The Bioethical Mandala
A Reflection on the Moral Structure of Health Care (part 2)
The Relationship of Care
Few would deny the idea that we are to some degree bound together by the strands of our common humanity. No doubt these cords are strongest in the more intimate relationships: I am more attached to my family and friends than I am to those with whom I come into contact less frequently, and I am more concerned for the wellbeing of these more casual acquaintances than I am, or could reasonably be expected to be, for that of perfect strangers, unknown foreigners and those from distant parts with whom I shall never conceivably form any sort of personal relationship.
Nevertheless, I do feel quite a degree of sympathy for their problems, should they be brought to my attention; I give willingly to campaigns that seek to relieve the suffering of those unfortunate enough to find themselves involved with the disaster of the month. I also regularly contribute time and money to causes that seem worthwhile, aiming as they do to relieve to some degree the chronic suffering of sick and disadvantaged people closer to home. Many of us do likewise.
There are those however, who choose to devote their lives to caring for others. Medical practitioners, orthodox or alternative, fee-based or salaried, form a subset of this group; it is with their activities and those of their allies, the members of institutional bureaucracies (medical research, health and hospital administration, drug companies and the like, plus those involved with the direction of relevant community funds) that bioethics in the twenty-first century is primarily concerned.
If we step back to look at the intimacies of the family, or of any small, self-contained community, we find that relationships of care are governed largely by the strength of emotional connections generating the coherence of the group. Universalisable principles of the sort espoused rather grandly by Immanuel Kant (all people should be treated as ends in themselves, deserving of equal rights to justice, to a fair share of the store of goods, by virtue of their rational identity as persons, irrespective of such instrumental regards as preferences or other utilitarian considerations) and to some extent by his utilitarian opponents (who hold that the maximisation of the balance of happiness over suffering should be extended to the widest possible scope in any given society, irrespective of any more abstract "rights") are hardly to be considered within such an intimately personal situation.
To care for the needs of those with whom we are familiar, especially when they are ill, is so clearly relevant to caring for our own needs that such caring is readily accepted as a primary function of human interaction. Seamless fabrics of family and community are torn and disrupted by the distressing breakdowns of regularities and intimacies that accompany the experience of sickness. To mend a disturbance in the bodily schema of a suffering friend or loved one is partly to repair rents in the social fabric of the general good, as experienced within the concourse of interpersonal relationship.
Where personal interests are involved, the emotional drive to maintain the stable balance of a functioning community is hardly a matter for the application of ethical principles, for it is an integral part of the intimate communal structure. This compelling attention to the needs of loved ones is, however, rather difficult to extend to members of the larger community with whom we may not be personally acquainted.
As communities grow larger and more complex, social and environmental pressures foster particular talents at the expense of more general abilities, producing a consequent narrowing of focus that leads to an increasing specialisation of knowledge and activity. The strong fabric of intimate, tribal society becomes increasingly attenuated, as individuals become more conscious of their own autonomous existences, within the broader domains of a society which has adopted the normalising strategies and ostensibly liberating discourses of subjective individualism.
The Surrender of Autonomy
In the mystery schools, the body of the novice was surrendered to the control of the initiate, in a declaration of absolute trust. Disbelief was put aside in an act of faith which sought in the hands of the expert a complete transformation of body and mind, which were no more than portraits of the soul. In modern medical treatment, the hierarchical place of the healer-initiate has been filled by the medical practitioner – and ideas of the soul have been dismissed as an irrelevance to the care of the body.
In submitting our bodies to the care of the medical professional, we too are committing an act of faith which may have far-reaching consequences for our wellbeing. Like the novice, we are entering an unfamiliar environment which is highly structured, authoritarian and stuffed with outlandish objects, which, if they are explained at all, are dressed in an exotic terminology apparently designed to delineate the structural economy of power, rather than explain their mysterious function. No doubt there is a therapeutic intention in this mystification; indeed, the total surrender of the right of informed control over our personal space to some benevolent power may fulfil an infantile yearning to return responsibility for our own wellbeing to the smiling giants of long ago.
On the other hand, it is more than likely that the agenda of the structural economy of modern health care is best served by keeping its clients at a distance, in terms of their understanding of the process. Within the maze of terminal obscurity, bureaucracy and protocol that characterises the complex infrastructure, human beings wander in trances of shelved responsibility that would make Franz Kafka turn in his grave.
This article goes on to consider the nature of health and disease, ethical positions, and the implications of harmony and wellbeing.
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