PM All use subject to JSTOR Terms and Conditions 72 Arthur Kleinman boundary of the body-self, connecting affect and cognition with cultural meanings, moral norms and collective identity with sense of self. Thus moral experience and personal experience are interfused: value with emotion. Modeling ethics as a person's individual choices, which in turn are supposed to be based in deep, philosophically and psychologically informed reflection shaped by religious and secular standards that seek universal application, simply does not account for the social processes of moral life. Those pro cesses illustrate how the person is located in economic, cultural, kinship, friendship, and work activities that powerfully define his or her moral horizon in ways of which he or she is likely to be only partially aware. In the end, then, ethics, once framed as models of moral reasoning championing the reflection and ra tional choice of autonomous individuals in quest of objective standards, risk irrelevance to the almost always uncertain cir cumstances and highly contextualized conditions of human experience.5 The irrelevance of ethics can be seen when considering uni versal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power. Dealing with issues of justice in the absence of these contextual concerns renders ethical formulations mere speculations, Utopian pronouncements that are gratuitous and beside the point. Consider, for example, the fact that bioethics generally regards informed consent an overriding ethical condition of international health research? say, in vaccine trials for HIV among impoverished African villagers. Of course, few villagers are likely to
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