Perhaps the central focus of American bioethics has been to push against medical paternalism on the grounds that it impedes the autonomy of patients—that is, their ability to make choices of their own volition. This preoccupation with autonomy has been criticized from both within and outside the field based on its atomistic view of the patient and corresponding lack of attention to how the patient is enmeshed in intimate social relations and broader cultural, political, and economic processes. Bioethics has responded to these critiques by trying to expand its moral scope, but it has maintained its concern for how patient autonomy might be violated. Paternalistic clinicians are now not the only parties who can be deemed guilty of infringing on the patient’s right to follow their preferences. Bioethicists commonly worry the patient must be protected from their family and even from themselves.
This issue’s target articles walk the narrowing tightrope of a still intensely autonomy-focused bioethics: They promote a moral imperative to provide care according to patient and family preferences while debating how clinicians should determine whether the preferences patients and families express are authentic. Moore and colleagues examine “ambivalent” situations—when patients do not articulate definitive preferences, or their stated preferences change over time and/or in consultation with family and clinicians. The authors reason that by identifying the mental state underlying a patient’s ambivalence, clinicians can efficiently decode what the patient truly wants. Caruso Brown’s attention is directed toward ascertaining and giving voice to the authentic preferences of pediatric patients’ family members. She argues that when family members are embedded in hierarchical kinship arrangements, clinical personnel may have difficulty differentiating their agreement with one another from deference to one another. To make discerning their authentic preferences easier, she keys in on certain familial, sociocultural, and demographic characteristics as indicators of the potential for marginalization of important decision makers.
In addition to their concern with parsing the authenticity of patient and family preferences, the two target articles share a second key characteristic. They both lay out typologies meant to aid clinicians in inferring the authenticity of patient and family preferences amid social complexity and a time-constrained clinical environment. These typologies are clinically expedient. They are designed to facilitate the “efficient biomedical consumption” of complex situations to arrive at decisions in a timely fashion so that clinical workflow can be maintained—what Kondrat, in his astute commentary in this issue, calls “clinical impatience”. We want to reflect more here on this drive to provide typologies for practitioners, both because it is common in bioethical work on medical decision making and because it has important ramifications for how the topic is approached.
Typologies, of course, consist of types. They encourage us to typify things in certain ways as we move through the world. What is typification, exactly? Let us imagine a hiker walking through the woods. He encounters a tree with damaged bark alongside the trail. He takes little note of it, treating it as a singular tree that happens to be the worse for wear, and walks past. A second hiker approaches and encounters the same tree. She surmises that the way the bark has been peeled from the tree is consistent with damage done by bears when they feed on sapwood. In making this inference, the second hiker has typified the damaged tree: She has posited that it is one instance of a general regularity.
We are surrounded by innumerable things and events, and we can attend to only a tiny fraction of them as instances of types. Typification is thus highly selective. It focuses on particular aspects of the world around us, looking past myriad others; it links these aspects to particular regularities instead of myriad others. Typification both highlights and erases.
The risks inherent to typification in the clinical setting are made clear by a vignette recounted by medical anthropologists Arthur Kleinman and Peter Benson in a piece critiquing the cultural competency paradigm. A Mexican father living in the United States fails to seek consistent treatment for his HIV-positive 4-year-old son. The son’s care team, attuning their focus to the father’s ethnicity, assumes that this failure is attributable to a cultural conflict between his Mexican belief system (whatever they think that might be) and the treatment. However, subsequent ethnographic investigation reveals that the father’s demanding, low-paying job has made seeking care for his son logistically difficult. The father’s failure to seek care for his son is not directly related to his ethnicity. The care team, by looking past his financial precarity, closes off the possibility of realizing why the son was not receiving adequate care.
The vignette is one illustration of how clinical personnel, as they try to navigate the complexity and uniqueness of clinical encounters, can make sweeping inferences about which dimensions of patients and their families are of import.
In this vignette, the care team is faced with a complicated situation calling for a resolution. Of all the details of the situation, they home in on a particular quality of the father—his ethnicity—which is brought to the fore, erasing other details, such as his job insecurity. They conclude that the situation is a particular instance of a general regularity—the views of people of Mexican heritage toward biomedicine—erasing other broad trends that might be shaping the situation. The vignette is one illustration of how clinical personnel, as they try to navigate the complexity and uniqueness of clinical encounters, can make sweeping inferences about which dimensions of patients and their families are of import. As in the vignette, sometimes clinicians get this process of typification very wrong.
Typologies, as instructions for particular modes of typification, are thus serious business. In clinical settings, they are exercises in “professional vision”. That is, they set out routinized ways by which clinicians see patients and, correspondingly, determine the care they need. Typification is essential to living creatures, as it allows us to relate one experience to another and make the world’s otherwise overwhelming novelty digestible. But in some cases, as in Kleinman’s vignette, it results in what William James called “vicious abstractionism”: when a mode of typification, instead of illuminating an aspect of a situation so as to enable an apt response, serves to so tightly and automatically narrow our focus that we are neglectful of contextual nuance and consider only a fraction of possible responses.
We have selectively attended to two attributes of this issue’s target articles—their concern with authentic preferences and their provision of typologies—that we think are instances of general regularities in bioethics. In doing so, we have surely overlooked many other important aspects. Nevertheless, we conclude by posing a couple of questions about these attributes that we believe are worthy of reflection.
First, what is highlighted by bioethics’ continued drive to pin down authentic preferences, and what is erased? For instance, in the case of Moore and colleagues’ typology, the clinician is encouraged to typify patients who are hesitant to state treatment preferences, or who change their preferences, as instances of ambivalent mental states. Potentially erased is that such patients may not be struggling with what they “prefer,” but rather struggling to come to terms with a new and terrible situation. When the primary focus is preferences, the patient and family are seen first and foremost as choosers among options.
Second, when it comes to attending to the humanistic aspects of health care, why is the role of bioethics so often the provision of formal typologies? In part this may be attributable to certain intellectual habits. But it is also in part a reflection of the state of medicine—or at least a particular bioethical view of it. Day-to-day medical care in America is apparently so pressured and frenetic that the utility of clinical bioethics is in providing lists of types and step-by-step instructions so that clinicians can sensitively interact with patients and families. We worry that these typologies are recipes for vicious abstractionism, and we encourage work that interrogates both the features of our medical institutions and the characteristics of bioethical thought that have made them so prominent.
The author(s) reported there is no funding associated with the work featured in this article.
For references, see the original editorial.
Samantha W. Stein, BA, is a linguistic anthropology PhD student at the University of California, Los Angeles, and the incoming manager of the Language and Bioethics Collaboratory.
Jason N. Batten, MD, MA is a research-track resident physician in the Stanford University Department of Anesthesiology, Perioperative, and Pain Medicine; an affiliate at the Stanford Center for Biomedical Ethics; and a founding member of the Language and Bioethics Collaboratory.
Bonnie O. Wong, MD, PhD is a recent graduate of Stanford School of Medicine and University of California Berkeley Department of Anthropology, an incoming resident physician in the Brigham & Women’s Hospital Department of Surgery, and a founding member of the Language and Bioethics Collaboratory.
Justin T. Clapp, PhD, MPH is Assistant Professor of Anesthesiology & Critical Care and Medical Ethics & Health Policy at the University of Pennsylvania Perelman School of Medicine and member of the Language and Bioethics Collaboratory.