The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:1329-32

• Unmaking the ethics case
• Leaving David
• Kinesthesia
• The day I took Mama to the nursing home

The fiction of bioethics: cases as literary texts
Tod Chambers
Routledge, New York and London; 1999
207 pp. $34.95 ISBN 0-415-91988-6 (cloth)

All ethics cases, even those drawn from actual events, are representations of reality inevitably coloured by the philosophical and other biases of their authors. The way cases are presented affects the way we understand the moral problems they raise. In The Fiction of Bioethics Tod Chambers tackles what bioethics has ignored: a critical assessment of the rhetoric of ethics cases. His work sheds light on the ideology embedded in ethics cases and offers us strategies to better develop and analyse ethics cases. It also reminds us of the value of interdisciplinary discourse. Anyone who writes or uses ethics cases will benefit by this book.

Chambers takes us through the deconstruction of ethics cases in the step-by-step fashion of literary criticism. Whole chapters are devoted to different segments of the case: point of view, issues of authorship and readership, location, the opening and closing of the case, use of character, the patient's voice, inclusion and exclusion of information, the influence of medium, the influence of gender. Chambers' analysis is brisk, with just enough detail to make his argument clear. His language is broadly accessible, and his use of well-known bioethics cases is strikingly effective, as it forces us to confront the inadequacies of our prior analyses of those very cases.

Chambers teaches us to pay attention to the narration of ethics cases. Narrators may seem to be, but are not, impartial observers, for the author of a case subtly weaves a commentary into the events narrated. We learn to listen for the patient's voice, realizing that in ethics cases patients rarely speak for themselves. We begin to question the events of the case. The author's choice of what to include or exclude — that is, the determination of what is relevant — depends on his or her philosophical point of view. For instance, Chambers contrasts different published versions of the "real" Dax Cowart case (in which a young man, badly burned, received treatment that he had refused): what is presented as fact in one version is mere point of view in another and entirely absent in others. When we are meant to see the moral problem as a tension between autonomy and beneficence, Dax's mother is not mentioned, which obscures the effect of the physician's action on her. When we are led to conclude that paternalism is justified, information is included that challenges Dax's rationality. That information is omitted when we are meant to judge that paternalism as unjustified.

Other features of ethics cases ignore — and, in so doing, sometimes sustain — matters of social injustice. Most bioethics cases take place in a generalized clinical setting, which has the paradoxical effect of narrowing the reader's philosophical and theological orientations. Accordingly, they lack sufficient particularity of location for issues of social justice to be meaningful. A lack of particularity extends to character as well. Characters tend to be so poorly developed that they are not characters at all, but mere roles. Their names, often "Smith" and "Jones," might be used to convey ordinariness, but they are not neutral. They signify only those particular communities where those names are ordinary. Their use distorts the variety and complexity of moral beings and moral situations, excluding or holding at a disadvantage those who are not "ordinary." Chambers also points out how ethics cases unintentionally privilege a male world view. With the historical predominance of men in both medicine and bioethics, the style of medical presentation and male literary modes mark ethics cases with a male voice. Thus, as opposed to the plotless, nonlinear, contextual, character oriented style of female literary modes, ethics cases marked with a male voice have linear plots that climax and lack attention to experience and character. They also emphasize binary oppositions such as autonomy vs. beneficence, giving priority to male traits of self-rule and independence over female traits of caring for the well-being of others. Chambers identifies a need to understand how other aspects of social injustice related to race, class and other social factors also influence the framing of ethics cases.

The shortcomings of Chambers' analysis lie mainly in what it does not do. I found myself wanting his literary analysis to give way to ethical analysis. Each chapter ends with insightful conclusions about how ethics cases are framed, but these endings are mere beginnings for a discussion of how ethics cases should be constructed, should be used, should be read. Chambers tells us that ethics cases are "still important" but provides no argument to convince us that this is so. He argues that we must learn to read ethics cases in a manner that uncovers their rhetorical force, but is silent about whether the way we write ethics cases should change. Leaving these issues hanging may be intentional on Chambers' part. After all, his aim is only to provoke an inward turn in bioethics toward greater intellectual honesty. Having provided an analysis that does this, Chambers leaves it to the reader to finish the job.

Carolyn Ells
PhD candidate
Coordinator, Hospital collaboration
Department of Bioethics
Dalhousie University, Halifax

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Frank stood at the nursing station, pausing to observe the boy who sat hunched over his drawing. The boy seemed not to care that his nurse was hovering around, stuffing tongue depressors and latex gloves into nearly full containers. Apparently oblivious to the noise of the emergency department and to his own predicament, he worked his pencil crayon until the tip broke, ripping the paper. He drove his fist into the stretcher and swore.

"It's okay, Davie. It's okay. Look, I can tape it up." Marie walked quickly toward the nursing desk; anticipating her, Frank picked up a roll of Scotch tape and tossed it over.

"This what you want?"

"You read my mind. Thanks." She returned to David's stretcher, flipped over the drawing and applied a piece of tape to the tear. "There, see? Good as new. I can bandage a picture just as well as a cut finger."

She turned the paper back over and looked at the boy's work. Frank noted the concern in her face. "It's okay," he heard her say, more softly. "You're going to be all right." She drew the boy close in an effort to hug him. David remained momentarily rigid, and then briefly relaxed into her embrace. He looked up at her and then twisted away. He returned to his drawing; she had been dismissed.

Frank recalled the events that had led to this exchange. Nearly through another busy shift in emergency, he had picked up the next chart in the queue. "Parents want to talk to doctor," was the presenting complaint. His interest piqued, he approached the pediatric stretcher.

"Hello, I'm Frank Breen, the doctor on duty tonight. You must be Mr. and Mrs. Spencer." They looked distracted; a current of anguish — or was it anger? — was palpable in the room. He shook their hands briskly.

"And you must be David. How are ya, big guy?" He smiled, trying to break the ice, but the boy's face was unreadable. Turning back to the parents, he said, "How can I help you?"

It was the woman who spoke. She was pleasant-looking, of medium build, with dark hair pushed back from her forehead in a hurried sort of way. Frank could see the gray just beginning to settle in. She seemed fragile, and he felt an impulse to protect her — from what, he didn't know. Her husband stood at her side; his droopy mustache and puffy eyes gave an impression of fatigue.

"I want you to understand that we've tried, doctor, we really have. But tonight we have made our decision and here we are." Her eyes were red-rimmed and moist.

"Okay, go on please," Frank said.

"We've had David two-and-a-half years. He was six when my husband and I adopted him. We knew it wouldn't be easy, but we wanted to bring him up as our son. We thought we could show him love and affection, give him a decent life. We thought he might show us love, maybe do us proud, in return." She stopped and wiped a tear from her eye.

"When we arrived home that first night, we changed him into fresh pyjamas, showed him the room we had fixed up for him, and tucked him into bed. When we woke up in the morning, we tiptoed into his room, hoping to catch him still asleep, all warm and cozy in his dreams. But there he was, awake, sitting cross-legged on his dresser. He had ripped the wallpaper off the wall. He said he hated stupid sports and didn't want pictures of hockey pucks and footballs in his room.

"It scared us. But we told him everything was going to be all right and gave him a hug. It was like holding a stone. Truthfully, I think I knew it was over right then. But we couldn't just quit; it seemed obvious that he needed us.

"By the end of the first week he had wrecked his bedroom. He broke the window, punched holes in the wall and ripped a pillow to shreds. And this went on. There was always a new problem. He'd hit other children, or swear at the teacher or find some other way to disrupt the class. And the lying. The constant lying. All this time and we haven't got anywhere with him. We have to face facts, doctor. He doesn't love us. And the truth is . . . I have to say it . . . we don't know anymore how we can love him."

"No, Mom!" David protested. "That's not true!" His face was contorted, his eyes glazed. "I love you, Mom. I love you too, Dad."

Frank felt a gnawing in his stomach. He looked at the child and then got up and lay his hand briefly on his shoulder. The gesture seemed weak, he thought, but he remained standing at the boy's side anyway.

"There you go again. Lying." She started to sob, mascara-stained tears running down her cheeks. "No. We're sorry, David. You just don't know how sorry we are. But we can't take you home with us. We can't be your Mom and Dad anymore."

"Pardon?" Frank said. "What do you mean?"

Her face seemed to harden, and her voice became more controlled. "Exactly what I said. We don't want him anymore. We're not taking him home with us. Call Social Services."

"I see." He looked at the boy. David's eyes were focused on some distant point; he was already somewhere else. "Do you agree with this?" he said to the silent father.

Mr. Spencer hesitated. Then looked at his wife. "Yeah, we can't go on like this, I guess."

"Okay, I'll call Social Services." He walked away, not daring to look again at the boy. He went straight for the telephone; it was clear that the parents had been pushed to their limit. Sending the child home with them again tonight seemed unwise, perhaps even dangerous.

"Another success story for the ministry," Frank thought, as he waited for the social worker to pick up the phone.

"Hello, John Wilson here, Social Services."

"Oh, hi. Dr. Frank Breen, calling from Emerg at City General. Listen, got a child here who's going to need placement." He explained the situation.

"Let me pull his file up. Okay, yeah. This kid's been around the block and then some."

"What do you mean, exactly?"

"How about sixteen different foster homes? One adoption prior to this, lasted six months."

"Poor kid."

"I'll say. Anyway, look, I don't know where I'm going to find temporary care on such short notice, but I'll be over in an hour or so."

By the time Frank hung up the phone, the Spencers were passing by the desk, on their way home. Breen studied their faces, trying to understand how they could abandon a child. He saw no peace in their expression, only bitterness and resignation. And he felt a twinge of pity.

The shift was nearly over. But there was the usual backlog of patients to attend to, so Frank hurried off, eager to put this case behind him. As he passed by the pediatric stretcher, he saw David there alone now, reading a book that Marie had dug up for him. She had brought him some milk and a couple of digestive biscuits as if hoping to soften the blow.

An hour and a half later David was marched out of the department, Wilson, the social worker, at his side. As much as he tried not to, Breen imagined David buckling himself into the back seat of the social worker's car, preparing for the lonely drive to temporary foster care. He pictured his arrival at another house to face a melancholy room with crisp, clean sheets on a sagging cot and second-hand toys to amuse himself with. He felt sure David would mistrust the new foster parents. He would remember a dozen, a hundred other adults, their faces blurred together.

"Stop it," he told himself. "Stop dwelling on the kid."

He saw Marie at the pediatric stretcher, tidying up. Having worked with her for years, he had come to know Marie well. He recognized her desire to shut out thoughts by focusing on simple tasks. Feeling a need to commiserate, he walked over to her as she picked up the drawing that David had left behind. Together they peered at the sketch of a boy with a down-turned mouth and tears leaping from his eyes, the central portion mended with Marie's application of tape. Beside this sad-eyed figure David has added a smiling woman in a nurse's uniform, her arm extended around his shoulder.

Beneath this was written: "To my nurse, from David."

Brian Deady
Emergency Department
Royal Columbian Hospital
New Westminster, BC

[Contents]

The drawing reproduced here is part of a series created by Mexican artist Galia Eibenschutz in 1993. These drawings convey a sense of the transience and contingency of physical experience, qualities later expressed in the artist's more situational photographs and three-dimensional pieces. They are also a remarkable exercise in kinesthetic awareness. Describing her process, Eiben-schutz writes: "The idea was to draw my memory of the feeling of my body in contact with the floor, so I used to take different positions and tried to translate into the language of drawing the sensation I was having. It was a way of "printing" my immediate memory ... an arbitrary translation of a feeling. It can be seen as a relation between the act of drawing, that is to say the pressure of the hand on the paper, and the feeling of the pressure of my body on the floor."

Galia Eibenschutz, 1993. Charcoal drawing, 80 cm × 1.20 m.

Eibenschutz was one the participants in c/o la Ciudad, an exhibition of works by seven young artists from Mexico City recently presented at Ottawa's SAW Gallery. Ranging from Yoshua Okón's Poli I (a videotaped confrontation with an irate policeman) to Jonathan Hernández' unassumingly elegiac SE BUSCA RECOMPENSA (Seeking Reward, a collection of "lost dog" posters) to Minerva Cuevas' Bar-code Stickers Service (a self-serve display of fraudulent barcodes to help ordinary citizens lower their grocery bills), the exhibition offered a rueful commentary on the adaptations necessary to survival in a congested and volatile city of 20 million. Eibenschutz's contribution, Sedentario(a) (Sedentary no. 1) was a three-legged wood and leather stool with attached seatbelt — a not entirely whimsical response to the long queues that are a daily fact of urban living.

Anne Marie Todkill
CMAJ

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