conditions that encourage or stifle clinicians’ ethical voice.
Chapter Six gauges the distance between the sensibility of ordinary clinicians and formal ethics statements about Assertive Community Treatment. This chapter reviews four topics of great interest in the relevant bioethics literature: (a) the strong critique of ACT as inherently coercive, (b) strategies to balance the principles of patient autonomy and professional beneficence, (c) Ulysses contracts—a novel approach that lets patients consent in advance to nonconsensual treatment, and (d) confidentiality. Each topic raises the question, How would Eastside workers react to the bioethics literature, and what position would they take up in these debates? The answers in this chapter are frankly speculative, but they are based on the contingencies of daily work and the situated knowledge of the worker. First, the ideology of biopsychiatry builds a wall around the logic of practice, and it makes the strong critique of coercion unthinkable for most ordinary case managers. Second, the mainstream tactic of balancing principles captures the flavor of staff room debates, but such guidelines can never remove all ethical ambiguity. Third, Ulysses contracts would likely have great appeal at Eastside Services because they ratify the model clients’ selfhood already held by frontline staff. In the case of confidentiality, by contrast, the paperwork actually undercuts the clinicians’ ethical sensibility, and this final case is illustrated by several vignettes.
The book ends with a reminder for all readers. Community psychiatry is a neglected corner of the U.S. health care system, but the struggles of frontline clinicians at places like Eastside Services implicate all of us. Their everyday ethics pose the overarching question, How should we bear responsibility for the most vulnerable among us? The book conveys the feelings and actions of just a handful of people. Nevertheless, the American body politic as a whole has forced them into a near impossible position. They struggle with some of the most marginalized people in our society, but with pathetically insufficient resources. The core tools for work contain, sedimented within them, highly controversial assumptions about pharmaceutics, proper relations of dependency, and the legitimacy of coercion. Young case managers start to use the tools innocently enough but are soon caught up in pitched battles between their own tenuous authority and the resentment of their clients. Even worse, they face such problems essentially on their own. Their labors are hidden in small storefront agencies with no connection to medical schools and no access to the expertise of academic psychiatry and bioethics. They work in neighborhoods long abandoned by deindustrialization and the retrenchment of public services. If they shoulder a crushing ethical burden, it is because we have placed it there. Their expressions of bewilderment and despair should come as no surprise.
NOTES
1. Sered and Fernandopulle (2005) describe how the current U.S. health care system neglects the sick poor. The spatial concentration of people dependent on publicly funded medical and welfare systems is analyzed by Dear and Wolch (1987). The survival strategies of homeless people with mental illness in North American cities is studied by many authors, including Desjarlais (1997), Rowe (1999), Lovell (2007) and Luhrmann (2010). For the dead ends and double binds experienced by people with mental illness as they cycle through the criminal justice system, see Rhodes (2004) and Human Rights Watch (2003).
2. The structural conditions of work among frontline providers in contemporary public sector psychiatry are analyzed by Rhodes (1991) for emergency rooms and Brown (1989) for community mental health agencies. Current figures for length of stay come from the U.S. Department of Health and Human Services (2008). Robins (2001) and Kirschner and Lachicotte (2001) document the impact of corporate metrics upon the self-conceptions of frontline psychotherapists and counselors.
3. David Oaks, executive director of MindFreedom International (a human rights advocacy organization for people with experience of psychiatric hospitalization) opposes the use of the words illness, diagnosis, and symptoms. From his standpoint, such terms impose a biological reductionist account of complex human realities because they implicitly endorse a narrow range of medical responses such as medication and electroconvulsive therapy (Oaks 2012). In this book, I continue to use these words for the following reasons. The words illness and ill have complex meanings in English, many of them connected to the experience of suffering. The Oxford English Dictionary entry on ill includes “causing pain, discomfort, or inconvenience: offensive, painful, disagreeable, objectionable; difficult, troublesome and hard.” I wish to bring these meanings under the ambit of the word illness. The word also recalls the early achievement of medical anthropology (e.g., Kleinman, Eisenberg, and Good 1978) in contrasting doctors’ reductionist perspective (“disease”) to patient’s embodied experience, articulated in their own idiom (“illness”). The terms diagnosis and symptoms are indeed deeply nested in the medical model of psychiatry. Precisely for this reason, the words cannot be avoided in an ethnography of psychiatric workers. Anthropologists must nevertheless heed Oaks’s warning and not allow the words themselves to legitimate professional dogma.
4. Eastside Services (a pseudonym) is staffed by two supervisors, eight case managers, a part-time nurse and a part-time psychiatrist. The names and identifying details of all clinicians and clients have been altered. As an ethnographer, I attended 120 staff meetings and accompanied six case managers, for approximately four months each, on their daily visits to clients’ homes and meetings with psychiatrists, lawyers, and family members. I observed 20 sessions of counseling and medication management between the psychiatrist and clients. Other sources of data include 30 semi-structured interviews: 20 with case managers, 5 with the program director, and 5 with the psychiatrist. In this book, all quoted speech from staff room debates and clinician–client interactions is taken from field notes handwritten at the time. This speech is indicated by specially indented paragraphs. Private interviews were recorded digitally and later transcribed; data from these interviews are indicated by double quotes. Background information about the local mental health system was obtained at training sessions for new case managers presented by the state Department of Mental Health, as well as four regional continued education seminars for social workers about ethics and boundaries. On-site and summary daily notes were taken after each period of ethnographic observation. Transcribed interviews and field notes were coded with NVivo 2.0 software for qualitative data analysis. Further information about Assertive Community Treatment and its place within contemporary mental health services was obtained by attendance at relevant professional meetings at the regional and national level, in both the United States and Canada. Research was approved by the Institutional Review Board of the University of Wisconsin–Milwaukee and funded by a grant from the Cultural Anthropology Program of the National Science Foundation, “Everyday Morality in American Mental Health Care: A Comparative Ethnography” (BCS-0522263).
5. The excess mortality of Americans with serious mental illness who receive services in the public sector was detected by Lutterman et al. (2003) and reintroduced into contemporary debates on health care reform by Druss and Bornemann (2010).
6. Exemplary studies of the impact of structural constraints, professional competition, and collective interests upon the ethical commentaries that circulate in U.S. health care settings include Anspach and Beeason (2001), Bosk (2003 [1979]) and 1992), and Chambliss (1996)
7. Key statements of the anthropological and sociological critique of US bioethics can be found in Fox and Swazey (2008), Kleinman (1995), Kleinman et al. (1999) Marshall (1992, 2001), Muller (1994), DeVries and Subedi (1998), and Hoffmaster 2001.
8. See Cohen (1999), Lock (2002), Scheper-Hughes (2000), Rapp (1999), and Kaufman (2005), among many others.
9. Clinicians are also frequently the authors of important bioethics texts. But their bioethics writings strive to rise above and comment upon the details of everyday clinical work “from the perspective of philosophy” (Tauber 1999) or “general rationality” (Engelhardt 1986).
PART ONE
Background to Practice
CHAPTER 1
Genealogy
