My critique of the casuist proposal serves to highlight several points of interest. With its insistence on practical reason as at once more grounded in our moral history and more capable of appreciating the exigencies of moral discourse, Jonsen and Toulmin’s approach strikes me as very productive. It nevertheless has certain unanswered problems, as was suggested, and in the end remains too centered on the ethics consultant’s relation to the physician—both of which are simply taken for granted as having priority as regards the identification and resolution of moral difficulties in clinical situations.¹ Hardly any attention is paid to those persons whose circumstances are most often at issue—patients and their significant others—and almost none to other clinical participants whose words and actions help to constitute the clinical encounter and clearly help to shape the moral issues embedded in any clinical encounter—nurses, physician consultants, therapists, and many others.

For all its problems, on the other hand, Glover et al.’s conception of the ethics consultant as decision facilitator working within “a community” seems an important ingredient to clinical ethics—although much remains to be systematically clarified about just what and whom that ‘community’ is or ought to include, whose voices should be given weight and why (as well as how this is to be done). Moreover, at every point, it is imperative that the ethicist be both accountable to and held accountable by those whose decisions are to be facilitated—they, after all, are the one who must then live with the aftermath of whatever decisions come to be made.

For all their obvious value, however, both these views (as well as the others considered in the previous chapter) conceive clinical ethics primarily from a single point of view: most often from what is taken for granted as the physician’s viewpoint, but at times including the ethicist’s perspective in relation to that of the physician. Both are problematic. First, neither emphasis appreciates the fact that every clinical encounter, even the simplest (say, a routine office visit), is essentially complex. As pointed out, each encounter includes multiple persons, each with their own set of concerns (‘voices,’ as I’ve termed them), and each of whom has (or claims to have) some ‘say’ in what occurs.

In part, the difficulty faced by the ethicist lies in the effort to explicate and assess that complexity and on that basis attempt to facilitate the conversation and eventual decision-making required by every clinical encounter. The ethicist faces a specifiably complex task: s/he needs not only to think and act in the most practical manner, but also must similarly help the other situational participants to think and reason in highly practical ways—about the clinical issues, options, decisions, aftermaths, and especially about what each of them takes to be most worthwhile within the constraints of the specific circumstances, as well as how to go about assessing that ‘worth’.

Equally important, to reason practically means, among other things, to recognize the presence in any situation of the different, typical understandings at work in and emergent from the various participants’ respective personal and professional experiences, interests, relationships to the special issues and to one another, etc. Hence, it seems clear, Jonsen and Toulmin’s otherwise fine study must be critically deepened in order for it to be capable of illuminating the very clinical encounters that prompted its revival in the first place. Working out an appropriate “paradigm” to which any “case” might refer (and precisely how and why this or that “case” can and should be regarded as “appropriate” to the “paradigm,” etc.) invokes a complex sense of practical reason and a fund of experience far richer than is recognized in their work. This is true especially if one invokes an ambiguous paradigm, or when a particular case involves a conflict among potential and competing paradigms. Indeed, it seems wise to resist a too-hasty move to the paradigmatic, for fear of missing precisely what is at issue: the search for analogies harbors more risks than they appreciate.

In fact, their emphasis on reasoning by analogy (as the basic sense of phronesis which, as I’ve already suggested in the second Chapter, ignores significant components of the mode of medical reasoning termed “semiosis” by the ancient empirics and later Skeptics), and this risks obscuring the most prominent characteristic of clinical encounters. They argue that clinical medicine provides “a powerful model” for understanding the ways in which practical and theoretical matters are related in ethics. In medicine, a description of a condition is clinical fruitful, they say, “only when it is based on perceptive study of actual cases, and it is practically effective only if paradigmatic cases exist to show in actual fact what can otherwise only be stated: namely, the actual onset, syndromes, and course typical of the condition.” Diagnosis is then for them a type of pattern recognition, or “syndrome recognition: a capacity to re-identify, in fresh cases, a disability, disease, or injury one has encountered (or read about) in earlier instances,” and the “reasons justifying a diagnosis rest on appeals to analogy” (Jonsen and Toulmin 1988, pp. 36, 40–41; Toulmin 1982).

This so-called “appeal” is not, I think, at all accurate; it is in any case surely inadequate, even risky. While not able to ignore such analogies and patterns, obviously, clinical practice is focused specifically on what is unique and individual: this unique individual now being diagnosed, cared for, and so on. Clinical practice is thus textured by a dialectical tension between the appeal to similarities (pattern recognition, analogy; more accurately, the typical) and the need to be specifically attentive and responsive to (as well as responsible for) each unique individual in his or her own unique circumstances. This unique person, after all, is who must be understood and helped, even while he or she, as well as the presenting illness or lesion, may show certain similarities to other persons.

This complex focus of clinical attention does not in the least belie the need to be capable of showing and not merely stating what’s going on in the particular encounter, nor that this attentiveness requires and builds on a fund of experience that provides the physician with “paradigms.” But it is precisely this dialectical play between past experience and now-presented individual patient which gives “pattern recognition” its strictest sense and helps to define clinical reasoning as preeminently practical, a clear instance of phronesis—or, to keep pertinent references within medical reasoning, a clear example of semiosis, which may well be understood as the more embracing concept. However that may be, as a therapeutic discipline, its focus is on the unique individual—who must never be forgotten in that tempting web of ‘similars,’ analogies, and paradigms, as ancient skeptical physicians knew well (Zaner 1992, 2001).

It is the same for clinical ethics: the individual encounter presented with its specific set of unique circumstances is the central and abiding focus of attention. It is to each specific situation and each individual whose situation it is that the ethicist must be responsive to and responsible for, even while this responsiveness and responsibility must surely be dialectically framed and informed by that fund of prior experiences—whose shadow, as it were, is invariably cast over every present event and thanks to which similar situations do indeed stand out as providing practical help for understanding and decision making.

Consistent with the seminal work of Aron Gurwitsch (1964, 1966) an encounter is a whole in the precise sense that it is the system of multiple interrelationships among constituents (Zaner 1981). Constituents are not lost in the whole, nor is the whole reducible to its parts; rather, they stand in a dialectical tension with each other, and it is this tensioned union, the “system of multiple parts,” that constitutes the whole (Zaner 1979). To enter a clinical situation is to be confronted with a whole, a “contexture” in Gurwitsch’s precise sense, (Gurwitsch 1964, pp. 105–54) that is, the set of relationships among clinical units, rules, procedures, standards of practice, as well as people, etc. This complex set of multiple interrelationships constitutes the encounter as the unique situation it is, and just this is the necessary, practical focus of clinical ethics. Some further detail is helpful, especially to contrast my own view from that of Jonsen and Toulmin and the others considered here and earlier.

Four main points are necessary to understand the notion of the whole (which Gurwitsch worked out in common with his colleagues in Gestalt psychology: the idea of “form”), Gurwitsch proposed a terminology to aid in distinguishing his concerns from others (such as the Gestaltists). He thus introduced the notion of “contexture” as a principle of organization of the experienced world of perception. To grasp his meaning, four important concepts are needed: (a) functional significance, (b) functional weight, (c) Gestalt-coherence, and (d) good continuation.

This absorption or placement within the whole gives each constituent a specific functional significance for the contexture: for instance, ‘being the right-hand member of a pair;’ or ‘being the third note in a minor chord.’ Accordingly, “the functional significance of each constituent derives from the total structure of the Gestalt, and by virtue of its functional significance, each constituent contributes towards this total structure and organization” (Gurwitsch 1964, p. 116). Only as thus integrated along with other constituents into a whole, and as systematically related to the others that are also related to each other (according to the same principle) and to the first, is a ‘part’ a constituent of a contexture.

Should a constituent be removed (in whatever way²) from its contextural placement, situating it within another, one cannot speak “of the same constituent being integrated into different contextures” (Gurwitsch 1964, p. 121). For instance, if a C-major chord is heard, and then a C-minor one, the note ‘G’ constituent to the first is not heard as ‘the same as’ the note ‘G’ constituent to the second. Although, Gurwitsch admits, there is a sense in which ‘the same’ objective state of affairs obtains, this is not the case for auditory (or any other mode of sensory) experience. Since the latter is precisely the issue, it would be a grievous error to confuse the two. What is at issue, in other words, is the functional significance, and in the example given precisely this is what alters. “It is the functional significance of any part of a Gestalt-contexture that makes this part that which it is” (Gurwitsch 1964, p. 121).

(b) Consider the way a red stoplight is experienced when seen during an urgent drive to take your injured child to a hospital. Clearly, not every ‘part’ has the same significance within this contexture. The light has greater functional weight in this example than it does, say, when you are merely driving along in a leisurely manner. What is ‘crucial,’ as we say, has greater functional weight, and this is getting your child to medical help. It is in reference to concern, thus, that the light stands out as ‘emphasized,’ weighted—a veritable obstacle. Such weight is, of course, relative: that is, relative to the functional significances defining the other constituents. As he points out, “This import is in proportion to the contribution which, by virtue of its functional significance, a part makes to the contexture.” (Gurwitsch 1964, p. 133), and is thus constituted in reference to the contributions of the other parts.

(c) It then becomes evident that the ‘whole’ or contexture is not the additive sum of its parts, nor is it reducible to its parts; nor for that matter is it ‘more’ than its parts. All such expressions are grievously ambiguous. A whole or contexture requires, in Gurwitsch’s words,

No unifying principle or agency over and above the parts or constituents which co-exist in the relationship of mutually demanding and supporting each other. The Gestalt…is the system, having internal unification of the functional significances of its constituents; it is the balanced and equilibrated belonging and functioning together of the parts, the functional tissue which the parts form…in which they exist in their interdependence and interdetermination. (Gurwitsch 1964, p. 139)

Every constituent not only refers to every other one, but also to the totality formed by that system of references; as any part is related to every other part, it is therefore also related to the fact that the other parts are similarly related. Hence, ‘relation’ here, is specifiably complex (Kierkegaard 1944/1957; Zaner 2012). A contexture or whole is precisely the system of mutually interdependent and cross-referential constituents or parts; it is this system of complex references or functional significances. Thus, not only does every part refer to every other part, but the whole is inherent to every constituent: precisely in virtue of its specific functional significance, each part ‘realizes’ and ‘references’ in its own specific way the whole contexture.

(d) Gurwitsch points out that it is the contexture (which he terms “theme”) which makes possible the organization of the context (the “field”) as materially relevant and as background for that theme. But what makes the theme itself possible? Several conditions have already been pointed out.

(i) Although the theme makes possible the organization of the field, it is reciprocally the case that every theme appears as within and standing out from its specific field. Thus, Gurwitsch points out that in the case of perception, “per-cipere may be characterized as ex-cipere;” (Gurwitsch 1964, p. 321) it is a “singling-out” of the theme from the field. In different terms, the “ground” can never be absent from perceptual “figure” (Gurwitsch 1964, p. 113).

(ii) The theme does not merge into, but emerges from, the field. Not to be absorbed into the field, thus, signifies the specific kind of “coherence” displayed by contextures—a ‘being-bound-together,’ as it were which does not hold among items in the field, or between the field and the theme. The segregation of themes from the field follows the lines of and “is a condition of” segregation” (Gurwitsch 1964, p. 138).

(iii) Every theme has a certain “positional index:” an orientation, position, or placement within the field. For instance, a particular proposition is (it has the functional significance of being) the conclusion of an argument. Its positional index consists of what Gurwitsch calls “contextual characters:” for example, “referring back” to premises as “derived from” them, and “referring forward” to other propositions, etc., all within the field of logical relationships among propositions. The theme appears within the field; it has a certain “position” within the field and thus serves to orient the field.

(iv) The field is thus not undifferentiated. Simply focusing on one thing (a house, a proposition, etc.) does not render the field of other items into an amorphous vagueness: consider, for example, the items in a room while you are focused on a particular painting on the wall. These other items in the field remain relatively distinct and definite, differentiated from still other items, even though not now attended to or thematized. In short, it is part of the organization of the field that each of its items is itself a potential theme—which is part of the meaning of material relevancy. When thematized, the item retains its sense of having been materially relevant, of having been potential. Briefly, then, the central conclusion follows: the organization of the field into theme/thematic field/margin is not ‘derived’ from anything else, but is rather, Gurwitsch says, autochthonous; (Gurwitsch 1964, pp. 30–36) it originates precisely there, where it is found.

Gestalt psychologists had already identified four factors that determine the organization of wholes. In ascending order of import these are: proximity, equality, closure, and good continuation. Although first established as regards only visual wholes, Gurwitsch shows that they have significance far beyond that. His analysis to this point already showed in effect that the first two (proximity and equality) are comprehended by functional significance and coherency; closure and good continuation remain to be accounted for by his proposed ‘field’ theory of consciousness. These two can best be elucidated in cases of incomplete contextures: e.g., a melody broken off before completion, a sentence left dangling, a face incompletely drawn, etc.

In each case there is an experienced incompleteness and a pronounced tendency toward completion (closure). This tendency, however, occurs solely along lines already laid out by the presented, partial contexture (good continuation). All incomplete contextures appear as “in need of support and supplementation…in accordance with their functional significance” (Gurwitsch 1964, p. 151). The actually given constituents include what Gurwitsch had already termed “pointing references,” but in the case of incompleteness, these references are toward other constituents as needing to be at certain places and with certain functional significances in reference to those at hand and thus in reference to the as yet incomplete contexture. Clearly, not just anything will serve to complete a melody (e.g., the noise of a passing train), or a sentence (e.g., the feel of a rough texture), or a drawn face (e.g., an odor in the room). The incomplete contexture “develops strong tendencies of its own toward completing itself” by setting out what sorts of constituents would or would not ‘fit’ into itself (Gurwitsch 1964, p. 151).

Such cases of incompleteness help make clear what even a well-formed contexture possesses but is not always easy to detect. Contextures have a striking tendency to persist and maintain themselves, and in this sense toward preserving their integral concord or coherence. Should such continuation fail to occur, thus, an incongruity is experienced, a being-out-of-tune, a clash and discord characteristic of abortive or flawed contextures—or, as might also be suggested, of impaired embodiments or mental life.

It is thanks to this tendency to good continuation and closure, that contextures present a kind of strength or connectedness, a remarkable unity. Yet, while each is thus a ‘one,’ a unity, each is also an intrinsic diversity, a ‘many.’ Systematically and functionally placed within the topography of the whole, each constituent is nonetheless differentiated from every other one. They also differ from the total system of functional references: each constituent is positioned in its own way, and each presents the entire contexture from its own position. Yet it is solely by virtue of the contexture that each constituent has its specific position, functional significance, and weight.

That is, diversity and unity are mutually conditioned and conditioning: a contexture is necessarily a unity-in-diversity, since it is the systematic significance of each constituent to be at once ‘itself’ and ‘different,’ and essentially to be a complex referencing and being-referenced vis-à-vis the total system (the whole). This could be seen, then, as Gurwitsch’s response to that traditional conundrum, active since at least early Greek times, the problem of the ‘one’ and the ‘many’.

Gurwitsch’s field theory is by any reckoning a powerful instrument for understanding the genuinely complex phenomena of perceptual experience, including clinical experience. That it is equally powerful as regards other objective phenomena seems quite as clear. He argues only, as mentioned, that it addresses the organization of the noematic-objective sphere of sense perception—the phenomenological term for the ‘what is experienced, precisely as and only as it is experienced—that of experienced objects in general, and thus in no way usurps the principle of temporality except as the argument is that the latter is now restricted to the noetic sphere.

But precisely in view of the impressive way in which his phenomenological theory is able to illuminate hitherto obscure or poorly understood phenomena, I have long been naturally led to wonder about its extension—i.e., to ask whether that restriction to the objective sphere of sensory perception is needed. This is neither idle speculation, nor an ad hoc way of engaging in cleverly sportive argumentation. In my work after studying with Gurwitsch, and studying his seminal writings, I have tried to do what he did with Husserl: to carry out the sense implicit to and consistent with the original.

For example, I have already suggested in some detail (Zaner 1981) that the notions of context and contexture are highly significant in that they usefully elucidate otherwise very puzzling phenomena relating to mental life, self and embodying embody. Nor would I be the first to find such extensions to such generative notions. After all, it could readily be pointed out that not only thinkers such as Wilhelm Dilthey, but Husserl and even Gurwitsch himself, frequently use descriptive locutions when referring to the sphere of self and consciousness which immediately suggest the very organizational principle used to articulate the noematic field. Thus in Dilthey’s programmatic but intriguing essay on descriptive and analytic psychology, (Dilthey 1894/1977, pp. 20–21) and elsewhere in his work, clearly one of the basic concepts is the “nexus” of mental life (psychische Zusammenhang) and much of Dilthey’s concrete descriptive analysis is strongly suggestive of the contextural principles Gurwitsch has delineated. Husserl, too, is often obliged to characterize consciousness as, in his term, a “concrete context of subjective mental life” (konkreten wesenseinheitlichen Zusammenhang eines subjektiven Erlebens) (Husserl 1928/1969, p. 157).

All of which states the matter somewhat abstractly. But what has been explicated above can be readily appreciated in any of the narratives that have been referenced in these Chapters. Indeed, every clinical encounter makes the point dramatically. Every such encounter invariably includes many situational participants (“constituents”): patients, families, and friends; also physicians, medical consultants, nurses, chaplains, social workers; even the clinical ethicist is obviously among the contextual constituents of the encounter. All of these persons have some legitimate (though perhaps not always clear) stake in analyses, decisions, outcomes, etc. and the variety of relationships among them frequently needs careful identification, sorting, and assessment. As gradually became clear to me, moreover, the ‘language’ most suited for expressing these highly complex and concrete interrelationships is that of narrative.³

Many of these issues, obviously, come into clear focus through the efforts to communicate the patient’s diagnosis, possible therapies, likely outcomes, etc. It seems to me that the ethicist’s main role is not what Agich terms the “watcher,” nor is it as the analyst of analogies and similarities (Jonsen and Toulmin), nor facilitator (Glover et al). The clinical ethics consultant is, rather, the participant who is invited by one or another of those already positioned within an encounter, and whose task to identify and help others to understand the variety and complexity of discourses going on within the clinical encounter—as well as whatever else may be associated with any of those discourses: goals, histories, and the like. In addition, the clinical ethicist attempts to help the various participants to understand each other (for their own sake and that of others), and to focus on whatever moral issues can be shown to be ingredient to the encounter, as clearly and amply as the always constrained and constraining circumstances permit.

In other words, I can now say, the central focus of the clinical ethicist is the specific whole, the contexture of multiple interrelationships that make up the specific encounter. It is the ethicist’s task, perhaps only ideally in many encounters, to enable or promote relationships that are most consonant with the respective participants’ own moral and/or professional traditions and commitments.