H E C FORUM 1996; 8(6):346-354.

© 1996 KluwerAcademic Publishers. Printed in the Netherlands.

T H E E T H I C S C O M M 1 T I ~ . E AS G R E E K C H O R U S

N A N C Y M. P. KING, J.D.

There is an essay that I return to over and over in my teaching, one that never fails to impress students and audiences, and that not many other people seem to know about. I had not been teaching for very long when a copy of it was given to me, and over the last twelve years it has stayed near the top of my list of favorite writings, because it resonates deeply with my views about the nature of moral decisionmaking and the work of ethics committees. It is Kathryn Hunter's "Limiting Treatment in a Social Vacuum: A Greek Chorus for William "P'(1).

In this essay, Hunter introduces us to a "sadly ordinary" patient in a persistent vegetative state and a classic decision-making problem: How aggressively should he be treated when nobody really knows what he would have wanted? Like the good literature scholar she is, Hunter does not walk the reader through the hierarchy of decision-making standards or analyze the appropriateness of discussing the cost of care or the scarcity of hospital beds. Instead she points out that most of the important ethical questions in William T.'s case do not have clear-cut answers. She focuses instead on acknowledging the tragedy that underlies the need for making decisions like the one faced here.

I like this piece for three important things it can teach to ethics committees about how best to do what they do. It teaches that autonomy and community are not concepts in opposition but interdependent; that the head and the heart both have roles in decisionmaking; and that the context of decisionmaking is of central importance and can be considered without risking radical relativism. For ethics committees to function as advisors with both compassion and consistency, these are necessary lessons to learn.

Autonomy and Commlmity in the Chorus: False Adversaries

My legal training took place before the "autonomy backlash" that began to sweep through bioethics in the late 1980s, and that continues to

346

N. King 347

pose autonomy and community as adversarial concepts. But as a lawyer I was trained to recognize the ways in which a community's social, political, and legal institutions foster, support, and enhance the autonomy of its members. I have therefore never quite understood the simplistic opposition of autonomy and community, 1 and have always found that thinking about ethics committees as moral communities makes sense and can be fully compatible with protecting the rights and interests of patients (2)(3).

Hunter 's essay, which recommends the establishment of an ad hoe community to consider the tragedy of William T., first of all points out that ethics committees don't have a corner on the market here. Many different ad hoc, temporary, and specialized acommunities° function in most healthcare institutions to assist patients, providers, and families in the decision-making process. An ethics committee may or may not be the best or only option available in a given situation. Indeed, Hunter argues that in William T's situation the committee's value may come not from the diversity of its membership or its expertise, but from its experience, its ability to witness, z and its sense of continuity.

In likening the moral community of decision in William's case to a Greek chorus, Hunter reminds us -- as Guido Calabresi and Philip Bobbitt did in choosing the title of their classic Tragic Choices -- of some important features of end-of-life decisionmaking. She notes that decisions like these involve aprocess" and even "ritual," and describes a Grand Rounds (certainly a well-established ritual if ever there was one in the hospital) about William's case as "formal and agonized." In an extended comparison, she observes:

Greek tragedy is about human fate, which is to die. Its heroes are caught in crises that neither logic nor good intentions can remedy. • . . The Greek chorus takes no action . . . . Instead of action, the chorus offers advice and history and support for the protagonist. • . . They are traditional moralists; they think and feel in clich 6s, they utter common wisdom. This is seldom any material help to the hero, for it is the nature of tragedy to enact crises about which common wisdom may be uttered on both sides . . . . The chorus, then, establishes a moral resonance for the hero's fate. Its virtue is its presence and its sympathy and its clear meditation on his or her predicament in a social and historical context. The hero cannot "win" in tragedy either because two

348 The Ethics Committee as Greek Chorus

right courses of action conflict or because the hero's fate is inexorably determined. It is not the chorus's job to choose for the hero. Instead it must present the conflict, agonize over its consequences for the hero and the community, reflect on its history and its moral significance, pointing to its inevitability, in light of all that has gone before. The hero, whatever course is chosen, whatever fate unrolls, bears the burden of what is left undone, the right course of action not chosen . . . . Beyond the tragic ending, we imagine, the chorus will store up the memory of the struggle just ended, and this will in its turn be the stuff of moral reflection on some future occasion"(2, pp. 717-18).

Most healthcare providers, and many if not most people interested enough in healthcare ethics to serve on HECs, are problem-solvers by inclination, training, and experience. Hunter notes that modern readers of Greek tragedy are often impatient with the chorus's "interruptions," because they do not further the action or the resolution. Similarly, at least some of the parties to any decision-making dilemma are likely to become impatient with others' inability to just get to the answer, do it, and be done with it. Physicians get impatient with nurses, committee members get impatient with each other, and everybody gets impatient with families. The Greek chorus reminds us that no matter how much we want to get things done, there is a close and necessary relationship between action and reflection, and that things done go on to take their places within traditions of memory, storytelling, and teaching, both within and outside the moral community of decision.

As Alex Capron pointed out more than 20 years ago, one of the key functions of informed consent is the occasion for reflection and self- examination that it provides for physicians (4). In other words, saying something out loud presents it for examination and ratification in a way that just doing it simply cannot. Discussion about a decision can only take place in a community, and it is necessary to a community's role in any decision. Thus, even when the community does nothing other than comment, it serves to promote the autonomy of the decision-making parties in a significant and memorable way.

Reason and Emotion in Decision

Hunter's choice of an ad hoc community rather than an ethics

N. King 349

committee in William's case is deliberate. She says: "Something more than a consideration of ethical and legal principles was needed, something prior to rational disciplines and more amenable to the individual and the empirical . . . . Above all, an impartial committee reaching an objective decision is alien to the philosophical basis of medical practice" (1, pp. 717, 718). In hindsight, it appears that Hunter has set up a whole field full of straw people for us to strike down: ethical principles with no connection to lived experience, rational disciplines, impartiality, and objective decisionmaking. All of these putative characteristics of hospital ethics committees, which in the modern era were grounds for praise of Reason and his servants, in the postmodern era are nothing short of epithets. But it has always seemed to me that neither characterization is valid, and more importantly, that the oppositions on which they are based -- principles as opposed to practices, the rational as opposed to the irrational, impartial versus biased, objective versus subjective -- are simply not true.

I 'm fundamentally a rationalist, with a pretty clear focus on reason rather than emotion -- a description that is rather common in medicine, and certainly has come to be viewed as characteristic of physicians in full professional mode. I can still recall vividly the moment in my legal education when I realized that judges -- even the Supreme Court -- can only take logic and precedent so far, and that there is always, at the end of the line and the moment of decision, something else, something that is not just reason, that tips the balance. I was bitterly disappointed to find that the world was not controllable in the way that I had hoped. Since then, however, I've learned to see the ways in which the two halves of all those false oppositions are woven inextricably together in all decisionmaking, and it's gotten very interesting.

In healthcare decisionmaking, emotion is still far too often psychologized and marginalized. Frequently it is seen as affecting only patients, and then only negatively. Emotion is invoked in order to describe the patient as "appropriate" or "inappropriate," and relegated to psych consults and social services rounds more often than it is permitted to inform and enrich our understanding of the decision to be shared. Hunter points out that healthcare providers' emotions and experience play significant roles in their decisions. She describes the ways in which residents, nurses, attendings, and consultants respond emotionally to William T., and permits readers to consider how such responses should or should not figure into his fate.

One of the things that ethics committees can do well is to return

350 The Ethics Committee as Greek Chorus

the language of emotion and experience to the conversation. Because a good committee is a diverse community, no single expert language can be used, and members can call for translations of terms and expressions that might otherwise go unremarked. Asking for a translation of =inappropriate" can lead to a lively discussion of how and by whom the unspoken standards of =appropriate ~ affect and behavior are set, as well as to a breadth of resources and approaches for ameliorating the situation without stigmatizing the players. Beyond that, it's time we recognized that separating the =objective facts ~ from their tone and color is an intellectual device, not a description of reality. Besides, all of us are thoroughly convinced that we are being rational and it's the other guy, the one who disagrees with us, who is being hamstrung by illogic and emotion. In healthcare decisionmaking, that understandable and convenient blindness generally works against patients, because of their relative powerlessness.

Because they are reflective and eclectic as much as they are administrative and expert, ethics committees are in a way naturally inclined to bring issues of the head and heart together in their deliberations, but they can do so even more effectively if they see it as an explicit concern. By habitually asking questions and using language that invites and encourages the head and the heart to be considered together, the ethics committee influences how people talk and think, not only about cases before the committee but about cases before they come to the committee. And that, incrementally, changes the memory, experience, and moral tradition of the institution.

Keeping the Devil out o f the Detmqs

One of the attractions of =objectivity" is of course its universal character. And one of the questions that has always dogged ethics committees is their universalizability, or fungibility. Juries, though made up of different people, are supposed to be sufficiently representative of their communities that one jury is as good as another, and even if that is not so, the legal system has mechanisms for curtailing and controlling juries. Ethics committees don't make decisions, but they obviously can be quite influential within an institution, and they are just a bunch of people. So why should we even consider letting them consider anything other than the facts and the principles of decision that will put those facts in good order and spit out a right answer? Why in the world did Kathryn

N. King 35i

Hunter want William T.'s moral community to do something individual, empirical, emotional?

There is a two-part answer to this. First, she points out that legal principles and moral rules are almost always, even necessarily, incomplete. Rarely do they provide "uniform, socially agreed on" policy. Instead, they must be defined, interpreted, and applied by people, and people perform this work in a variety of ways. Some of it is analytical work, but much of it is emotional reflection and even storytelling. William T. is in a persistent vegetative state; part of determining what care and treatment he should receive depends on what he is owed as a patient. Is he a person? That question has medical, policy, and philosophical answers, but it is also important, somehow, that he looks responsive and that caregivers consider themselves to be in relationship with him.

For Hunter, it is important that William has no family to decide for him, but there is no reason not to involve an ethics committee if the family is willing. She notes that decisions about treatment for patients like William are especially difficult if there is no one available to say uWilliam would never have wanted to go on like this" or "William was not a quitter." But even when we know these things we may need to figure out together what not being a quitter means for William here and now. In William's case, his story is told in fragments -- the resident who remembers him from clinic, and recalls that he told her he didn't want to die, even though he did not manage his diabetes well; a small amount of information from distant family members; his months in the hospital, as recounted by his nurses.

Ultimately, either William will be treated aggressively or his treatment will be abated. Both options are potentially correct, potentially wrong, and unavoidably immersed in tragedy. But if either is to be the choice that is made for William, it must be based upon all of the context and detail that we can muster on WiUiam's behalf. It is also the choice that is made by someone, by the healthcare team or the family, and their reasons, doubts, difficulties, and hopes all likewise deserve recognition.

Second, however, Hunter recognizes that particular decisions should not be idiosyncratic. The ethics committee as Greek chorus also helps to protect against that risk. The resident who knew William when he was conscious and living in the world has emotional ties to him for that reason; however, she did not know another patient, a young woman whose PVS resulted from complications of childbirth, and she therefore feels differently about her. That patient does have a family, but what will their

352 The Ethics Committee as Greek Chorus

love and grief mean to their advocacy for her? And what if she had no family? Or what if William did? What if the formerly intact William was as unknown to his caregivers as the young woman was? What if he did not look quite so awake, or was not quite so young? What if he were in the last bed in the ICU? What if he were white?

Hunter's awareness of the what-ifs has two kinds of import. First of all, every answer cuts at least two ways. Second, the exercise of imagination and memory by a moral community is what keeps the risk of idiosyncrasy at bay. We can't be uniform, and even consistency is hard to come by, but if we can begin to unearth the important, we can invoke them in every case in after tragedy.

kinds of factors that are hopes of finding fairness

Hunter says that the chorus "must come together . . , to state what seems to be the obvious predicament, its possible solutions, and the nature of the reservations about each of them. It must take account of conflicting opinion, divergent principles, and strong feelings. It must acknowledge emotional attachments or their absence. It must ignore temporarily some of the hospital hierarchy while everyone speaks on one side or the other." And I would add that when the ethics committee serves as the chorus, its capacity to address the details and particulars can work hand in hand with its development of collective experience, fostering of institutional memory, and capacity for teaching.

Bioethics and Moral Life

Kathryn Hunter is one of the pioneering literature scholars who has shaped the emerging field of literature and medicine and the emerging discipline of narrative ethics. For that reason it was natural to her to envision the modern Greek chorus as something other than an ethics committee, which already had a discipline-based function of its own. But what she points to as necessary to moral decisionmaking has since begun to emerge in bioethics itself, as it has turned lately from exclusive reliance on principlism to revivals of virtue ethics and casuistry, and to the inclusion of power analysis through feminist ethics.

Implicit in Hunter's view, however, is the recognition that lived moral experience is broader, richer, deeper, and more meaningful than can be captured by any claimed moral expertise. I learned this from growing up professionally in a Department of Social Medicine where multidisciplinary collaboration is the norm, and where it simply makes no

N. King 353

sense to consider moral activity in health care apart from its social, cultural, and historical context. My department chair has always said this best, and most recently he has put it this way:

[H]uman moral activity is complex and multi-faceted. It includes decision and action, reflection and contemplation, sustaining habits over time, nurturing character, and many other kinds of activity. It is part logic, part acts of will, part turning and tuning emotional sensibilities, part feats of imagination. Because moral activity is complex and multi-faceted, ethical theory must be multi-faceted as well . . . .

The first and most basic task of ethics is paying attention to the moral phenomena. Paying attention requires not only suspending immediate judgments of right and wrong, but also suspending our usual categories of interpretation. If ethics is not one thing but many -- not one kind of human activity, but a complex variety of activities held together for each person in unique ways -- then it is essential to let people speak for themselves, and in their own terms, about the moral dimensions of their lives. Interpretation, of course, always follows, but it should not precede and preempt the voices of the morally perplexed, nor should it presume finality of interpretive power over these voices" (5).

There is an enormous and ever-growing literature about what ethics committees are supposed to be doing and how they are supposed to be training for it, including specialized journals, course syllabi, reading lists, and even calls for professional standardization and certification for persons doing ethics in institutional settings. The ethics committee as Greek chorus shows why and how the professionalization of the work of committees is wrongheaded, and provides committee members with at least some sense of what it is they really ought to be doing: listening, with all their heart, to stories about tragic choices, and working, as a moral community, to support and memorialize the process of choosing. This may not sound scholarly or certain, and it is often muddy and difficult, but it is responsive to what human moral activity really is -- and that, frankly, is very interesting stuff indeed.

354

°

2.

o

2.

.

.

.

The Ethics Committee as Greek Chorus

NOTES

Neither does Jim Childress. See Childress JE The place of autonomy in bioethics. Hastings Center Rep. 1990; 20(1):12-17. The role of witness or keeper of the record is ascribed to the physician in a number of sources, including Berger J, and Mohr J. A fortunate man. London: Writers and Readers Publishing Cooperative; 1976.

REFERENCES

Hunter KM. Limiting treatment in a social vacuum: The case of Wiliam T. Archives of Internal Medicine. 1985; 145:716-19. Duff RS. Unshared and shared decision making: Reflections on helplessness and healing. In: King NMP, Churchill LR, Cro~ AW (eds.) The physician as captain of the ship: A critical reappraisal. Dordrecht, The Netherlands: D. Reidel Publishing Company; 1988:191-221. King NMP. Ethics committees: Talking the captain through troubled waters. In: King NMP, Churchill LR, Cross AW (eds.) The physician as captain of the ship: A critical reappraisal. Dordrecht, The Netherlands: D. Reidel Publishing Company; 1988:223-241. Capron AM. Informed consent in catastrophic disease research and treatment. Un&ersity of Pennsylvania Law Review. 1974; 123:341-429. Churchill LR. Bioethics in social context. In: Ronald Carson and Chester Burns (eds.) The PhilosOphy and Medicine series, vol. 50. Dordrecht, The Netherlands: Kiuwer Academic Publishers (forthcoming).