Confronting the Medical Leviathan: Reading a Report from the Front Lines.

This essay discusses how two physicians in Britain's National Health Service describe and analyze the conditions of their work: how algorithms and protocols structure the care they can provide and create the dilemmas they and their patients face. In these issues, the NHS is a canary in the mineshaft of contemporary Western health care. NHS practices are understood as how states and state-like entities, Leviathans, seek to render their subjects legible; in this instance, to make both physicians and patients transparently visible to surveillance and administration by standardizing medical work and patient need. Physicians respond by engaging in workarounds, finding ways to provide care despite systemic restrictions.

Three Types of Stories About Encountering Bioethics.

This commentary discusses 12 stories about receiving ethics consultation in hospitals. Five stories are by physicians, three by nurses, and four by family members; three of the writers have training in bioethics. Some writers requested the consultation, others experienced the consultation as an imposition forced upon them, and in two cases, the story is about the absence of any consultation service. Three types of narrative are found to structure the stories: the genuine dilemma narrative, the institutional intransigence narrative, and the relational care narrative. Throughout, the question is what makes for a valuable consultation, and the general answer is whether consultation enables the development of mutually supportive relationships.

While Icarus Falls: Conditions for Pandemic Ethics.

This symposium contribution presents three vignettes of resistance to COVID-19 public health measures in Alberta, Canada, where I live. These show resolutely individualistic attitudes toward health and a desire to understand the pandemic as a one-off aberration. I then suggest four ways that the work of bioethics needs to change. These begin with situating the pandemic within the context of global climate emergency and end with how a new polarization diminishes possibilities for the rational dialogue that bioethics has here-to-fore assumed people would engage in.

Becoming a cancer survivor: An experiment in dialogical health research.

The article makes cancer survivorship the topic of an experiment in a form of writing we call dialogical response. First, in the style of autoethnography, each author presents an account of her or his long-term survivorship of cancer and the issues that involves. Less conventionally, we then respond each to the other's story. The article seeks to contribute to an in-depth understanding of long-term cancer survivorship. More important, we offer it as an example of a form of writing rarely practiced in health research: speaking to those who participate in research, rather than speaking about those people. Among the multiple theoretical implications that could be explored, we consider Foucault's concept of subjectification. Our argument is that recognising the discursive formulation of the subject can and should be complemented by recognition of the local, immediate dialogical formulation of subjects. Rather than presenting research findings about cancer survivors, we offer a performative enactment of survivorship as an ongoing process of dialogical exchange. We show ourselves, responding to each other, in the process of becoming the cancer survivors we are as a result of those responses.

The Twin Crises of Principles and Stories.

This symposium contribution argues that politicized responses to the COVID-19 pandemic mark the fracturing of the consensus that bioethics has been built upon. This consensus involved the mutual dependence of principles and stories: principles need stories to become applicable in clinical action, and stories need to reflect principles if they are to make generalized claims. Two mid-20th-century theorists, Erving Goffman and Walter Benjamin, each predicted the thinness of appeals to principles and to stories, respectively; their skepticism describes our moment. Anti-public health responses to COVID restrictions show that principles now have radically different meanings within different factional groups, so appealing to them perpetuates divisions. Complementary to that, stories are told more as displays of group membership than as testimony of individual experience. The predictable future is that bioethics controversies will become more fraught.

Moral Distress in Deciding How Others Die.

This essay discusses how Susan Shapiro's Speaking for the Dying (2019) contributes to understanding surrogate decision-making in intensive care. Shapiro's ethnography is based on over two years of observing day-to-day decision-making by surrogates and family members who found themselves having to speak for loved ones who were no longer capable of expressing their own wishes for treatment or its termination. After summarizing Shapiro's specific findings-in particular what made no observable difference in decision-making, including advance directives-greater attention is given to how she acts as a witness to the emotional burden and distress that these decisions cause for both family members and professional staff. Shapiro allows us to hear the voices of people forced to make high-stakes decisions in the most stressful conditions with little guidance. We hear the contradictions inherent in surrogate decision-making and gain insight into how the institutional organization of intensive care produces moral distress.

The Voices that Accompany Me.

This essay begins with a metaphor describing who enters the field of humanities in medicine and healthcare and the types of work they do. The role of witness is discussed, underscoring tensions between witnessing and analyzing. The essay then turns to my own background as an example of how each professional in this field brings something distinct. I briefly describe the three basic principles of my work with narrative: the injunction to keep the stories in the foreground, the work of amplifying and connecting stories, and the need for generous interpretation. The second half of the essay tells three illness stories, describing their importance to me over several decades. These stories are by Audre Lorde, Reynolds Price, and Stewart Alsop, dealing with problems of silences imposed on ill people, problems caused by physicians' perceived lack of time, and dilemmas of the end of life, respectively.

Tragic Realism: Reading Simon Critchley for Bioethics.

The essay explores how Simon Critchley's critique of philosophy and understanding of tragedy might affect bioethics and health-care practice. What I playfully call the Critchley Doctrine begins with a rejection of philosophy's aspiration to a non-contradictory life and its premise that humans act on rational deliberation. This rejection opens us to a recognition of the uncontainable that is expressed in tragedy, and that speaks to what is inexplicable about the suffering of illness. Critchley advocates an ethics of heteronomy or hetero-affectivity rather than autonomy, but his version is distinguished by its recognition of how crushing the demands of the other can be. Tragedy and humor offer what he calls aesthetic reparation. A tragic medicine balances grieving with humor and seeks above all honesty in communication.

Not Whether but How: Considerations on the Ethics of Telling Patients' Stories.

The ethics of telling stories about other people become questionable as soon as humans learn to talk. But the stakes get higher when health care professionals tell stories about those whom they serve. But for all the problems that come with such stories, I do not believe it is either practical or desirable for bioethicists to attempt to legislate an end to this storytelling. What we need instead is narrative nuance. We need to understand how to tell respectful stories in which the patients are fully acknowledged fellow participants, not one-dimensional objects of a knowing gaze. The problem is not narration itself but a particular version of narrational privilege, and getting rid of that would have benefits far beyond practices of writing case studies. In this essay, I first offer four considerations that I have found either omitted or underemphasized in discussions of the ethics of telling stories about patients. I then sketch a model of medical storytelling that might be the basis for shifting the ethical question from whether to how.

"Who's There?": A Vulnerable Reading of Hamlet.

Vulnerable reading asks how literary works can be useful as companions to people who suffer; its focus is literature as solace. Questions of why we should turn to Shakespeare to express suffering, and why to poetic literature, are considered. An exemplary reading of Hamlet discusses three levels of vulnerable reading: the play as mirror in which readers can see reflections of their own troubles and gain new expressive possibilities for themselves; the play as training in acquiring a new voice to resist these troubles; and the play as a pedagogy of engagement in dialogue with others in relations of care. Hamlet proclaims that the "readiness is all." How does the play mentor that readiness?

Suffering, Medicine, and What Is Pointless.

Beginning with Eric Cassell's much-cited definition of suffering, this essay engages with Scott Samuelson's Seven Ways of Looking at Pointless Suffering (2018). How each of Samuelson's seven ways is relevant to health care and bioethics is suggested through various examples. The discussion underscores the crucial choice for health-care professionals between being an expert technician who provides treatment or being a healer, in an expansive sense first described by Cassell and elaborated by extending Samuelson's useful typology. Also at issue is Samuelson's title word pointless. Samuelson's seven ways each attempt to make suffering seem to have a point. The essay questions whose needs are met, either by declaring suffering pointless, or by asserting what its point is. Examples relate these issues to clinical practice.

When Professional Rightness is Personal.

This commentary discusses twelve stories in which physicians tell what happened when they were involved in the care of a family member. The stories display considerable differences in attitude toward the ethics and usefulness of physicians treating members of their own families. But the more significant tension is between the analytical or objective attitude that all the writers presuppose as necessary for doing good medical work, opposed to the emotions aroused by seeing a loved one suffer. The commentary explores the implications of assuming this binary opposition, whether it is correct, and how far it is actually necessary. Concluding comments discuss what kind of ethics is involved in stories that are all about dilemmas and decisions, but rarely invoke concepts from bioethics.

Bioethics and "Rightness".

If bioethics seeks to affect what people do and don't do as they respond to the practical issues that confront them, then it is useful to take seriously people's sense of rightness. Rightness emerges from the fabric of a life-including the economy of its geography, the events of its times, its popular culture-to be what the sociologist Pierre Bourdieu calls a predisposition. It is the product of a way of life and presupposes continuing to live that way. Rightness is local and communal, holding in relationship those who share the same predisposing sense of how to experience. Rightness is an embodied way of evaluating what is known to matter and choosing among possible responses. Bioethics spends considerable time on what people should do and on the arguments that support recommended actions. It might spend more time on what shapes people's sense of the rightness of what they feel called to do.

Truth Telling, Companionship, and Witness: An Agenda for Narrative Ethics.

Narrative ethics holds that if you ask someone what goodness is, as a basis of action, most people will first appeal to various abstractions, each of which can be defined only by other abstractions that in turn require further definition. If you persist in asking what each of these abstractions actually means, eventually that person will have to tell you a story and expect you to recognize goodness in the story. Goodness and badness need stories to make them thinkable and to translate them into individual and collective actions. Yet after more than two decades of considering the issue, I do not believe that a collection of stories can by itself guide actions in ways that are sufficient to respond to ethical troubles in institutional settings. The question will always remain open for me, but my present belief is that narrative bioethics is always hyphenated, in the sense that guidance from stories needs to be allied with other ethical guidance. Each side of the hyphen qualifies the other side. The hyphenation I will argue for in this essay is "narrative-deontology."

From sick role to narrative subject: An analytic memoir.

Questions of illness experience and identity are discussed, based on the analysis of a story told by the breast-cancer activist Audre Lorde. Displacing Parsons' conceptualization of illness as a sick role, I understand the ill person as a narrative subject, defined by discursive possibilities. Three discourses of illness are proposed: the medical institutional discourse, the discourse of illness experience, and the pink-ribbon discourse. Each has its preferred narratives. These discourses overlap and mutually affect each other. Problems with the Foucauldian conceptualization of the subject are considered, and a dialogical imagination of relations of governmentality is proposed.

Virtue Ethics in Monetized Medicine.

This review essay situates Abraham Nussbaum's The Finest Traditions of Our Calling (2016) within the contemporary genre of physician memoirs that shade into critiques of institutional medicine. Nussbaum's primary concern is the demoralization of medicine as it becomes increasingly monetized; patients are reduced to body parts and reimbursement schedules. He argues that physicians continue to have considerable choice in how they practice, despite institutional constraints. For bioethics, Nussbaum's advocacy of virtue ethics is notable. His book is a moving testimonial to contemporary problems, but also a manifesto for possibilities of change at the individual level.