Retrieval of meaning in clinical ethics

In the literary sense, retrieving meaning can present a challenging endeavor. For example, French literary theoretician and avant-gardist Alain Robbe-Grillet’s phenomenological Heideggerian style is showcased in his novels and films which are filled with figurative imagery composed of fractured labyrinthine plots, stylistic free associations, repetitive symbolic descriptions, and parallel narratives; ultimately, rather profound psychoanalytic meanings are retrieved from his nouveau roman approach. In the existentially charged realm of clinical ethics, moral reflection does not begin with the application of normative principles, nor can it be sustained by an attitude of resignation toward the pursuit of the good. It begins, rather, with a free and open confrontation with the meaning of the experience we face.

Experience is not merely an objectively described empirical entity, though empirical analysis might have an important part in it. Already at the level of its etymological meaning, experience entails a reference to subjective intermediation: experience speaks of the predicament of the passing or living through a situation of crisis, and of the personal growth effected by such existential challenge. We are summoned by ‘ meaning’ in an integral fashion, and the radicalness of such call can only be answered by a synthetic act of reciprocity, a response to an intrinsic source of value to borrow from the phenomenological tradition, which we confront with that most intimate and all-encompassing definition of the self we identify with the notion of conscience.

Some clinicians posit that questions of meaning can only have a secondary importance when tough decisions need to be made, in the L-hic et nunc, the ‘ here and now’ of concrete clinical challenges. In this perspective, “ gazing into the meaning of things” can be, at best, an interesting theoretical exercise; at worst, a useless distraction that utterly fails to address the call of the moment. It does indeed make good sense to put meaning in a secondary place and give primacy, instead, to one’s immediate reality, e. g. when confronting the premature cry for survival in the neonatal intensive care unit, or the puzzlement over the competence of a surrogate decision maker acting on behalf of an elderly patient now mentally incapacitated.

At the same time, when the larger world of wellness, suffering, being struck with affliction, being sick, dying and so on, does not find its proper way into the decision-making process of clinical ethics; when, instead, clinical ethics relies, in a rather mechanical fashion, on an algorithmic approach to problem-solving, with its plethora of predefined categories – advance directives, consent forms, values inventory, etc., we end up creating obstacles to good habits of moral reasoning hindering the disclosure of moral meaning while, quite paradoxically, producing the “ right” answer for the quandary at stake.

Attending to the moral meaning of concrete situations entails recognizing that formal modes of logical argumentation are only derivative functions of the moral language. Prudential or practical meaning unfold as dimensions of a more original form of mindfulness, a synthetic act of discernment, which includes elements of detecting, sensing, sifting, discriminating, comparing, connecting, and, ultimately, deciding.

17th century French physicist, mathematician, and philosopher Blaise Pascal suggested distinguishing between esprit de finesse and esprit de geometric. Thus, there are two kinds of minds: a deeply and rapidly penetrating one concerned with the consequences of principles is the intuitive mind (esprit de finesse); the other is capable of grasping a great number of principles without confusing them is the geometric mind (esprit de geometrie). The first has strength and rightness of mind, the second breath of mind. One can exist without the other; that is, the mind can be strong and narrow and also broad and weak.

Ethicist and phenomenologist Richard M. Zaner (“ Experience and Moral life: A Phenomenological Approach to Bioethics”) expresses the matter perspicaciously when analogizing such phenomenological probing with the work of a detective: “ One must deliberately be alert to the multiple ways in which participants interrelate and variously experience and interpret one another, and with that relationship, the relationship itself. Even a brief moment reveals a number of interrelated voices, each with its own emotional, volitional, valuational, and cognitive tonality…The ethicist’s involvement is thus a work of circumstantial understanding.”

I share and underscore the view poignantly stated by urbanist William Hollingsworth Whtye: “ The great enemy of communication, we find, is the illusion of it. We have talked enough; but we have not listened. And by not listening we have failed to concede the immense complexity of our society—and thus the great gaps between ourselves and those with whom we seek understanding.”