‘What Patients Teach: The Everyday Ethics of Health Care’ by Larry R. Churchill, Joseph B. Fanning, and David Schenck (Oxford University Press, 2013).
These three authors from Vanderbilt University share a long standing engagement with the fields of medical humanities and bioethics. Larry Churchill and David Schenck earlier joined forces in a project on the concept of a healing relationship, which resulted in a volume based on interviews with doctors called Healers. Since this view was restricted to the physician side of the relationship they, joined by Fanning, have undertaken a new set of interviews with patients. These were recruited from the network of their earlier physician interviewees.
The authors argue convincingly that much ethical work on ‘being a patient’ may overemphasise the etymologically grounded dimension of suffering. Here, they depart from the logical point that being a patient involves being dependent on health care professionals. Thus, rather than starting with an ethical argument for their perspective, they present a conceptual one.
Much of the argument in the book is built around extended quotes from the interviews. In Chapter 4, Three Journeys, three of these exchanges are represented in several page long quotes. A number of categorizations that make up the backbone of the book, are emphatically presented as the outcome of a grounded theory style approach:
- Ten signs of a good click with the doctor (Chapter 1)
- Ten positive (“healing”) clinician traits (Chapter 2)
- Ten negative clinician traits (Chapter 3)
- The five key elements of being a patient (Chapter 4)
- The agency structure of being a patient and the four stages of patient experience (Chapter 5)
The final chapter is a call for a less doctor centred (‘narcissistic’) health care ethics. It’s refreshing that, in a discussion of ethical codes, the authors praise nurses for displaying a more relational image of their work than doctors.
In the interviews, patients were stimulated to place their relationship with their physician in the context of their life story. Although the authors believe their findings are valid for all kinds of settings, the predominant setting appears to be one of an extended and quite personal relationship between patient and doctor. Where the personal elements of the relationship are explored deeply, attention to the institutional, social and cultural context is strikingly absent.
Churchill et al present this volume as both an addition to and correction of Healers. Thus, together, they should potentially deliver an integrated picture of the healing relationship between doctors and patients. Although the previous volume is referred to in passing throughout the book, in the concluding chapter they curiously shy away from such an endeavour, instead offering a manifesto in a familiar virtue and care ethics mode that does not specifically build on the earlier results. That’s a pity, since the fruits from both books could well be extended to a quite systematic overview from the relationship between patients and their doctors from a virtue and care perspective.
Of course, the authors won’t fool critical readers into accepting that the main categorisations and arguments of the book are derived from the material without the aid of the virtue and care ethics framework. These claims could be passed over, if they had succeeded or at least attempted to give a systematic account of their findings in relation to their earlier work and to other empirical and theoretical work. No such thing is offered, leaving the critical reader with the suspicion that the interpretative choices not accounted for were heavily influenced by perspectives that have not been critically discussed in the research process. The level of methodological awareness of these authors, with their background in philosophy and medicine, does not really seem to stretch beyond the point that quotes speak for themselves.
Still, the basic intuition behind the book remains promising. Let’s really work towards a two sided and empirically grounded normative analysis of the relationship between patients and physicians. But undertaking such a project would require a much broader scope than the one presented here and delving into quite different bodies of literature and varieties of research.
Quintessential would be to take in the kind of anthropologically inspired science and technology work in the vein of Annemarie Mol’s The Logic of Care. Such observations of doctors and other personnel in action to make medical devices work in everyday life, offers key advantages over the work at hand: it integrates material aspects in the relationship and it’s not restricted by the specific humanistic morality of the present authors. This leads to a more modest and open picture of the relationship. Not that Mol with her rich and powerful analysis has succeeded in giving a convincing systematic account, but that only means there’s rewarding integration work to be done.
As it stands, the book will only offer fresh observations to those not yet very familiar with empirical and theoretical work on the relationship between patients and physicians or unaware of virtue and care ethics. But, of course, it will offer new logs on the fire of those with strong normative convictions of a peculiarly American humanistic kind.
Reviewed by Dr Rob Houtepen directs the programme in Ethics, Law and Humanities at the Maastricht Medical School in the Netherlands. His main interest in this context is to influence the ‘habitus’ of medical students into a more discussion minded one. In his experience, the nature and value of normative discussions of any kind are totally unfamiliar to these young people.
Correspondence to Rob Houtepen.
Churchill, Larry, and David Schenck. 2011. Healers: Extraordinary Clinicians at Work. Oxford: Oxford University Press.
Mol, Annemarie. 2008. The Logic of Care: Health and the Problem of Patient Choice. Abingdon: Routledge.