Over the past 25 years, I was privileged to consult on a large number of individual clinical encounters, during which I was seen, and served, as an “ethicist”. At the same time, these and other facets of health care attracted my philosophical interests. Accordingly, a distinction became necessary so to enable keeping very different sorts of questions and problems distinct.

Whichever encounter it may be, what are the questions the participants themselves have to face, whether they want to confront these questions or not? How can they be assisted to face those issues clearly and squarely? What does the situation itself make it necessary for them to face and find some way or other to resolve, so that they may go on with their lives? More simply: what are the issues any specific clinical event poses, which decisions must be faced and what choices made, and with which aftermaths of decisions are they most likely to be able to live with? The ethics consultant seeks to help such people become more aware of and clear about their own moral views so that they can more likely reach decisions commensurate with those views.

In this case, the philosopher’s attention and focus is strictly on a particular encounter, not for its own sake, but rather for the sake of what is exemplified by and through it and others examples of such encounters. Such reflective consideration is most helpful to the work as a consulting ethicist, but must not be confused with it. Either manner of attending to a particular event, thing, person, etc., either for its own sake or as an example is possible for any phenomenon. How they relate and mutually clarify each other, as well as the specific nature of each mode of attention are issues, among others, that cannot be taken up here, but must be left for another descriptive analysis (Zaner 2012). What follows below is but one effort to become clearer about prominent features of the clinical event, and is based on my own experiences as a consultant on ethical issues in many clinical situations.

Whatever the clinically presented problems may be, they are strictly problems facing the people whose situation it is most immediately—for instance, the expectant couple mentioned above and their physicians.¹ By the same token, the problems, alternatives, decisions, and outcomes, are strictly theirs as well. Any encounter presents its own set of issues, moral and other, and these are context-specific in the sense that working with and listening to such persons, helping them appreciate and advising them regarding specific issues needing resolution, and the like, requires a strict focus on the situational definitions of each involved person (Schutz and Luckmann I 1973). To understand a clinical encounter, there is nothing for it but to try one’s best to get at the concrete ways in which the participants themselves experience and understand themselves and their circumstances, and endow its various components (objects, people, things, time, relationships, etc.) with meaning, in light of which they proceed to make decisions and act.

Thus in the situation presented by the problematic pregnancy mentioned above, (Zaner 2005a, b, 2007–2008) although the attending physician had told me that “abortion” was the “problem” needing attention, this was not in fact an issue—neither for the couple nor for the attending physician, since without mentioning this to each other they were each prepared to accept the possibility of early induction and fetal demise. When the dismal prognosis was mentioned and the couple seemed to become “angry,” however, the attending broke off the conversation, as he thought they were angry with him for using the word “abortion.”

With conversation at a standstill, one issue was obvious: to enable them to talk and listen to one another and, thus, to straighten out the different understandings in order to identify precisely what was at issue for each of those involved, so as to work toward a common understanding of problems, needed decisions, and, hopefully, acceptable solutions. As was emphasized above in Chap. 6, in every clinical encounter, moral issues specific to the participants and their circumstances are presented for deliberation, decision, and resolution solely within the contexts of their actual occurrence. To find out and understand what’s going on in any clinical encounter—what’s troubling the people, what’s on their minds, and thus to know what has to be addressed and how—requires cautious, attentive listening and probing of their ongoing discourse, conducts, the setting, and other matters presented as constituting this specific context. For instance, the couple’s puzzlement about the meaning of “statistically significant”—a term used by the physician while discussing the results of several tests of the fetus—was central to what was interpreted (prematurely, as it turned out) as their “agitation” and “anger,” and this indicated (at least in part) one important theme to be addressed. But these matters could not be considered in abstraction from the actual circumstances: what each person understood, what this led them to think about, etc.

I was invited into an already ongoing clinical encounter between the couple and their physician (and others: nurses, medical and radiological consultants, etc.). As I’ve emphasized earlier, physicians are in the nature of the case involved in a complex moral relationship with persons who, due to impairment (in a broad sense, including a difficult pregnancy) and to the relationship itself, are uniquely vulnerable, exposed to the power of those who wield the ‘art’ (tēchne). The latter are in turn under the obligation always to act justly and with restraint.²

In this respect, every physician (and other health provider) is as such focused exclusively on helping each patient under his or her care: diagnosing, outlining available therapies, and working with each patient to reach decisions most acceptable and reasonable to both physician and patient (and, at times, the family and/or loved ones). The patient (and family) is on the other hand focused on the his or her own condition and on doing whatever is necessary to be cured, feel better, or at least be helped as needed (perhaps, with palliative care, with pain management, and the like).

I have also emphasized earlier that neither patient nor physician (nor other health care provider) is focused on the relationship itself as the primary theme. To be sure, they are, as noted, obviously aware of that relationship; but reflecting on the relationship as such (for instance, with determining and assessing its asymmetrical structure) is not their primary concern. Patients are not philosophers, though philosophers, of course, are patients from time to time. Just that mutual relationship, however, is precisely the focus of the clinical ethics consultant and will, moreover, be a central theme for the reflecting philosopher when he or she considers examples of clinical events. This needs to be clearer.

Experienced by the impaired person, the impairment is also interpreted by, and thus has meaning for that person. Others also experience and interpret the person’s condition: family members, those in the person’s circle of intimates (especially close friends and associates), persons in the wider social ambiance, but also the physician, nurse, and other providers helping to take care of the person. Hence, to speak of “the experience and meaning of illness,” as many including myself have done, (Cassell 1973; Kleinman 1988; Pellegrino and Thomasma 1981) is necessarily to face a highly complex phenomenon—but this has not often enough been recognized.

Nor is this all. As Schutz has shown, every situational participant experiences and interprets the encounter within his or her own biographical situation: (Schutz and Luckmann I 1973, II 1989, pp. 243–47) typifications, life-plans, senses of self and others, undergirding moral and/or religious frameworks, etc. These encounters are socially framed by prevailing social values, as well as by written and unwritten professional codes, governmental regulations, hospital policies, unit or departmental protocols, etc.—any or all of which may and often do contribute to ‘what’s going on’ in any specific case.

Cautious probing reveals that experience and meaning are still more complicated. Again, consider only a patient and her physician. She, like every patient, is this person, a self, and thus is essentially a reflexive being (Zaner 1981, pp. 144–64). Briefly, this signifies that the patient experiences and interprets her own problems or impairment. She also experiences and interprets the physician’s conduct, physiognomic expressions, experiences and interpretations, including his experiences and interpretations of her (how she is thought to experience and interpret the doctor, her illness, etc.). And both she and her physician are, in the nature of the case, aware of, though not always focally attentive to this very complexity. In a word, the relationship is complex and reflexive: minimally, each experiences and interprets the other, their various expressions, their respective interpretations, and at the same time, within their relationship each experiences and interprets the relationship itself (Kierkegaard 1954; Zaner 2005a).

In the terms used by Aron Gurwitsch,³ every constituent of a contexture is related to every other constituent (each is placed in some way with respect to every other), and vice versa; furthermore, each is related to the entire set of relations, as is the set itself related to each constituent. The relationships that constitute a contexture are, thus, at once reflexive (by referring to another constituent, the first relates to itself as what the other is related to; and vice versa) and therefore complex (a ‘whole’ is precisely that entire set of mutual, complex and reflexive relations).

For example, the pregnant woman in the encounter already mentioned not only experiences her pregnancy and her developing fetus,⁴ but this experience is complexly textured by the ways in which she experiences and interprets what her physician (husband, and others) tell her.⁵ Similarly, her physician experiences and interprets her words, expressions and gestures—for instance, he interpreted her “anger” as directed at him and his use of the terms, “statistically significant,” and “abortion.” In some respects, moreover, both of them experience and interpret the relationship itself. Regarding diagnostic data, for instance, she told me, “I know they’re only trying to do their best” (i.e. she interprets the relation as “they are only trying to help”); and her physician said, “She seems to think we’re being deliberately unclear” (i.e. the relation is “not going well”). But, as emphasized, the relationship itself—its characteristics and features—is not reflectively attended to by either of them.

To work as an ethics consultant is thus to be a kind of detective or, better, a type of literary interpreter: deliberately probing into the multiple situational ‘texts’ or ways in which the situational participants interrelate, variously experience, talk, listen, and interpret one another. The involvement of the ethicist is thus a work of circumstantial interpretation (both understanding, and being-understanding); reflection on this and other cases is a matter of phenomenological explication.

What has been pointed out, to repeat, emerges from considering the range of clinical encounters as examples; that is, from philosophical reflection. By contrast, clinical consultation (as opposed to describing or talking about it) is a specifically different kind of activity: its focus is on the effort to listen to and help the unique and individual in specific circumstances and for the sake of the individuals themselves.

The stories patients and others tell invariably arise from and express themes intrinsic to clinical encounters—more accurately, from those encounters in which patients understood that much was at stake, much to be won (by ‘successful’ treatment) and much to be lost (when everything has been done and rescue, cure, or restoration is no longer possible). At the core of these clinical events is an encounter with our own, specifically my own mortality and the circumstances which make that especially exposed and exigent: questions of dying and death, loss and grief, and how people deal with them.

It seems true that most of us nowadays are only too well acquainted with the excruciating experience of having to deal with the death of a parent, child, spouse, close friend or other loved one. Those of us in our middle years have learned that we have no choice but to count on facing such situations: not merely to think and make choices about what to do for terminally ill relatives—parents, grandparents, children, or others—but to talk about them with strangers—nurses, administrators, physicians and, at times, social workers, chaplains, and still others—many of whom possess real power to control what will occur during those arduous, sad, and painfully extended moments of serious illness or injury, especially at the end of life.

It is not easy to for any of us to discuss such situations in any event; it is all the more awkward and difficult to talk about when someone else who is an intimate is faced with the extreme situation: someone close and dear is dying or faces severe compromise, is in great pain with relief only barely in sight, if at all. It is for most of us next to impossible when the individual in question is yourself, is myself. When faced with such situations, Ronald Blythe’s terse comment about Tolstoy’s The Death of Ivan Ilych comes to mind: that the character of Ivan reveals the “plight of a man who has a coldly adequate language for dealing with another’s death but who remains incoherent when it comes to his own” (Blythe 1991, p. 10). Faced with the prospect of my own dying—say, on receiving a diagnosis of serious cancer—I may be struck dumb, without words or wits to withstand the onslaught of the unspeakable. But, it has also seemed to me, faced with the pending death of a loved one—wife, husband, child, sibling, mother, father—so are we often struck dumb as well. Facing our own not being, just as when we face the no-longer-being of a loved one, we know the profound inability of language to say it well, and for us to bear needed witness.

We rarely if ever have the right words at hand, if we ever do have them, to talk candidly about dying, loss, grief, profound sadness, fear, dread—the inner tremblings of the soul. Instead, we fumble and mumble, waiver and stall for time and still more time waiting for some way to make up our minds. Until, often as not and with a sigh of detectable relief, we revert to talk about ‘nature’ or ‘God’: rather than making our own decisions, we talk about letting ‘nature take its course,’ or issue desperate, prayerful pleas to God, thinking that things are surely out of our hands—it is instead due to God’s will or blind nature, we believe—which only masks needed decisions. Many of these awful questions are insistently present as well for those of us actually involved in taking care of such patients, whether as physicians, nurses, chaplains, or ethics consultants—not merely, I mean to say, talking about patients with colleagues on committees, but rather with those who are actually facing a moment of extraordinary decision.

Beyond the exigencies of discussing ethical questions with those who actually have to face them, most of whom have never had to do this before, and perhaps helping them find some way to settle on some course of action—be they patients, doctors, nurses, family members, or any other—there is also, if we are honest, the arduous chore of putting that talk into written form at some point, into words that go beyond the moment, words that will truly get across the actual sense and feel of those disturbing situations. It is so very difficult, we then realize, to write without obscuring, concealing, masking, or even forgetting to mention precisely what was vital for others and ourselves as we then strived to understand what we were going through.

For me, James Agee said it best, in Let Us Now Praise Famous Men, that remarkable work for which he and Walker Evans were once commissioned, in order to write about unique individuals facing themselves across the awesome horizon of their own unique lives and deaths:

For in the immediate world, everything is to be discerned, for him who can discern it, and centrally and simply, without either dissection into science, or digestion into art, but with the whole of consciousness, seeking to perceive it as it stands: so that the aspect of a street in sunlight can roar in the heart of itself as a symphony, perhaps as no symphony can: and all of consciousness is shifted from the imagined, the revisive, to the effort to perceive simply the cruel radiance of what is. (Agee and Evans 1939, p. 11)

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