perspective (evaluative, indexical, and practical) in favor of the analytic and theory-heavy frameworks preferred by academics. It should instead complement the insiders’ perspective, so the insider’s and the ethnographer’s accounts ultimately take their place as equally provisional commentaries on the difficulties of clinical work. In the end, the language of the ethnographer-translator should be powerfully affected by the foreign tongue (to paraphrase Benjamin again). The chapters in this book document the ethical sensibility of clinicians, as expressed through their words and actions, and then frame them ethnographically in terms of the structural constraints of work. The goal is to amplify the voice of frontline workers, who have the most intimate knowledge of clients but the least influence in broader conversations about public mental health services.
A second goal is to advance the knotty and frustrating conversation between ethnography and medical ethics. So far, the cross talk between these two fields involves mostly attack, defense, and counterattack. The standard social science critique (inaugurated by Fox and Swazey 1984) claims that ethnography supplies a better translation of clinicians’ moral life than does formal bioethics. According to this argument, people engage with the ethics of medical care not by invoking abstract principles and values (autonomy, utility, care, etc.) but rather through local idioms and reflections on their immediate, practical activities. People’s moral perspective on medical treatment emerges from the concrete details of inequality and local notions of suffering, not high-order virtues or rules of conduct. Emotional experience and local institutional arrangements drive many of the social conflicts that later get formally labeled as bioethics disputes. Ethical discussions by both staff and patients are thus inseparable from their immediate life circumstances, social roles, political interests, and cultural beliefs.7
On this basis, social scientists have criticized the experience-distant language of formal bioethics for misrepresenting the way clinicians actually think about their conduct and obligations. An important stream of U.S. bioethics is committed to liberal individualism, contractual relations, and core principles such as autonomy, beneficence, nonmaleficence, and distributive justice. It prescribes rational and systematic deliberation as the proper response to moral uncertainty (Beauchamp and Childress 2009, Lo 2009). But its logic and vocabulary do a poor job of analyzing how medical workers actually reflect on ethical problems in the midst of practice. For the latter task, according to social science critics, ethnography is the preferred method. Long-term qualitative research has shown that clinical and ethical issues always become entangled and that ethical decision making is a shifting, shared, and implicit process, not the premeditated action of autonomous individuals, as envisioned by mainstream bioethics (Kaufman 1997). Ethnographies replace the remoteness of abstract moral theory with accounts of short-term decisions made in the face of local constraints. They explore how medical professionals identify certain social conflicts, but not others, as ethical dilemmas. They demonstrate that clinicians talk about ethics in specific cultural idioms, framed by their own class identities and institutional loyalties and rooted in a historical context.8
The ethnographic critique of bioethics relies on a categorical division between “moral talk” and “ethics.” For the above authors, moral talk is utilized by ordinary frontline practitioners as they handle particular illness episodes. Ethics, by contrast, is the codified, reflective language of elite experts, located far from the scene of clinical action (Kleinman 1999)9. Moral talk addresses everyday experience and gets expressed idiomatically in the midst of ongoing social life. Ethics is based on the human capacity for reasoning and gets expressed through formal systematic theory (see Hoffmaster 1992, Jennings 1990). The categorical division itself sums up the central argument. Conventional bioethics offers an inadequate and misleading representation of the ordinary moral experience of practitioners. Ethnographic research, by contrast, is uniquely fitted to the task.
The critique successfully carves out a space for the prime anthropological method in a terrain otherwise monopolized by law and moral philosophy. It nonetheless has several shortcomings. First of all, bioethicists themselves have responded to the ethnographic critique point by point (Turner 2009, Hoeyer 2006, and DeVries et al. 2007). They point out that it misconstrues the internal diversity of contemporary bioethics. For decades, mainstream bioethicists have argued against formal inductive methods (see Dubose et al. 1994). Some privilege the cultural and institutional contexts of moral deliberation (Churchill 1997). Others draw from narrative theory and philosophical pragmatism to explore how ordinary people make (and represent) ethical decisions (Chambers 1999, McGee 2003). The ethnographic critique mistakenly loads all the abstraction on one side (formal bioethics), and all the concrete details of history, practice, and structural constraints on the other (ethnography). That false dichotomy in turn fuels the call for ethicists to become more like empirical social scientists. Raymond DeVries sensibly responds that the two fields are not obliged to agree with each other or use the same methods. They should instead regard their distinctiveness as a source of strength, because, after all, they have legitimately different endpoints. The contextualizing and often debunking style of social science aims at something quite different than the normative analysis, advice giving, and regulatory activities of bioethics professionals.
Even on empirical grounds, the sharp divide between disciplinary bioethics and everyday moral commentary starts to break down. Routine clinical work is deeply infused with the categories and instruments of formal bioethics, as illustrated by the above vignette from Eastside Services. The paperwork required to commit someone, for example, is mandated by the state mental health code, which itself arose decades ago out of explicit debates about patient autonomy and the obligation to treat (explored in Chapters Two and Six). Efforts to reform the inhumane state hospital system of the 1950s and to protect patients’ rights once dominated newspaper headlines and courtrooms, but they never quite went away. They instead became sedimented into everyday routines about commitment and many other basic clinical gestures. Even mundane bureaucratic procedures bear the marks of prior ethical debates. Eastside case managers, for example, must show people a paper labeled “patient’s bill of rights” when they get admitted to the program. Clients must sign a written consent form every year in order to receive services. Techniques to hold back people’s money and to write the treatment plan involve similar paperwork and have embedded in them similar ethical rationales, explored later in this book. These forms of regulation continue to shape daily work, whether or not clinicians acknowledge them. In the end, spontaneous commentaries about right and wrong are coproduced by high-order mandates as well as the local context of practice. To set up a categorical division between abstract normative ethics and everyday moral talk obscures this reality (see also Brodwin 2008).
According to the standard ethnographic critique, universalizing ethical frameworks are irrelevant to frontline workers. But this claim seriously mischaracterizes the moral life of clinicians. Listen again to Neil Hansen commenting on Andrea Watkins: “[She] manages never to be trained by the ringmaster. Why kill that? . . . We kill the spirit chemically or sociologically. And to do that to another human being is so unethical.” Neil Hansen, a low-level case manager, refuses outright the norms and standard practices endorsed by his agency. In fact, he uses the word unethical precisely because in colloquial English it enacts a blanket condemnation. He engages with the rightness or wrongness of his job by distancing himself from the local context and usual justifications. His reaction suggests that people socialized in a given setting—as small as a clinic or as large as a “culture”—do not necessarily respect the moral walls that surround them (Moody-Adams 1997). The walls are not impenetrable. Insiders actually find ways to criticize standard practices and assumptions, often by reference to high-order virtues and universal imperatives. To make sense of how frontline clinicians struggle through their work, thick description is necessary, but not sufficient. Ethnography must also ask how they manage to wrench themselves free, if only for a moment, from the near-at-hand warrants for action and the local moral worlds (see Kleinman 2006).
To drown clinicians’ ethical voice in layers of social context is a mistranslation—even a betrayal. The notion of everyday ethics seeks an alternative. It takes seriously people’s ability to evaluate their actions and express concern about their world, using criteria not
