Blurry lines and spaces of tension. Clinical-ethical and Existential issues in Intensive Care: A study of three European Intensive Care Units
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“Come on”, the medical student said, practically tugging my sleeve. “We’re gonna go talk to a patient. And he has AIDS! It’s super interesting.” We went in a hurry, a young doctor, two medical students, and myself, off to see the patient, and to evaluate whether or not to admit him to the Intensive Care Unit. Walking briskly down the halls of the ICU on our way to the next floor, it did feel, I reluctantly admitted to myself, rather interesting indeed. I first entered the ICU as an observer for my Master thesis in philosophy in 2012, and then later in 2014 in connection with my PhD work. I had never experienced intensive care, and my expectations of the hospital were colored by typically Hollywood-ized television representations. Consequently, I expected an environment of glorious mayhem and constant dramatic action. Judging from the reactions I continue to get from friends and peers upon hearing about the object of my study, I suspect that their ideas are much the same as mine were. I have no medical or nursing training. Consequently, when I decided to do fieldwork in the ICU, not only did I receive a fair share of concerned looks; I was warned. On the one hand, there was the concern that such a topic might be awfully depressing. This is a tendency identified by several authors working on sensitive topics, especially end-of-life, or death (Hockey 2007). Concerns also centered on my physical well-being. A friend of mine who was an intern physician at the time cautioned me. Are you prepared for this? He asked. Prepared for the sights? The sounds? Indeed, it is no secret that the hospital, or any form of clinic, may confront the observer, next of kin, or the patients themselves with distinctly uncomfortable sights, sounds, and smells. Anyone who knows someone who has gone to medical or nursing school knows that fainting or vomiting are expected rites of passage during training, although this normally occurs in the surgical suite or by the autopsy table. As Kate Watson poignantly puts it, medicine (and I would add nursing) is “an odd profession in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not at all remarkable, and death is not frightening.” (2011: 43). Indeed, the medical gaze does not come naturally to most, and has to be achieved through training. Untrained as I was, I braced myself. Much of the time, being an observer in the ICU means observing in the classical sense of the word: standing on the sidelines and watching. Being trained in philosophy, I planned to conduct a form of epoché, disregarding any nuisances in order to get to the ‘real’ information, and I was prepared to take steps to prevent any emotional or somatic reactions from endangering my mission of observation. They were something that needed to be overcome. I prepared for gruesome sights of blood and goo, and if there was one thing that I did not expect, it was to be bored. Arriving at the main adult ICU of a large Norwegian university hospital then, I found myself profoundly surprised. There was in fact hardly a sound. There was no running, no yelling—there was hardly any talking at all. Quiet control reigned in this country of sleeping patients. No fuss, no movement, no emotion, and no unnecessary words were uttered. I quickly adapted to the general mood of the place, and understood that loud noises and commotion would have been perceived as quite disrespectful. As I moved from site to site, becoming increasingly familiar with the world of the ICU, I made a surprising and initially rather satisfying realization. The truth was that no amount of slime, bags of adult feces, blood and urine, open surgical wounds, necrotic skin, or amputated limbs had the appalling effect on me that I had anticipated. So little in fact, that I on several occasions felt prompted to lie to staff when they rhetorically questioned me, saying, “How hard it must be for you to be here.” Somehow, it felt like an insult to them if I told the truth that no; it did not really bother me. I was relieved that I managed to withstand feelings of nausea and disgust when faced with things that are normally thought to be quite off-putting. And of course, had I fainted at the sight of these things, any fieldwork in the clinic would have been nearly impossible to carry out. Indeed, I concluded, not without certain smugness; I might have made an excellent surgeon. Nevertheless, this is not to say that I remained unaffected—in the most literal sense of the word—by the experiences of the ICU. By its very nature, the intensive care unit can be an overwhelming space. One student who had previously spent time in many other hospital units, at one point described coming there as receiving a slap in the face. I suffered feverish dreams every night for weeks, waking up freezing in a clammy cover of my own cold sweat. I started regularly eating more. On several occasions, I felt a distinctive burning sensation coming from within, resulting in cold sweat on my forehead, peering through the pores of my skin, my heart pounding. seemingly in my stomach, eyeballs feeling too large for my eye sockets. Months after fieldwork was concluded, some of the people I had encountered continued to haunt my thoughts. Whilst observing, I frequently experienced the feeling of violating upon something, of performing some transgressive act by virtue simply of my presence. The reason for this autobiographical note, is that herein indeed, lay the very center of my investigation. Conducting ethnographic research on a high-tech biomedical environment, the researcher comes face to face with an exotic world that simultaneously feels strangely familiar. In my earliest exploration of intensive care, my Master thesis entitled “Fully human, fully technical” (Toute humaine, toute technique) (2012), I argued that this branch of technology-heavy, highperformance clinical practice had the possibility to destabilize categories, not least with regard to human existential concerns. Nature and culture, technology and biology, body and person, subjectivity and objectivity, science and art, life and death, the secular and the sacred. Dealing with these realities involves a balancing act—a separation, and a bridging, of categories. There is a definite allure to intensive care. It is a place where sometimes awesome—in the very literal sense of the word—recoveries take place. Simultaneously, it incites fear. This is a thesis about intensive care. It is about hospital work. It is about the closeness of life and death, and more generally about what it means to be human. The way care is practiced, and the ways in which death is enacted and talked about. The ways in which personhood takes form in this setting, and those for whom this category is restricted. All of these aspects reveal something about both the values of our society and of human resilience. In many ways I attempted in this thesis to work from the statement made by Foucault at the end of his “Naissance de la Clinique”, namely that if, in the biomedical era, medical scientists have been central to European culture, this is not due to their qualities as philosophers. It is because medical thought (la pensée médicale) engages intimately with the philosophical status of humankind (1966: 202). In the spring of 2014, between January and June, I conducted a multi-sited fieldwork in three European intensive care units—in Norway, France, and Spain. I spent a month at each place. This research was spurred by my Master thesis work for which I did a three-week long fieldwork in Norway in 2012. Combined, these field experiences comprise the empirical basis of my PhD project. Although the dissertation belongs to the discipline of social anthropology, the project deliberately crosses disciplinary boundaries, combining practical philosophy and ethics with ethnographic methods. The working title of the project was “Clinical-ethical and existential issues in intensive care.” My PhD project has been a part of the interdisciplinary, international research program “The Cultural Logic of Facts and Figures” (CUFF), funded by the Research Council of Norway. The overall ambition of the CUFF project was to examine a number of contemporary modes of objectification, measurement, and standardization to see how they constitute a cultural logic and shape four main dimensions of social life: meaning/representation, morality, notions of thinghood, and notions of personhood (NTNU, n.d.). It was decided already at the proposal stage of my work that I would write an articlebased thesis. In an article-based project, each article stands on its own as independently published or publishable pieces of academic production, allowing for a different focus in each article. There is little precedence for writing article-based dissertations in anthropology. In a casual discussion with two experienced anthropologists, one of them suggested, referencing the classical anthropologist Clifford Geertz, that in fact, since the discipline developed together with the format of the monograph, the two indeed became intertwined, and the monograph become the very language, or script, of anthropology. Consequently, the arrival of the article-based thesis into this discipline presents a problem, because there is no script for it. No recipe. My colleagues’ reasoning, in line with Geertz, resonated with me. Yet rather than see this lack of a script as a problem, I have chosen to view it as an opportunity to be creative. It is my hope, and intention, that the articles may take on a new richness and texture, through this preliminary part. Moreover, I would be delighted if my work could be a contribution to legitimating article-based thesis work within the discipline, and contributing to changing and evolving the script of anthropology.
Has partsPaper 1: Koksvik, Gitte. Silent subjects, loud diseases: Enactment of personhood in intensive care. Health 2016 ;Volum 20.(2) s. 127-142 https://doi.org/10.1177/1363459314567792 The final, definitive version of this paper has been published by SAGE Publishing, All rights reserved.
Paper 2: Koksvik, Gitte. Dignity in Practice: Day-to-Day Life in Intensive Care Units in Western Europe. Medical Anthropology 2015 ;Volum 34.(6) s. 517-532 - Is not included due to copyright available at http://dx.doi.org/10.108/01459740.2015.1037391
Paper 3: The Microethics of non-treatment decisions. Examples from European Intensive Care. - Is not included due to copyright
Paper 4: Medically timed death as an enactment of good death. An ethnographic study of three European Intensive Care units.