Book of the Week - What Would You Do? Juggling Bioethics and Ethnography

Bill Smith was a doctor who ofttimes had counselled the parents of children with terrible genetic problems. At one meeting, though, he was so upset that he could only read from a prepared statement. In What Would You Do?, Charles Bosk relates how, at this meeting, "Bill began to read in a quavering voice - it was clear that he was close to tears - and he was able to get through half his statement before he threw it on the table, turned to one of his colleagues and said simply, 'finish,' and left the room sobbing". Bosk's ethnographic study, said Smith, "had destroyed everything he had accomplished ... (and) erased 20 years of professional achievements". Particularly upsetting was that Smith "had always considered (Bosk) a friend".

Bosk is a medical sociologist and ethnographer of medical action; his fieldwork is not on remote Pacific islands but in downtown American tertiary-care hospitals that are cutely anonymised here as "Pacific Hospital". Smith had certainly acted as if Bosk were his friend, because the previous day, a few hours before the lawyers had gotten involved, Bosk describes how Smith had "received the text (of Bosk's book) with what seemed to be genuine joy - a huge grin followed by a warm hug - at my having completed a much-delayed project". The genetic counsellors had themselves invited Bosk to study their clinic and provide advice, "as they entered socially uncharted waters" at a time when prenatal genetic testing and molecular genetics were becoming ever more sophisticated and invasive. Although Bosk's research, All God's Mistakes, was published in 1992, the fieldwork had taken place a decade and a half earlier. Bosk understands Smith's anger, as the counsellors "had asked for help and what they felt they got was public humiliation". A "warts and all" account had been expected, but Bosk says he "produced one that looked only at warts".

Ever since Bronislaw Malinowski visited the Trobriand Islands, ethnographers have seen themselves as objective observers, documenting and recording, as well as interpreting, the societies they came across, and as a young ethnographer Bosk was confident in that role.

However, the morning that Smith wept was a crux, an epiphanic moment, in Bosk's ethnographic career: "I lost my certitude in the harmlessness of my methods and of my ways of describing them to my subjects on the morning Bill Smith tossed his written statement on the table and fled the room crying."

The discontents that Bosk airs have much of the confessional about them, with Bosk admitting that "absolution might be one reason that I am choosing now 'to put on a hairshirt'". Central to Bosk's critique is that ethnography is itself socially constructed, the practitioners making their own demands and teaching their own norms: "I had always been taught that a good fieldwork account contained insights unpleasant to subjects, the dirty professional secrets that subjects would prefer to keep hidden, the ass end of the sacred." For a person to be honest, decent, legal or truthful is seemingly excluded a priori, for no man is allowed to be a hero to his ethnographer. Bosk's reflexive reflections show ethnography and the ethnographer auto-ethnographised and found wanting.

A particularly revealing moment is when Bosk describes how in writing up research, "no voice is so cultivated as the ironic, and ... no spirit so characterises work so much as a debunking one".

As it happens, Bosk's own account has a rich irony, for in recent years his professional work has examined the growing field of bioethics (and much of the book consists largely of previously published articles that are rich with insights into that emerging discipline). Bioethics, however, "impelled me to think harder about the ethics of my own practices", says Bosk, and to conclude that "ethnography (is) a morally problematic activity".

Certainly there is little sign of those four horsemen of bioethical principlism - autonomy, beneficence, nonmaleficence and justice. Proper informed consent and confidentiality are impossible, and the central conceit of pure observation is untenable (as Bosk reflected whenever he was asked, "OK, Bosk ... What would you do?"). The participants' sense of total betrayal becomes apparent only when the book finally appears, long after the fieldwork is finished and the ethnographer disappears, never to return. Then the participants spot the Trojan horse they've unwittingly pulled into their midst, with their private thoughts and conversations revealed to the world, often with unnecessarily pejorative theoretical interpretations and analyses that emphasise only the negative. What differs so much from Malinowski's ethnography is that his books were never read in the Trobriand Islands themselves.

Bosk muses at length, both on the things that written accounts intentionally omit or unthinkingly distort, and on those events never even recorded. All God's Mistakes was not Bosk's first encounter with doctors, for in 1979 he had published Forgive and Remember, which catalogued how surgeons handle mistakes and errors. One long section described the surgical faculty dealing with a problem resident called Jones. He was thought to be technically inept, a poor communicator, and he was even seen as physically or psychiatrically ill. The 2003 revision of the book contains an amended account, wryly entitled "An ethnographer's apology, a bioethicist's lament", in which Bosk reveals a key detail that was intentionally obfuscated in the 1979 account, and that Bosk now sees as "deliberately misleading": Jones was actually a woman. A gendered reading transforms the entire account, with Jones being the sole female surgeon in the hostile, threatening, predominantly masculine locker-room culture of surgery. Bosk worries that if as an ethnographer, he couldn't see that in 1979, then the fear is that ethnographers "are trapped in the values of the everyday".

The 2003 revision in which Bosk reveals Jones to have been female also has another revelation. The pseudonym "Bill Smith", included ostensibly to protect the genetic counsellor's identity, also distorts one's reading of the earlier incident. Go back to the top of this review and re-read it, but now knowing that Bill is in fact female, and judge how that knowledge potentially changes much of the interpretation.

There are complexities and riches in Bosk's apologia pro vita sua. While the elegant, thoughtful writing is mostly nuanced, subtle and careful, occasionally a brutal, self-flagellatory honesty leaps from a book written at the end of a long professional career. "Bill Smith" clearly still haunts Bosk, with Bosk giving the impression of wanting nothing less than to erase 35 years of his own professional achievements.

Social science always suffers the dilemma shown in Marx's withering reply to Ludwig Feuerbach that the point is not to interpret the world, but to change it. Intriguingly Bosk quotes this twice, with the first time being tragic: "as an ethnographer ... I do not know how to change it (the world)". The second time, though, is closer to farce, with the quotation seemingly ignored for 17 pages, until the last words of the book say "social scientists and ethnographers ... need to find ways to demonstrate that we can be useful without being helpful". It is hardly a resounding manifesto. Better perhaps to return to Malinowski, who said: "The final goal, of which an ethnographer should never lose sight, (is) to grasp the native's point of view, his relation to life, to realise his vision of his world."

THE AUTHOR

Charles L. Bosk was educated at Wesleyan University, as an undergraduate, and at the University of Chicago, where he received an MA and PhD in sociology. He then moved to the University of Pennsylvania to study law, before getting a position there as assistant professor of sociology.

Bosk has been at Pennsylvania for more than 30 years and is currently professor of sociology, as well as the graduate chair. Within sociology, he specialises in medical sociology/professions and professionalisation, deviance and social control, field methods of research, research ethics and the sociology of bioethics. He has written four books on those topics and dozens of chapters for edited works.

Bosk is also a dedicated and passionate teacher and Pennsylvania awarded him the Provost's Award for Distinguished Graduate Student and Mentoring.