Nathalie Egalité, a new faculty member in the Memorial University Centre for Bioethics, discusses the pace of clinical ethics work.
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The acclaimed television drama series The Pitt has been hailed as the most realistic depiction of medicine to emerge in the era of prestige television. Throughout its two seasons replete with ethical dilemmas, the Hollywood production does not portray ethicists. As a bioethicist who studies ethical issues pertaining to narratives, I have been long fascinated by the absence of ethicists employed in a professional capacity in popular depictions of health care, research, and policy. That the ethicist as narrative figure remains missing when its presence would be expected illustrates the power that storytellers have in shaping ideas of reality. Engaging with representational practices that deny visibility to ethicists provides an opportunity to reflect on our work.
While no ethicists appear on screen, the show emphasizes the interprofessional nature of care by depicting social workers, paramedics, technicians, and support staff alongside nurses and physicians. A review of the series’ screenplays over two seasons uncovers one solitary mention of the “Ethics Committee.” In a revelatory exchange, Dr. Robby (Chief of Emergency Medicine) and Dr. Collins (senior resident) have concerns over a patient’s adult children wanting their father to be intubated. This painful procedure would offer no guarantee of recovery. It would cause distress for a confused patient with Alzheimer’s and would likely require physical restraints. Crucially, intubation would go against the father’s expressed wishes in an advanced directive specifying no artificial life support beyond intravenous fluids and medications.
Robby: They’re threatening to go to the hospital attorney.
Collins: Let them. Call the Ethics Committee. They’ll agree with us.
Robby: No, no, you’re probably right. But we don’t have that kind of time. We are stuck. [8:00 A.M. (Season 1 Transcript)]
The absence of ethicists on The Pitt is explained by the care team’s perception of their slowness: in the fast-faced environment of the emergency room, clinical decisions about life and death leave no time for outside intervention. Yet, as Ryan Pferdehirt emphasizes in his analysis of the show, clinical ethicists routinely intervene in the emergency room and can quickly provide ethical expertise in urgent situations through rapid ethics consults. The portrayal of ethicists functioning as a committee that must be convened bears little resemblance to embedded ethics models where ethicists interact directly with patients as they occupy a “recurring, predictable role in the work of the clinical team.” Viewers are left with a conception of the work done by ethicists that is both misleading and confining.
Photo Credit: Ann Douglas/flickr. Image Description: A “slow” traffic sign.
Nevertheless, the missing ethicists serve as a narrative foil for the clinical team. Their distanced authority, rivaling that of hospital attorneys, is meant to contrast with the maverick Dr. Robby who is quick-thinking, unorthodox, and personable. He relishes challenging higher-ups from the hospital administration over patient satisfaction metrics and financial pressures; his escalating conflicts with a meddlesome overseer correspond to a worn trope in medical procedurals used to create dramatic tension. An attunement to storytelling thus compels us to look beyond the main character to bring the unseen ethicists into sharper relief. Specifically, I want to probe this idea of slowness. Whereas some would bristle at the representation of ethicists as incompatible with the speed imperatives of modern medicine, I welcome the transformative possibilities of slow bioethics.
Ethical appreciation, ethical deliberation and ethical renegotiation are well-suited to slowness. Ethicists have had to contend with a conception of their work as an obstacle to scientific discoveries and technological innovation. The oft-repeated dictum “guardrails, not speedbumps,” applied to ethical issues in genetic engineering and artificial intelligence, exemplifies a vision for bioethics that rejects slowness. Identifying moral problems outside of prevailing normative framings takes time. Susan Sherwin contends that bioethicists are roped into a shell game when they orient themselves to respond to “challenges initiated by others.” A reactive bioethics replicates power structures while a focus on reducing friction distorts the wider scope of inquiry in which bioethicists should engage.
Ann Gallagher argues for the integration of tenets of the slow movement into the work done by clinical ethicists. In her articulation of slow ethics, she notes that the authors of Slow Living describe “a process whereby everyday life – in all its pace and complexity, frisson and routine – is approached with care and attention, as subjects attempt to negotiate the different temporalities that they daily experience. It is above all an attempt to live in the present in a meaningful, sustainable, thoughtful and pleasurable way.” Accordingly, the ethical competence that informs practice should be grounded in ethical perception, knowledge of moral philosophy, critical thinking, ethical action and the creation of conditions favourable to human flourishing and virtue. Treatments of slowness in global health research contexts and philosophical scholarship have similarly foreground the importance of creating knowledge in ways that differ from valued modes of productivity and efficiency.
Slow bioethics situates the labour of ethicists in extractive capitalist logics that prioritize speed, and opposes this prioritization. The domination of economic justifications over intellectual concerns in the neoliberal academy threatens care, reflection and relationality. Slowness emerges as a form of resistance. So rather than dwell on the fact that ethicists are slow to appear on the small screen, a critical look at television narratives allows for a reframing that changes the story we tell ourselves about bioethics.
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Nathalie Egalité is an assistant professor in the Centre for Bioethics and Faculty of Medicine at Memorial University.
