Richard M Zaner - Böcker

In these essays, discussing clinical ethics consultation, three sorts of reflective writing are presented. The first is a description of a clinical ethics consultation, obviously limited as a documentation of the experiences at its source. It is followed by three examples of a second kind in the probing commentaries by figures in biomedical and clinical ethics - Francois Baylis, Tom Tomlinson, and Barry Hoffmaster. Finally, these are followed by a third variety of reflection in the form of responses to those three commentaries, by Bilton and Stuart G. Finder, and an Afterword - a further reflection on some of the issues and questions intrinsic to clinical ethics consultation and to these various essays. assisted at one point (he is the colleague mentioned in Bliton's manuscript) but frequently participated in the discussions that are invariably part of the clinical ethics consultative practice in the Center for Clinical and Research Ethics at Vanderbilt University Medical Center. It was thus natural for Finder to participate in the response.

From the tone of the report by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Re­ search, one might conclude that the whole-brain-oriented definition of death is now firmly established as an enduring element of public policy. In that report, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death, the President's Commission forwarded a uni­ form determination of death act, which laid heavy accent on the signifi­ cance of the brain stem in determining whether an individual is alive or dead: An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards ([1], p. 2). The plausibility of these criteria is undermined as soon as one confronts the question of the level of treatment that ought to be provided to human bodies that have permanently lost consciousness but whose brain stems are still functioning.

At the edge of mortality there is a place where the seriously ill or dying wait - a place where they may often feel vulnerable or alone. For over forty years, bioethicist cum philosopher Richard Zaner has been at the side of many of those people offering his incalculable gift of listening, and helping to lighten their burdens - not only with his considerable skills, but with his humanity as well. The narratives Richard Zaner shares in Conversations on the Edge are informed by his depth of knowledge in medicine and bioethics, but are never "clinical." A genuine and caring heart beats underneath his compassionate words. Zaner has written several books in which he tells poignant stories of patients and families he has encountered; there is no question that this is his finest. In Conversations on the Edge, Zaner reveals an authentic empathy that never borders on the sentimental.Among others, he discusses Tom, a dialysis patient who finally reveals that his inability to work - encouraged by his overprotective mother - is the source of his hostility to treatment; Jim and Sue, young parents who must face the nightmare of letting go of their premature twins, one after the other; Mrs Oland, whose family refuses to recognize her calm acceptance of her own death; and, in the final chapter, the author's mother, whose slow demise continues to haunt Zaner's professional and personal life. These stories are filled with pain and joy, loneliness and hope. They are about life and death, about what happens in hospital rooms - and that place at the edge - when we confront mortality. It is the rarest of glimpses into the world of patients, their families, healers, and those who struggle, like Zaner, to understand.

This book is a critical examination of certain basic issues and themes crucial to understanding how ethics currently interfaces with health care and biomedical research. Beginning with an overview of the field, it proceeds through a delineation of such key notions as trust and uncertainty, dialogue involving talk and listening, the vulnerability of the patient against the asymmetric power of the health professional, along with professional and individual responsibility. It emphasizes several themes fundamental to ethics and health care: (1) the work of ethics requires strict focus on the specific situational understanding of each involved person. (2) Moral issues, at least those intrinsic to each clinical encounter, are presented solely within the contexts of their actual occurrence; therefore, ethics must not only be practical but empirical in its approach. (3) Each particular situation is in its own way imprecise and uncertain and the different types and dimensions of imprecisionand uncertainty are critical for everyone involved. (4) Finally, medicine and health care more broadly are governed by the effort to make sense of the healer’s experiences with the patient, whose own experiences and interpretations are ingredient to what the healer seeks to understand and eventually treat. In addition to providing a way to develop ethical considerations in clinical life and research projects, the book proposes that narratives provide the finest way to state and grapple with these themes and issues, whether in classrooms or real-life situations. It concludes with a prospective analysis of newly emerging issues presented by and within the new genetics, which, together within a focus on the phenomenon of birth, leads to an clearer understanding of human life.

This book is a critical examination of certain basic issues and themes crucial to understanding how ethics currently interfaces with health care and biomedical research. Beginning with an overview of the field, it proceeds through a delineation of such key notions as trust and uncertainty, dialogue involving talk and listening, the vulnerability of the patient against the asymmetric power of the health professional, along with professional and individual responsibility. It emphasizes several themes fundamental to ethics and health care: (1) the work of ethics requires strict focus on the specific situational understanding of each involved person. (2) Moral issues, at least those intrinsic to each clinical encounter, are presented solely within the contexts of their actual occurrence; therefore, ethics must not only be practical but empirical in its approach. (3) Each particular situation is in its own way imprecise and uncertain and the different types and dimensions of imprecisionand uncertainty are critical for everyone involved. (4) Finally, medicine and health care more broadly are governed by the effort to make sense of the healer’s experiences with the patient, whose own experiences and interpretations are ingredient to what the healer seeks to understand and eventually treat. In addition to providing a way to develop ethical considerations in clinical life and research projects, the book proposes that narratives provide the finest way to state and grapple with these themes and issues, whether in classrooms or real-life situations. It concludes with a prospective analysis of newly emerging issues presented by and within the new genetics, which, together within a focus on the phenomenon of birth, leads to an clearer understanding of human life.

Under the title of "Phenomenology: Continuation and Crit­ icism," the group of essays in this volume are presented in honor of Dorion Cairns on his 70th birthday. The contributors comprise friends, colleagues and former students of Dorion Cairns who, each in his own way, share the interest of Dorion Cairns in Husserlian phenomenology. That interest itself may be best defined by these words of Edmund Husserl: "Philosophy - wis­ dom (sagesse) - is the philosopher's quite personal affair. It must arise as his wisdom, as his self-acquired knowledge tending toward universality, a knowledge for which he can answer from the beginning . . . " 1 It is our belief that only in the light of these words can phenomenology and phenomenological philosophy be continued, but always reflexively, critically. For over forty years Dorion Cairns has, through his teaching and writing, selflessly worked to bring the idea expressed by Husserl's words into self­ conscious exercise. In so doing he has, to the benefit of those who share his interest, confirmed Husserl's judgement of him that he is "among the rare ones who have penetrated into the deepest sense of my phenomenology, . . . who had the energy and persist­ ence not to desist until he had arrived at real understanding.

Phenomenology in the United States is in a state of ferment and change. Not all the changes are happy ones, however, for some of the most prominent philosophers of the first generation of phenomenologists have died: in 1959 Alfred Schutz, and within the past two years John \Vild, Dorion Cairns, and Aron Gur­ witsch. These thinkers, though often confronting a hostile intel­ lectual climate, were nevertheless persistent and profoundly influential-through their own works, and through their students. The two sources associated with their names, The Graduate Faculty of The New School for Social Research, and the circle around John Wild first at Harvard and later at Northwestern and Yale, produced a sizable portion of the now second gener­ ation American phenomenological philosophers. In a way, it was the very hostility of the American philo­ sophical milieu which became an important factor in the ferment now taking place. Although the older, first generation phenome­ nologists were deeply conversant with other philosophical move­ ments here and abroad, their efforts at meaningful dialogue were largely ignored. Determined not to remain isolated from the dominant currents of Anglo-American philosophy in par­ ticular, the second generation opened the way to a dialogue with analytic philosophers, especially through the efforts of the Society for Phenomenology and Existential Philosophy, led by 2 INTRODUCTION such men as James M. Edie and Hubert Dreyfus and, in other respects, Herbert Spiegelberg and Maurice Natanson.

Historically, philosophy has been the point of origin of the various sciences. However, once developed, the sciences have increasingly become autonomous, although often taking some paradigm from leading philosophies of the era. As aresult, in recent times the relationship of philosophy to the sciences has been more by way of dialogue and critique than a matter of spawning new sciences. This volume of the Selected Studies brings together a series of essays which develop that dialogue and critique with special reference to the insights of phenomenological philosophy. Phenomenology in its own way has been interfaced with the sciences from its outset. Perhaps the most widely noted relation, due in part to Edmund Husserl's characterization of the beginning steps of phenomenology as a "descriptive psychology," has been with the various psychologies. It is weIl known that the early Gestaltists were influenced by Husserl and, later, the Existential psychologies acknowledged the impact of Martin Heidegger and Jean-Paul Sartre, to mention but two philosophers. And, of course, Husserl's lifetime concern for the foundations of logic and mathe­ maties, especially as these (the former in particular) were developed into a foundational "theory of science," has figured prominently in these dialogues. 2 INTRODUCTION Less directly but more currently, the impact of phenomenology upon the disciplines has begun to be feIt in a whole range of the sciences.

The French version of this book, Theorie du champ de la conscience (1957), appeared under the auspices of the International Phenomenological Society. This present version appears through the collaboration of the staff of the Duquesne Studies, Psychological Series. In writing this book, I wanted to make it a phenomenological study, not a book about phenomenology. The intention was to advance c- tain phenomenological problems rather than to present a survey of or a report on phenomenology. My point of view is that of the pheno- nologist at work, not of an observer of a methodology from without. While it appeared desirable to expound in a detailed manner some of Husserl's notions and theories which have importance for phenomen- ogy as a whole, I have con?ned my treatment to those which have direct and immediate reference to the problems treated in this study. The manuscript of this book was completed in 1953 before the appe- ance of several volumes of Husserliana among which vol. VI, Die Krisis der Europaischen Wissenschaften und die transzendentale Phanomenologie (1954), and vol.IX, Phanomenologische Psychologie (1962), have particular bearing upon the problems dealt with in this book. Also the most recent presentation of Gestalt theory by W. Metzger, Psychologie (1st ed. 1940, 2nd ed. 1954) did not come to my attention before the completion of the manuscript.

In the following essays discussing clinical ethics consultation, three sorts of reflective writing are presented. The first is a description of a clinical ethics consultation, more generously detailed than most that have been published, yet obviously limited as a documentation of the experiences at its source. It is followed by three examples of a second kind in the probing commentaries by highly regarded figures in biomedical and clinical ethics - Francois Baylis, Tom Tomlinson, and Barry Hoffmaster. Finally, these are followed by a third variety of reflection in the form of responses to those three commentaries, by Bilton and Stuart G. Finder, and my Afterword - a further reflection on some of the issues and questions intrinsic to clinical ethics consultation and to these various essays. The consultation itself was conducted by Bliton; but Finder not only assisted at one point (he is the 'colleague' mentioned in Bliton's manuscript) but frequently participated in the discussions that are invariably part of our clinical ethics consultative practice in our Center for Clinical and Research Ethics at Vanderbilt University Medical Center.It was thus natural for Finder to participate in the response. Each of these essays is fascinating and important on its own; together, however, they constitute a truly unusual and, we believe, very significant contribution that will hopefully figure prominently in subsequent discussions, and in shaping and deepening an endeavor - clinical ethics - still in much-needed search of its own discipline, method rationale and place in the domain of clinical practice more generally. This group of essays is also quite unique, addressing as it does the coherence of a form of practice - and, it must be emphasized, several forms of writing about as well as theoretical proposals for understanding that practice - whose current and future character remains very much in contention. That a situation such as the one discussed here often provokes strong and passionate responses will be no surprise -- whether because of its relative novelty, its risky nature, the high stakes involved, or something else.It is in any event a striking feature of ethics consultations that the people directly or even indirectly involved tend at times to feel rather passionately about what is said (and not said), what is done (and not done), and what is then reported (or, it may be, left out). Even so, such energetic feelings, much less the candor of my colleague's response to such passion, are rarely if ever apparent from published reports. For this reason alone, a considerable debt of gratitude is surely owed to our commentators -- reflective and deliberative, yet passionate and forceful as each of them are.

The French version of this book, Theorie du champ de la conscience (1957), appeared under the auspices of the International Phenomenological Society. This present version appears through the collaboration of the staff of the Duquesne Studies, Psychological Series. In writing this book, I wanted to make it a phenomenological study, not a book about phenomenology. The intention was to advance c- tain phenomenological problems rather than to present a survey of or a report on phenomenology. My point of view is that of the pheno- nologist at work, not of an observer of a methodology from without. While it appeared desirable to expound in a detailed manner some of Husserl's notions and theories which have importance for phenomen- ogy as a whole, I have con?ned my treatment to those which have direct and immediate reference to the problems treated in this study. The manuscript of this book was completed in 1953 before the appe- ance of several volumes of Husserliana among which vol. VI, Die Krisis der Europaischen Wissenschaften und die transzendentale Phanomenologie (1954), and vol.IX, Phanomenologische Psychologie (1962), have particular bearing upon the problems dealt with in this book. Also the most recent presentation of Gestalt theory by W. Metzger, Psychologie (1st ed. 1940, 2nd ed. 1954) did not come to my attention before the completion of the manuscript.

Under the title of "Phenomenology: Continuation and Crit­ icism," the group of essays in this volume are presented in honor of Dorion Cairns on his 70th birthday. The contributors comprise friends, colleagues and former students of Dorion Cairns who, each in his own way, share the interest of Dorion Cairns in Husserlian phenomenology. That interest itself may be best defined by these words of Edmund Husserl: "Philosophy - wis­ dom (sagesse) - is the philosopher's quite personal affair. It must arise as his wisdom, as his self-acquired knowledge tending toward universality, a knowledge for which he can answer from the beginning . . . " 1 It is our belief that only in the light of these words can phenomenology and phenomenological philosophy be continued, but always reflexively, critically. For over forty years Dorion Cairns has, through his teaching and writing, selflessly worked to bring the idea expressed by Husserl's words into self­ conscious exercise. In so doing he has, to the benefit of those who share his interest, confirmed Husserl's judgement of him that he is "among the rare ones who have penetrated into the deepest sense of my phenomenology, . . . who had the energy and persist­ ence not to desist until he had arrived at real understanding.

Early in the first volume of his Ideen zu einer reinen Phiinomeno­ logie und phiinomenologischen Philosophie, Edmund Husserl stated concisely the significance and scope of the problem with which this present study is concerned. When we reflect on how it is that consciousness, which is itself absolute in relation to the world, can yet take on the character of transcendence, how it can become mundanized, We see straightaway that it can do that only by means of a certain participation in transcendence in the first, originary sense, which is manifestly the transcendence of material Nature. Only by means of the experiential relation to the animate organism does consciousness become really human and animal (tierischen), and only thereby does it achieve a place in the space and in the time of Nature. l Consciousness can become "worldly" only by being embodied within the world as part of it. In so far as the world is material Nature, consciousness must partake of the transcendence of material Nature. That is to say, its transcendence is manifestly an embodiment in a material, corporeal body. Consciousness, thus, takes on the characteristic of being "here and now" (ecceity) by means of experiential (or, more accurately, its intentive) relation to that corporeal being which embodies it. Accordingly, that there is a world for consciousness is a conse­ quence in the first instance of its embodiment by 2 that corporeal body which is for it its own animate organism.