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01-10-2015 | Symposium: The Religious and Secular in Medicine and Health

Death’s Broker: the Ethics Consultant in the ICU

Published in: Society | Issue 5/2015

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Modern Western medicine may be seen as an effort to wrest the phenomenon of healing away from religious communities. Peter Berger and Jonathan Imber have proposed that it might be especially fruitful to investigate the encounter of the religious pluralism that has persisted thorough the modern period with the full-blown secularization as both are found in the contemporary Western hospital.¹ …

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The Hospital: On the Interface between Secularity and Religion. From the conference invitation: “Recently we {Berger and Imber] were discussing a possible topic for yet another conference in our series on pluralization, and Jonathan Imber came up with one we had not previously thought about—modern medicine. As we played with the idea, we narrowed it down to one crucially important institution—the hospital, which may well be described as a temple of modernity.” And then: “. . . in most of the world the hospital is not at war with religion, but rather is the locale of peaceful interaction between its secular discourse and religious beliefs and practices. In America as elsewhere this occurs both on the formal professional level, and on the level of ordinary people in contact with the hospital.”

In the light of the overly-determined conflict of bioethicists and sociologists studying bioethics, it is with some trepidation that I suggest that the ethicist schooled by social scientists might qualify as a “lay ethnographer”. In my defense I introduce Mol (2003: 26, my emphasis): “[This ethnography] is informed by my own observations and by attending primarily to the words of another group of lay ethnographers: medical professionals.” However, DeVries (2003) discussion of sociology in bioethics over against sociology of bioethics would, by implication, lead one to be at least initially skeptical of any claim a bioethicist might make of having practiced social science. See also Bosk (2008a), and DeVries (2009) on the value of the cobbler sticking to his last.

Wendy Cadge’s comments on negotiation and spirituality helped me refine the formulation of “negotiated transcendence”. (Cadge 2012: 14–17 et passim.)

I deliberately say negotiator or broker, and not translator, because the latter would obviously be impossible—too many languages, way too many dialects. True enough, negotiation does involve translation in some sense—but I would argue, mostly by way of pidgin variants of the major secular and religious languages commonly found in hospitals.

In this vein, we might say that the technical body is presented in particularly pure form in the daily rounds that take place in ICU’s.

My colleague Joe Fanning has pointed out that families have their own interpretations of the “technical body”, though talk about it is likely not to be (in his felicitous phrase) “their preferred nor predominant idiom”. One might adduce as evidence this scene in a children’s hospital: The dad is sitting in that severe kind of recliner found in hospitals watching the numbers and the graphs on the monitor as if he were at home in front of the TV. Meanwhile the mom is in the rocking chair studying her tablet, researching terms and numbers that have been thrown at her by the teams during the day.

In terms of the argument I am developing in the text: Does this make the family a potential “interested party” in technical dying—just as a clinician who knows a patient personally might be an “interested party” in bodily dying? Yes. But lesser shareholders, if you will—on each side.

It is not uncommon to hear as one walks onto a unit: “Ethics is here.” How bizarre. And unsettling. Further: It is customary in our service to sign our notes in the EMR with “Thank you for calling Ethics.”

I would hasten to add that I consider the people filling these roles in the hospitals where I have worked to be the heroes of the healthcare these institutions offer.

For a brief look at the history of the ICU see Reiser (1985). The idea that a technological space might “create” a role, might “enact” a feature of the social, is drawn from Actor-Network Theory. See especially: Latour (2002, 2011); Law (1992); and Mol (2003).

This perspective on negotiation has at least as much explanatory power for the rise of ethics consultation as do the “origin myths” propagated by bioethicists’. See Gains and Juengst (2008). I would see my account as supplementing sociological and historical perspectives on the field. Required reading here for bioethicists being of course the works of Renée Fox and Judith P. Swazey. Essential would be “Medical morality is not bioethics—medical ethics in China and the United States”. 1984. (And then also Fox and Swazey 2005, 2008).

People with many kinds of training and experience can fill the role of ethicist: M.D.’s, nurse practitioners, nurses, social workers, lawyers, chaplains and philosophers. There is every reason to be skeptical that this last group will have any special advantages over the others when it comes to filling the Ethics role successfully. Indeed, there is much reason to suspect the contrary.

Not that there isn’t formal institutional structure for ethics consultation—there is. But the range of approaches, the shifting expectations, and the wide variety of training and backgrounds mean that much of the purchase one has walking into a unit is local and situational, rather than bureaucratic. The classic treatment of charisma and instituationalization is of course Max Weber’s.

It would not be too much of a stretch to say that roughly 95 % of ethics consultation cases in the hospital where I work involve negotiations back-and-forth between those with interests in the technical body and those with interests in the patient’s body. More specifically, 100 % of end-of-life decision-making, DNR/DNI, and “medical futility” cases count here. And roughly 80% of goals-of-hospital-care and surrogacy decision-maker cases as well.

In terms of being drafted for ICU negotiations, chaplaincy is hampered by the same constraints noted in the text for nursing and social work. And then there is the scorn on the part of many physicians for the “crying and dying” service. Here again I recommend Cadge (2012).

In this vein: After my first or second official consultation, my supervisor told me that offering and then giving a hug to an obviously distressed family member after a family conference was “the sort of thing a chaplain does, and not appropriate for an ethics consultant.”

DeVries and Conrad have argued that ethics consultation is essentially social work (1998). But the problem with this is two-fold. 1) Social workers have a vast array of technical knowledge ethics consultants can’t begin to match. They know stuff; we don’t. They have skills to which we should consistently defer. 2) As argued in the text, ethics consultants engage in negotiations that social workers are not called into. In our many hospitals, social workers are mostly delighted to turn those situations over to Ethics. And in others, social work sees Ethics as competition. Studies of these dynamics would be most instructive.

There is extensive discussion of this topic. But see especially Sharpe (2007). And then also “DeVries and Bosk (2004), DeVries and Keirns (2008) and Elliott (2007).

Going further: “Bioethics is the public relations division of modern medicine, whether physicians (or bioethicists) like it or not.” (Imber 1998). And then, from a conversation with a private investigator who has much experience researching complex malpractice and workman’s compensation cases, of necessity a “lay ethnographer” of considerable talent: “You’re in risk management. That’s what you are—risk management.”

With this argument in mind, I remain terribly skeptical of efforts to delineate “core competencies” for consultant/negotiators like that found in Ausilio et al. (2000).

“. . . there now exists a powerful discourse which operates without recourse to religious definitions of reality. . . . I am not sure if this is the most felicitous phrase, but I would call it the default discourse: It is, as it were, the first call, made ‘naturally’ even by religious individuals before they deliberately switch to their particular ‘supernatural’ discourse.” Berger (2012: 315, his emphasis)

For an account that captures the inherent messiness of the consultation enterprise see Andre (1998).

Have we thought enough about the ethical responsibilities of ethics consultants to develop healing skills?

In keeping with the conventions of the modest genre of “consultation anecdote”, I shall use a combination of chart-note language and cadence, and commentary sentences. This being a rhetorical mode that has certain assets here. Cf. Bosk (2003: 229–235) on the different kinds of stories told by “insiders” and “outsiders”. The anecdote is an “insider” genre. See Chambers (1999) and Montgomery (2006) for very thorough treatments of the “case study” as a literary strategy and thinking method.

“The medical profession was the mediating institution between these sacred traditions of respect for the body, on the one hand, and the palpable, often painful realities of bodily living, on the other.” Imber (1998: 18).

We have to keep asking ourselves: “What are we doing here? How does this work?” Whatever it is, it is not theology, not witnessing, not interpreting the law. See Engelhardt’s penetrating assessment of what he calls “the ordination of bioethicists (2002). More pointedly: “Are we simply manipulating sacred tongues in service of hospital agendas?”

Sahih Muslim. Chapter 20: THE MERITS OF ABU TALHA ANSARI

Anas reported that the son of Abu Talba who was born of Umm Sulaim died. She (Umm Sulaim) said to the members of her family: Do not narrate to Abu Talha about his son until I narrate it to him. Abu Talha came (home) ; she presented to him the supper. He took it and drank water. She then embellished herself which she did not do before. He (Abu Talha) had a sexual intercourse with her and when she saw that he was satisfied after sexual intercourse with her, she said: Abu Talha, if some people borrow something from another family and then (the members of the family) ask for its return, would they resist its return? He said: No. She said: I inform you about the death of your son. He was annoyed, and said: You did not inform me until I had a sexual intercourse with you and you later on gave me information about my son. He went to Allah’s Messenger (may peace be upon him) and informed him what had happened. Thereupon Allah’s Messenger (may peace be upon him) said: May Allah bless both of you in the night spent by you! He (the narrator) said: She became pregnant. Allah’s Messenger (may peace he upon him) was in the course of a journey and she was along with him and when Allah’s Messenger (may peace be upon him) came back to Medina from the journey he did not enter (his house) (during the night). When the people came near Medina, she felt the pangs of delivery. He (Abu Talha) remained with her and Allah’s Messenger (may peace be upon him) proceeded on. Abu Talha said: O Lord, you know that I love to go along with Allah’s Messenger when he goes out and enter along with him when he enters and I have been detained as Thou seest. Umm Sulaim said: Abu Talha, I do not feel (so much pain) as I was feeling formerly, so better proceed on. So we proceeded on and she felt the pangs of delivery as they reached (Medina) and a child was born and my mother said to me: Anas, none should suckle him until you go to Allah’s Messenger (may peace be upon him) tomorrow morning. And when it was morning I carried him (the child) and went along with him to Allah’s Messenger (may peace be upon him). He said: I saw that he had in his hand the instrument for the cauterisation of the camels. When he saw me. he said: This is, perhaps, what Umm Sulaim has given birth to. I said: Yes. He laid down that instrument on the ground. I brought that child to him and placed it in his lap and Allah’s Messenger (may peace be upon him) asked Ajwa dates of Medina to be brought and softened them in his month. When these had become palatable he placed them in the mouth of that child. The child began to taste them. Then Allah’s Messenger (may peace be upon him) said: See what love the Ansar have for dates. He then wiped his face and named him‘Abdullah. (my emphasis)

Sahih Muslim, by Imam Muslim, translation by Abdul Hamid Siddiqui , Book 31: The Book Pertaining to the Merits of the Companions (Allah Be Pleased With Them) of the Holy Prophet (May Peace Be Upon Him) (Kitab Al-Fada’il Al-Sahabah), Number: 6013.

Accessible at: http://www.usc.edu/org/cmje/religious-texts/hadith/muslim/031-smt.php.

This passage from the Qur’an 15:28–29 (in from Pickthall’s translation) was pointed out to me later:

And (remember) when thy Lord said unto the angels: Lo! I am creating a mortal out of potter’s clay of black mud altered,

So, when I have made him and have breathed into him of My spirit, do ye fall down, prostrating yourselves unto him.

Accessible at: http://www.usc.edu/org/cmje/religious-texts/quran/verses/015-qmt.php.

I understand now that it is the custom for a same-sex member of the family to wash the body of the newly dead, but that this does not apply to younger children and infants. A ready-to-hand if rudimentary resource, which I only came upon well after the case above was resolved: Tanenbaum/Center for Interreligious Understanding (2009: 78–95, especially 94). It also turns out, to my considerable surprise, that similar though more abbreviated information is found in the Policies and Procedures manuals of a number of medical centers under the heading of “Pastoral Care.”.

I had likewise assumed teachings concerning the desecration of the dead, and that these teachings would address autopsy and organ removal, too. (Tanenbaum 2009: 94).

And, with an element of what might be called “residual piety” (following the lead of Philip Rieff), the consultant did not say “In the Name of . . .”, thinking that ritual formulation only for priests to speak, but rather “In the presence of . . .”). See Rieff (1972: all Index entries for “Piety” and “Pietist(s)”).

Berger (2012: 316).

There are those who feel that these two factors together result in inferior care for some Amish families. But such a conclusion would depend on sorting out with some precision what the goals are of the care of which we are speaking. In terms of certain technical goals, perhaps the care is not “as good.” But doesn’t the very existence of Amish communities constitute an intentional challenge to the assumption that the technical can guarantee the achievement of goals that are suitable final ones for human life?

This being but one among many efforts to secularize death. (Actuarial tables and automotive safety tests being others, e.g.)

“The medical profession—insofar as it remains a mediating institution between sacred acknowledgment of the body and scientific uses of it—is constantly tested in how it makes connections between means and ends, creating the many forms of public ambivalence about medical practice in its wake.” Imber (1998: 25).

Berger (1967: 51). “The power of religion depends, in the last resort, upon the credibility of the banners it puts in the hands of men as they stand before death, or more accurately, as they walk, inevitably, toward it.”

Also Berger (1967: 80). “To repeat, every human order is a community in the face of death. Theodicy represents the attempt to make a pact with death. Whatever the fate of any historical religion, or that of religion as such, we can be certain that the necessity of this attempt will persist as long as men die and have to make sense of the fact.”

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Title: Death’s Broker: the Ethics Consultant in the ICU
Publication date: 01-10-2015
Published in: Society / Issue 5/2015
Print ISSN: 0147-2011
Electronic ISSN: 1936-4725
DOI: https://doi.org/10.1007/s12115-015-9928-9

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