Which empirical research, whose ethics? Articulating ideals in long-term mental health care

Jeannette Pols

in Empirical Ethics in Psychiatry

Published on behalf of Oxford University Press

Published in print February 2008 | ISBN: 9780199297368
Published online February 2013 | e-ISBN: 9780191754586 | DOI:

Series: International Perspectives in Philosophy & Psychiatry

Which empirical research, whose ethics? Articulating ideals in long-term mental health care

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I ask Lisa, a psychiatric nurse, if she notices any differences between before and after rehabilitation was introduced on the long-stay ward. She says she does. She says care used to be oriented towards managing the patients as a group. ‘Now an individualised approach is central. Much more attention is given to the patients’ self-organisation and their own responsibility’.

This fieldnote shows one of the most influential ideals in present long-term mental health care: the ideal of individualized care. Individualized care is regarded as a way of improving care and is contrasted with older forms of care that did not help patients to develop and be cared for according to their own preferences and possibilities. In this chapter I will study the ideal of individualization in order to demonstrate a specific form of empirical ethics: a theoretically informed ethnography of good care.1 What characterizes this style of empirical ethics?

First, the object of research is ‘good care’. However, what constitutes ‘good’ care is not defined beforehand, but is studied in an ethnographic way. The characteristics of good care in my study were explored by observing how nurses and patients in their daily life and work try to shape good care. I analysed everyday caring situations and discussed these with the participants. Key questions that emerged were: how can actual care-practices be perceived as ‘good’ practices, or as attempts to practise good care? What ideals of good care are thus at stake?

Analysing the nature of good care was done in a specific way: instead of attending to culture or talk about good care, I specifically attended to ‘practices’ of good care. Good care was analysed as it was shaped in daily activities, events, and routines. Together, people and artefacts were observed as doing different forms of good care. This is called the performance or enactment of ideals (Mol 1998, 2002).

A result of such an analysis is that forms of good care are made explicit. Thus, ideals that are taken for granted can become topics for discussion, for instance by analysing what type of practices come into being by enacting specific ideals. I questioned whether a certain ideal is dominant, are other ideals pushed to one side as a result? And is this what we actually want? This is an important characteristic of this style of empirical ethics: it ‘articulates’ ideals and their related practices that were tacit, taken for granted, pushed away, or ‘forgotten’ (Haraway 1991, 1992). In this process, words are given to implicit ways of framing good care. As I will show later, the ideal that runs the risk of being pushed to one side by the dominant ideal of individualization is the ideal of patient sociability.

By articulating ideals that are embedded in care-practices, this style of empirical ethics aims not to describe practice and neither does it aim to judge it. It does aim to interfere in the practices studied by opening up implicit notions of good care for (self) reflection. Thus, this style of empirical ethics does not restrict itself to describing what others think is good, neither does it impose its own norms in the form of prescriptions. Harbers (2005) calls the resulting interference the ‘re-scription’ of practice. It questions norms and ideals by articulating them as they are hidden in activities and routines to provide participants with fresh ways to look at their practice.

In order to present this style of empirical ethics I will not talk about it, but demonstrate it by analysing the enactments of the ideal of individualization.2 Fieldwork for this study was done in four long-stay wards in two psychiatric hospitals, and five residential homes for the elderly that started housing patients who left the long-stay ward.3 In the psychiatric hospitals, individualization inspired the development of a method of caring called rehabilitation, adapting it for the patients who did not make it out of the hospital. For the psychiatric nurses in the residential homes individualization of care is thought of as one of the benefits of this new care setting, as opposed to the long-stay wards of the psychiatric hospitals where they came from. I will discuss more backgrounds later, but will start by developing the concept of enactment. What does it mean to study enactments and how can the ideal of individualization be seen as enacted in daily care?

Chapter.  7909 words. 

Subjects: Psychiatry

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