Justifying Clinical Deception: Some Amendments to Brummett and Salter

In Abram Brummett and Erica K. Salter's excellent paper, “Mapping the Moral Terrain of Clinical Deception,” they rightly note that it is sometimes ethically appropriate for health care professionals to deceive patients and families. However, they also note that because doing so violates a prima facie duty of honesty, the ethical burden of proof falls upon the deceiver. Hence, they also provide a sophisticated framework for determining whether any given case is warranted. I applaud their overall approach but also critique some of their claims, in particular, their conclusion that lies of commission require greater justification than those of omission and their conflation of the principles of beneficence and nonmaleficence. I also urge them to give greater attention to how power asymmetries should be accounted for and to the impact such deceptive choices might have on the clinician's character.     

Deception,Pain, and Placebo: Applying the Brummett-Salter Deception Framework

In this commentary, I explore the usefulness of the framework Abram Brummett and Erica K. Salter present in their article “Mapping the Moral Terrain of Clinical Deception.” Deception cases are divisive because they nearly always evoke the metadilemma of clinical ethics: a clash between duties (in these cases, truth telling) and consequences (whatever good might come of the lie). Here, I describe a patient case in which the clinical team considered deceiving a patient about his pain-medicine dosage in exchange for his allowing the clinicians to properly care for his percutaneous endoscopic gastrostomy tube stoma, so as to prevent infection. Applying the framework that Brummett and Salter have developed helped our clinical team parse the numerous complex issues involved. The nuances of our case also illustrated additional ways in which the ethics of deception needs to be further refined.     

Mapping the Moral Terrain of Clinical Deception

Legal precedent, professional-society statements, and even many medical ethicists agree that some situations may call for a clinician to engage in an act of lying or nonlying deception of a patient or patient's family member. Still, the moral terrain of clinical deception is largely uncharted, and when it comes to practical guidance for clinicians, many might think that ethicists offer nothing more than the rule never to deceive. This guidance is insufficient to meet the real-world demands of clinical practice, and this article endeavors to articulate a framework to help clinicians better navigate the ethics of clinical deceit. The framework articulates four morally relevant dimensions of a potential deceptive act that should be examined to better determine the moral justification that might be required: the target of the act, the nature of the information, the nature of the act, and the context of the act.     

Deception and Distress

In the lead article in the January-February 2023 issue of the Hastings Center Report, Abram Brummett and Erica Salter provide a conceptual framework to help physicians think through the ethics of deceiving a patient or someone closely connected to the patient. Brummett and Salter identify four main ethical features of any act of clinical deception and elaborate on how, in a given case, these features together influence the degree to which a deception could be justified. A second article in this issue presents an ethnographic study of the effect of the Covid-19 pandemic on critical care workers in an intensive care unit. The authors describe a level and form of moral distress that, they argue, goes beyond what the term “moral distress” captures. The authors offer “distressed work” to better mark the broad consequences for care workers’ roles, occupations, and vocations.     

Your Father's a Fighter; Your Daughter's a Vegetable: A Critical Analysis of the Use of Metaphor in Clinical Practice

There are two widespread beliefs about the use of metaphors in clinical medicine. The first is that military metaphors are harmful to patients and should be discouraged in medical practice. The second is that the metaphors of clinical practice can be judged by and standardized in reference to neutral criteria. In this article, I evaluate both these beliefs, exposing their shared flawed logic. This logic underwrites the false empiricist assumptions that metaphorical language and literal language are fundamentally distinct, play separate roles in communication, and therefore can be independently analyzed, systematized, and prescribed. Next, using the resources of ordinary language philosophy, I lay out a theoretical view of medical metaphors that is grounded in metaphor use within clinician-patient relationships. Finally, drawing on the work of philosopher Max Black, I diagram a practical conceptual framework for clinicians to use when they consider whether a metaphor is appropriate for a specific patient encounter.     

A Man of Vision: Daniel Callahan on the Nasty Problem and the Noxious Brew

This essay, published shortly before the 2020 U.S. presidential election (mired in controversy over a potential judicial appointment to the Supreme Court), celebrates Daniel Callahan's prescient book Abortion: Law, Choice and Morality. Nothing could be timelier. Callahan's central question was the “moral and social” struggle requisite for coherent policies and laws regulating abortion. He rejected “one-value” positions and strove to develop an expansive middle ground. He decried emotion untutored by reason, crude polemics, and bludgeoning: his recipe for a “noxious brew.” Callahan's way of thinking preceded the development of a critical health humanities, the advent of moral foundations theory in psychology, and the philosophical concept of a moral imagination. Each of these inheres in his rigorous approach to the abortion problem. His honesty and humility led to a sea change in his position on abortion. Fifty years later, much can still be learned from Callahan's arguments—about abortion and other bioethics issues—most importantly, in how we address wider social issues in these polarized times.     

Excavating the Personal Genome: The Good Biocitizen in the Age of Precision Health

The rise of genomic technologies has catalyzed shifts in the health care landscape through the commercialization of genome sequencing and testing services in the genomics marketplace. The development of consumer genomics into a growing array of information technologies aimed at collecting, curating, and broadly sharing personal data and biological materials reconstitutes the meaning of health and reframes patients into biocitizens. In this context, the good biocitizen is expected to assume personal responsibility for health through consumption of genomic information and acquiescence to public and private efforts at data surveillance and aggregation. These shifts raise fundamental questions about how competing interests of the public, the state, and corporate entities will be reconciled and what trade-offs are demanded for the promise of precision health.     

Caring for Premature Life and Death: The Relational Dynamics of Detachment in a NICU

Drawing on fieldwork in a neonatal intensive care unit (NICU) in Chiang Mai during 2010 and 2012, I examine neonatal care as a contingent entanglement of technological and ethical relationships with vulnerable others. Along the continuum of universal antenatal and delivery care, neonatal medicine becomes a normative part of reproductive health care in Chiang Mai. As the NICU opens its door to sick newborns whose belonging to kinship and the nation-state is uncertain, neonatal care requires deliberate practices to incorporate them into life-sustaining connections. By tracing medical staff’s effort to be accountable to their fragile patients, I show that withdrawing of intensive care is relational work that requires affective involvement and distancing through commensality, prosthetic extensions, and karmic network. This specific mode of care, which is premised on the combination of unconditional openness and careful detachment, offers insight into a possible enactment of hospitality within biomedical institutions.     

Dueling Definitions of Abortifacient: How Cultural,Political, and Religious Values Affect Language in the Contraception Debate

Contraception works by preventing fertilization of an egg or preventing implantation of a fertilized embryo. For those who believe pregnancy begins at implantation, contraceptives preventing implantation are not abortifacient. However, for those who assert that pregnancy begins at fertilization, any agent causing the intentional loss of an embryo, even prior to implantation, is abortifacient, both morally and for lack of a different term to describe the postfertilization, preimplantation loss. In the debate on this topic, much of the discourse on both sides wrongly focuses on the opposing side's perceived ignorance in denying scientifically proven definitions rather than on the substance of the conflict. Indeed, both sides accuse the other of prioritizing its “subjective” views over “objective” facts. In this essay, we unpack the scientific, cultural, and religious factors that underlie this debate. We argue that the only way to move forward is to clarify our terminology and engage with the substance of the argument, rather than merely the rhetoric.     

Vaccine Rationing and the Urgency of Social Justice in the Covid-19 Response

The Covid-19 pandemic needs to be considered from two perspectives simultaneously. First, there are questions about which policies are most effective and fair in the here and now, as the pandemic unfolds. These polices concern, for example, who should receive priority in being tested, how to implement contact tracing, or how to decide who should get ventilators or vaccines when not all can. Second, it is imperative to anticipate the medium- and longer-term consequences that these policies have. The case of vaccine rationing is particularly instructive. Ethical, epidemiological, and economic reasons demand that rationing approaches give priority to groups who have been structurally and historically disadvantaged, even if this means that overall life years gained may be lower.     

The Criminalization of Physicians and the Delegitimization of Violence in Turkey

In June 2013, protests that erupted in Gezi Park in Istanbul, Turkey were met with state violence, mobilizing hundreds of native physicians to deliver emergency medical care. Drawing on ethnographic fieldwork in makeshift clinics during these protests, interviews with Gezi physicians and analyses of recent laws restricting emergency care provision, in this article I explore the criminalization of clinical practice through legal and coercive means of the government and the delegitimization of state violence through clinical and expert witnessing practices of physicians. As I show, material, legal, and discursive articulations of the idiom of medical neutrality revolve around the tension between medical praxis as neutrality and medical praxis as political participation. I offer a reconsideration of medical humanitarian and human rights regimes in terms of their consequences for inciting, documenting and restricting state violence.     

The Power of the Single Story: Surrogacy and Social Media in Israel

Analyzing interviews with 20 Jewish-Israeli gestational surrogates who gave birth in 2014–2016, I examine the common narrative structure of their personal stories and the way that this becomes what Adichie calls a “single story”. This idealized, romanticized, utopian story includes: 1. an intimate bond between surrogate and intended parents; 2. an epic birth; 3. a happy ending, told publicly. After illustrating this structure, I present the consequences of this single story for surrogates whose experiences diverged from, yet were constantly compared to, the “perfect journey” narrative. Anthropologists of reproduction must pay careful attention to digital storytelling as a new reproductive technology.