The research for this thesis started with my curiosity about healthcare ethics, which was first impelled by hearing about the field of bioethics. I was fascinated by its claim to be the subject of multidisciplinary scholarship—including
1 Direct link to the English translation of the law: https://www.finlex.fi/fi/laki/
kaannokset/1994/en19940559_20110312.pdf
by nonphysicians like me—in which people were pondering upon the very fundamental value questions of medicine. This bioethical beginning prompted my first interest in the topic, and it has followed throughout the thesis ever since.
It seemed clear from the start that having to make difficult decisions—such as forgoing life-sustaining treatment—has the potential to raise uncertainty in any professional, a human being, standing at the bedside. After all, these were the very questions of life and death whose answers were not simply found in technical guidebooks; they were decisions touching upon levels of thinking that are not simply guided by cold rationality. Rather, they manifested the kinds of issues that delve into much more personal, spiritual and value-laden levels of thinking. My curiosity as a social scientist found its focus on this uncertainty, sparked by wondering how professionals dealt with it. I wanted to discover what kinds of professional constructions of ethics they had to guide them when confronting and solving such situations. After all, being present in ethically confusing and emotionally heart-wrenching situations was their job, so it seemed obvious that professionals would have developed some kind of knowledge, method and practical wisdom over time for such situations.
Ethical assessment extends to all aspects of life, but it seemed clear from the start that perhaps nowhere else were they as important as in healthcare, an environment in which people are vulnerable, their lives depending—quite literally—on the expertise and good intentions of professionals. The particular weight put on ethical dimensions in the healthcare environment stems not, however, merely from those individuals’ vulnerability but also from the overall complexity of the situations. Ethical quandaries can be no less than questions about life and death, such as end-of-life decisions (see, for example, Berlinger, Jennings & Wolf 2013) or about prioritizing scarce healthcare resources (see, for example, Brock 2007; Daniels & Sabin 2008). After all, doing something good is a moral deed; therefore, practicing healthcare is never only a technical performance but is also an action requiring ethical sensitivity and thorough assessment and evaluation. In other words, in healthcare, “clinical care and ethical duties run smoothly together” (Jonsen, Siegler & Winslade 2010, 1). I refer in this thesis to this incredibly vast scale of topics and discussions by the
general term healthcare ethics. This is because I do not want to frame these questions as concerning only physicians by calling them “medical ethics” or only bioethicists by calling them “bioethics.” The term healthcare ethics, thus, meets in the middle, bringing different professional views under the same conceptual roof. However, I will further explain in more detail how bioethics in particular sparked my curiosity and research design in a way that led to studying different professions side by side in the first place.
For a social scientist interested in the social construction of discourse, ethics as a concept appeared as something so abstract, so hidden between the lines in everyday life that it seemed to offer boundless opportunities for studies that could grasp constructions lying beneath the surface. “Ethics” is, after all, a difficult word, because it can easily be used not only in the search for the good but also in vague and even misleading ways. It is as much a philosophical term as it is a word characterizing professional guidelines—and yet it is so much more than this. It is also a socially powerful word that can be used in ceremonial orations to emphasize noble goals, while actual decisions may, in fact, be made with the intention of gaining economic, legal or other forms of social power for an institution, group, or individual. Thus, when viewed as a social concept, healthcare ethics has a confusing—and therefore an endlessly fascinating—array of meanings. However, it was clear to me from the start that I would not have very much to offer to healthcare ethics in a philosophical sense. However, I sensed that not all had been written about the social construction of the world of healthcare ethics, especially its forms of dealing with uncertainty. This interest led me early on to discover the research tradition of descriptive ethics, the empirical rather than normative study of moral thinking and action. This thesis and its substudies further found their place under this umbrella of ethical inquiry.
The initial questions prompting this study’s research were, how do healthcare professionals make sense of the abstraction of what ethics means to them in their professional role in which dealing with moral uncertainty is a given? And how do these constructions differ between the studied professions? After all, I started with the idea that all professions would face some kind of moral uncertainty. This curiosity was further fueled by the very idea stemming from bioethics to bring the perspectives “around
the same table” and reflect upon them. I was also aware from the beginning that this kind of an interdisciplinary bioethics approach was not very well known or commonly practiced in the Finnish healthcare setting. Needless to say, it seemed obvious, as an inquisitive young Finnish scholar, to ask why should it not be—is there something in Finnish healthcare ethics that resists bioethics? Is bioethics just not fit for the Finnish context? Or is it just something we have yet to discover? I hoped understanding healthcare ethics discourse both in clinical bioethics in the U.S. and Finnish professions could offer some insight into these questions.
I start this thesis from the social constructionist theoretical beginning that any social reality consists of social construction—discourse—that shapes the common ways of talking about and understanding the topic. Healthcare ethics is no exception to this, and my exploration begins with a curiosity about the constructions that are circulated in relation to healthcare ethics for different professionals, in both the American bioethics discourse and the Finnish healthcare professionals’ discourse. My primary attempt in exploring the ethics discourse of the studied professions is to understand differences and to reflect upon them, because my view is that it is only by understanding differences that we can become aware of the things we take for granted. After all, the discourse that surrounds us is typically invisible to us, just as water is to a fish. For the fish to understand the water it swims in, it is important that it become aware of both the water and what is beyond it. Making differences explicit is a way to explore discourse and is aligned with the method of critical discourse analysis (CDA) used. Analyzing discourse means making the familiar strange and making the implicit (the
“water”) explicit and open for reflection. What better way to do this than to hold different traditions side by side and reflect upon them? For this reason, I not only contrast data from two very different cultures—Finland and the United States—in my research, but I also study different professions side by side. Just as returning home from a trip to a faraway country can make one suddenly more aware of one’s own culture and surroundings, taking on different realities for side by side analysis makes the differences more visible than how they would appear without the contrast. My point of entry to the data, the “home base” from which I start and return to, is the bioethics
perspective of viewing healthcare ethics as a pluralistic collection of voices that are all welcomed in one thesis under one roof, so to speak.
In summary, in this thesis I explore how ethics is understood in medicine, nursing and clinical ethics consultation by starting from the basic tenet that while discourse varies, dealing with moral uncertainty is confronted by all of these professions in the healthcare context. My inquiries begin with the following research questions:
1. How do the different studied healthcare professions think about ethics?
2. What kind of worldview do they construct? What do they see through that lens when they talk and write about ethics?
3. What is implicated as important and meaningful for the different pro-fessional perspectives—and what, in turn, is not?
I also take different kinds of angles to the questions in the separate substudies.
I am curious about themes such as professional vision, professional identity, and moral expertise. These themes are all bound together by the effort to understand and reflect upon the different kinds of healthcare ethics discourses. In the end, I will return to the bioethical claim that first launched me on this research journey and discuss whether I view bioethics as offering something new to the Finnish healthcare ethics discourse.
My intention throughout this thesis has been to retain an open mind for understanding difference and to cultivate a sense of open-ended diversity when facing the ethical landscape of healthcare, while I simultaneously encourage the readers to reflect on their own ethics worldview. I put the same grand vision in the famous words of T. S. Eliot, who said, “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started, and know the place for the first time.”