Leigh E. Rich

The Afterbirth of the Clinic: a Foucauldian perspective on "House M.D." and American medicine in the 21st century

Mirroring Michel Foucaults The Birth of the Clinic (1963), which describes the philosophical shift in medical discourse in the 19th and early 20th centuries, the Fox television series House M.D. illustrates the shift in medical discourse emerging today. While Dr. Gregory House is Foucaults modern physician made flesh-an objective scientist who has perfected the medical gaze (le regard) and communicates directly with diseases instead of patients-his staff act as postmodern foils. They provide a parable about the state of biomedicine, still steeped in modernity but forced into a postmodern, managed care world. House M.D., however, is more than a mere depiction of the modern-postmodern tension that exists in todays exam rooms. It is an indication of a transition period in American medicine. House M.D. nostalgically celebrates what once was and simultaneously questions what currently is, while what is about to be is in the midst of becoming.

“Born Like This / Into This”: Tuberculosis, Justice, and Futuristic Dinosaurs

I was born of disease. Not in the same circumstances as too many still today and so many others in the past, but my existence—or at least key narratives from life courses entwined with my existence—are rooted in disease. Had it not been for the BSpanish flu,^ I would cease to exist. For it was the death of my paternal grandfather’s first wife during the 1918–1919 influenza pandemic that left him a widower, with three young children to raise. Out of this tragedy came marriage to my grandmother and ten more children, my father eighth in that line, eleventh in the blended family overall. And had it not been for tuberculosis, my grandparents never would have met. For it was my great-grandfather’s affliction with TB that brought this small immigrant family of three—him, my great-grandmother, and my barely born grandmother—from New York to Denver. They cameWest, into the dry, thin High Plains air of Colorado, where the sun reputedly shines three-quarters of the year (Colorado Climate Center 2010) and the climate was a prescriptive for what was then called Bconsumption^ and those ill with it Blungers^ (Lewis 2015). Perhaps this health history somehow found its way, Lamarckian-style, into my being. For I am otherwise not Bioethical Inquiry (2016) 13:1–5 DOI 10.1007/s11673-016-9710-8

Intergenerational Global Heath

This special issue of the Journal of Bioethical Inquiry focuses on global health and associated bioethical concerns. As a concept, global health broadens the focus from national public health situations to the international sphere and concerns itself with the health of all humans, but particularly those in developing countries who suffer from severe health inequalities. However, there is one sense in which global health is lacking: Its primary focus is on those currently alive and, in some cases, their offspring. But what about future generations, who may suffer from even more pronounced inequalities? In this editorial, we consider the bioethical implications of failing to adopt an intergenerational concept of global health. One of the major strengths of global health is its emphasis on disenfranchised populations who do not enjoy the advantages of the medical systems of developed countries. By drawing attention to the issues that affect billions of disadvantaged people around the world, global health campaigns attempt to reduce the moral distance that makes many in developed countries neglect the needs of those most in need in other countries. It is unsurprising that governments (and people donating to charity) have tended to focus on looking after their own citizens first, but increasing public awareness of the effects of disease, famine, drought, and natural disasters—and how such events may have ramifications on distant, seemingly unconnected populations—has in turn led to greater investment in improving global health, with beneficial consequences for those most immediately affected. However, it can be argued that global health does not go far enough. First, although some work is currently being done in this area, we still tend to paint the Bglobal world^ with a broad and unwieldy brush. Health, economic, social, and political disparities occur in the developing world but also throughout societies that seemingly should have health-promoting and healthprotecting infrastructures in place as well as access to health care and socioeconomic opportunities for their citizens. As Hans Rosling demonstrates in a 2006 TED Talk, there’s Ba tremendous variation^ within global health regions and within countries (Rosling 2006, 10:17), but we continue to view the world from a binary perspective (rich–poor, developed–developing) and Blook at the average data of the countries^ (Rosling 2006, 13:40).

HIV/AIDS among BrazilÂ’s Prison Populations: Significant Political, Public Health, And Human Rights Implications for Failing to Provide Prisoners with Adequate Care

There are significant ethical, public health, and human rights implications for failing to provide detainees and prisoners with adequate safety and health care, particularly with regard to infectious diseases such as HIV and AIDS. In other words, there is an ethical obligation to earmark resources, even when scarce, toward the study and care of prisoners. At the same time, however, how disease surveillance and treatment are carried out in this population—especially with regard to infectious diseases associated with stigmatized or illegal behaviors—raises a different set of ethical issues: For example, obtaining an accurate picture of disease prevalence and incidence rates in prisons as well as effectively treating prisoners may place prisoners at increased risk of physical and legal harms. Thus, both failing to advocate for the incarcerated as well as advocating in a poorly considered way are cause for concern. Additionally, misleading metaphors surrounding prisons and penal systems and the marginalization of prisoners and certain socioeconomic classes lead to a perpetuation of diseases such as HIV and AIDS throughout societies in general. Brazil provides a telling example in that, despite the fact that it has one of the most innovative and proactive HIV/AIDS programs in the world and its Constitution frames health care as a right of all, its imprisoned populations, like those in other countries, shoulder the double burden of being both from lower socioeconomic classes with limited access to resources and at markedly higher risk of contracting HIV than those in the general population. Appropriate solutions will require political, institutional, and cultural changes that assure equitable access to medical care, avenues for real rehabilitation, and safe environments within and beyond prison walls, as well as actions to reduce legal prohibitions against drug use, destigmatize sexual behaviors, and resolve entrenched social inequities.

Rethinking the Body and Its Boundaries

Until recently, the idea that the nature of the body is acontested matter may have seemed to many people,whether inside or beyond the ivory tower, as butanother sign of the silliness of the academy. Advancesin biotechnology such as organ transplantation,assisted reproductive techniques (ART), genetics,stem cell research, enhancement, and regenerativemedicine have made use of and manipulated bodies inincreasingly fantastic ways, offering us—academicianand layman alike—new eyes with which to view thebody and unprecedented vantage points from which toconsider what it means to be embodied. The discussionon the nature and limits of human bodies is a specialcaseofamoregeneralproblem:amatterofindividualityand individuation of biological entities. The humanbody is a particular instance of living organisms, andthe frontiers of the body in the case of an animalconstructing its milieu are sometimes no less clearthan in the more familiar cases of organ transplants,and so on. The necessity of understanding the bodyas more than “natural object,” of course, is not new(see, e.g., Wolfe and Gal 2010 for a discussion ofthebodyasbothan“object” and an “instrument” ofresearch, knowledge, and power in the 17th and18th centuries). Western scientific history has paperedits ivy-covered walls with bodies that have beencuriously prodded and oftentimes callously dismissed;we need only look for such horrific evidence to theanthropological collections of indigenous bodies, theanatomical dissection and pathological displays of the19th and early 20th centuries, the medical experimenta-tion on vulnerable people and populations in the name

Prestidigitation vs. Public Trust: Or How We Can Learn to Change the Conversation and Prevent Powers From “Organizing the Discontent”

When Drs. Silvia Camporesi, Mark Davis, and Maria Vaccarella (2017) approached the Journal of Bioethical Inquiry about a symposium on BPublic Trust in Expert Knowledge^ as well as a panel session at the October 2016 meeting of the American Society for Bioethics + Humanities in Washington, D.C. (Camporesi et al. 2016), two books immediately sprang to mind. The first was Strangers at the Bedside by David Rothman (2009, originally published in 1991). Subtitled A History of How Law and Bioethics Transformed Medical Decision Making, Rothman describes his book as an attempt to understand Bhow bedside ethics gave way to bioethics^ (2009, 11). His central thesis revolves around the concept of trust—and the erosion of trust within medicine. From aU.S. vantage point (although the Unites States is not alone in this metamorphosis), Rothman critically examines how the rise of human experimentation, especially in BThe Gilded Age of Research^ followingWorld War II, the distancing of doctor from patient in terms of social demographics, culture, and connection to a common community, and rapid advances in biotechnology have helped increase expert knowledge. However, this has often come at the expense of unacceptable costs, such as wartime medical researchers carrying out studies from a bastardarized utilitarian perspective that prioritized Burgency^ and the need for all citizens, including child, mental health patient, prisoner, or conscientious objector—and whether knowingly or not—to play their part. BHands-off^ policies within universities, the National Institutes of Health, and the U.S. Senate allowed postwar researchers continued freedom from oversight, and, as Rothman emphasizes, policymakers and participants alike conflated researchers’ aims with a doctor’s duty of care and therefore trusted them to act in the best interests of their subjects (and disregard the inherent conflicts that exist in this relationship). And although the concept of consent was neither non-existent nor new (having at least been acknowledged in the clinical encounter and the law), because the Allies were Bnot Nazis,^ there was little self-reflection, recognition of moral abuses, or changes in medicine or medical research until whistle-blowers like Maurice Pappworth and Henry Beecher (Harkness, Lederer, and Wikler 2001; Beecher 1966) or Jean Heller (1972) of the Associated Press, with help from Peter Buxtun, published their exposés about clinical experimentation or governmental research like Tuskegee. Bioethical Inquiry (2017) 14:1–6 DOI 10.1007/s11673-017-9769-x

Cases and Culture

In Utilitarianism, John Stuart Mill wrote that “[t]here exists no moral system under which there do not arise unequivocal cases of conflicting obligation” (1957, ¶2.25). This is what makes the practice—as well as the teaching—of bioethics so difficult and the reason that many students and members of the general populace are wont to believe that doing “the right thing” is relativistic. Engaging in careful, protracted moral reflection, particularly in cases that clearly present such “conflicting obligation,” is hard. It is intellectually and emotionally taxing as well as time-consuming, requiring material resources and ongoing, honest dialogue with others. Unfortunately, our modern systems of biomedicine that train health care professionals are hard-pressed to include in curricula (in meaningful and lasting ways) “people skills,” communication skills, and cultural competence, not to mention the philosophical foundations of ethics that might guide practitioners through tough cases. There are, of course, many reasons for this: The biomedical framework has been late (or errant) in formally recognizing and prioritizing these less “clinical” gaps in education; the biomedical industry in many nations leaves little time (and often fails to sufficiently reimburse) for nonmechanistic care; and society in general has increasingly become enamored with being fast, being first, being famous. One need only turn on the television, whether so-called “reality” programs or cable news, to witness contestants, broadcasters, business moguls, or politicians clamoring to cook the best food, sew the best dress, report the latest scandal, and generally beat out the competition before the clock runs out. Not only is there no reason to work together and no time for deliberation in such an environment, today’s world often rewards those who “do what they have to do” to get ahead, the spoils of this mock war going to the most titillating and dramatic, not the most contemplative or most sincere. (For an interesting exploration of the rise of self-aggrandizement and “spectacle” in media, politics, education, science, and culture, see Hedges 2009.) While it is true that time is of the essence in many health-related settings, requiring practitioners to take immediate, life-saving actions with little room for Bioethical Inquiry (2012) 9:371–376 DOI 10.1007/s11673-012-9408-5

Two Deaths and a Birth: Reminiscing and Rehashing Principles in Biomedical Ethics

Two anniversaries and one notable death have been observed in the last two months of 2013: the 50th anniversary of the assassination of U.S. President John F. Kennedy, the centenary of the birth of French Algerian Nobel Prize-winning author and philosopher Albert Camus, and the passing from this world of South African social activist and President Nelson Mandela. These three lives have left indelible marks on the human experience in myriad ways, but each, as a defining characteristic, placed an emphasis on the necessity of individual moral responsibility. In his June 1963 commencement address to the graduates of American University in Washington, D.C., just five months before he died, JFK emphasized the importance of the individual ethical responsibility to work for peace. “[E]very graduate of this school, every thoughtful citizen who despairs of war and wishes to bring peace,” he intoned, “should begin by looking inward—by examining his own attitude toward the possibilities of peace, toward the Soviet Union, toward the course of the cold war and toward freedom and peace here at home” (Kennedy 1963, ¶10). This speech is argued to have been one of the most important made by a president in the 20th century (see Clarke 2013 and Sachs 2013), as it gave the signal to Soviet leader Nikita Khrushchev for a common disarmament goal and opened the door for the United States, the Soviet Union, and the United Kingdom to initiate the nuclear test ban treaty (United Nations Office for Disarmament Affairs 1963; Etzioni 1967). The American University address built on a liberal construct that was immortalized in JFK’s 1961 inaugural address: “ask not what your country can do for you— ask what you can do for your country” (Kennedy 1961, ¶26). This was liberal, of course, in a British and not an American sense, in its purer political science meaning of supremacy of the individual over the collective or crowd, in the Mill tradition rather than Marx! So for Kennedy (and his speechwriter Ted Sorensen), the appeal in the oft-quoted speech is to the individual citizen (of the United States and the world) as a moral agent. Philosophically, this important exhortation should come as no surprise to anyone, then or now. There is no doubt, though, that most people feel powerless in “big picture” global political matters, so it may in fact come as “news” to most of us that we can change anything, no matter what we may first think or believe. Bioethical Inquiry (2014) 11:1–4 DOI 10.1007/s11673-014-9509-4

Should Health Care Providers Be Forced to Apologise After Things Go Wrong

The issue of apologising to patients harmed by adverse events has been a subject of interest and debate within medicine, politics, and the law since the early 1980s. Although apology serves several important social roles, including recognising the victims of harm, providing an opportunity for redress, and repairing relationships, compelled apologies ring hollow and ultimately undermine these goals. Apologies that stem from external authorities’ edicts rather than an offender’s own self-criticism and moral reflection are inauthentic and contribute to a “moral flabbiness” that stunts the moral development of both individual providers and the medical profession. Following a discussion of a recent case from New Zealand in which a midwife was required to apologise not only to the parents but also to the baby, it is argued that rather than requiring health care providers to apologise, authorities should instead train, foster, and support the capacity of providers to apologise voluntarily.

From Personal Misfortune to Public Liability

The tension between a notion of the “common good” and individual liberty is one that political theory knows well. Indeed much of human political history is written around this central theme. In health matters, for example, we are now quite used to state regulation of products and practices that harm life or limb. The state, having a responsibility for the welfare of its citizens, has an accepted role—a duty, even—to mitigate exposure to harm, a sort of presumption in favor or even a casus belli in wars against public danger. The force majeure that justifies these regulations, including those associated with behavior and consumption, is the preservation of life itself and as such has found increasing support since the late 20th century in both the political process and the court of public opinion. Laws promoting smoking cessation and the use of seat belts or prohibiting drinking and driving and drug and alcohol abuse are all grounded in both common sense and scientific justifications that are hard to argue against. But as public health regulations have come into their own—turning from tobacco and alcohol to what we eat and how much—it is a reasonable necessity to ask where the limits of such state intervention and regulation might lie, lest excessive control infringe upon or even remove personal agency, risking both transgressions against autonomy and a Prohibition type of backlash that could undermine the public health impacts of well-intentioned policy. In other words, at what point should the state stop saving ourselves from ourselves? And what role does personal responsibility play—though we also must ask how much can be expected when structures in a capital-driven society purposefully seek to weaken self-efficacy (individuals’ confidence in their ability to enact and carry out healthful decisions) or obstruct agency (individuals’ actual capacity)? In societies where external loci of control are avidly sought when things go wrong, to what extent is it possible to experience personal misfortune without public liability? When is it “my responsibility” and when is it up to the government to restrict “my choices” as I cannot myself? Part of the problem—and one that receives scant attention in consideration of public health—is that there is a side of human nature that is dark and Bioethical Inquiry (2013) 10:1–5 DOI 10.1007/s11673-013-9427-x