HEC Forum DOI 10.1007/s10730-015-9277-5
New Places and Ethical Spaces: Philosophical Considerations for Health Care Ethics Outside of the Hospital Rachelle Barina1
Springer Science+Business Media Dordrecht 2015
Abstract This paper examines the meaning of space and its relationship to value. In this paper, I draw on Henri Lefebvre to suggest that our ethics produce and are produced by spaces. Space is not simply a passive material container or neutral geographic location. Space includes the ideas on which buildings are modeled, the ordering of objects and movement patterns within the space, and the symbolic meaning of the space and its objects. Although often unrecognized, space itself is value-laden, and its values are suggested as people interact within that space. By reflecting on the spaces of health care, we will see that we not only must attend to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by spaces. These values influence our moral imagination and shape us as people. Keywords space
Non-acute care health care ethics Bioethics Henri Lefebvre Social ‘‘(Social) space is a (social) product’’ (Lefebvre 1991), p. 26. ‘‘The space of a (social) order is hidden in the order of space’’ (Lefebvre 1991), p. 289.
The spaces of hospitals and medical offices have designated purposes, and objects fill the spaces accordingly. Unused space is uncommon. As soon as a vacant space is noticed, it is usually given a purpose and filled with objects accordingly. When I toured a hospital in the midst of its construction, the space of the hospital peaked my & Rachelle Barina [email protected] 1
Albert Gnaegi Center for Health Care Ethics, Saint Louis University, Salus Center 3545 Lafayette Ave., St. Louis, MO 63104, USA
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interest. Strolling through the halls, I began to imagine how the empty, vacant space would become a functional hospital. And, I assumed that ethical considerations would arise when beds and machines were added and occupied and staff began to care for patients. Today, that space is full of all kinds of objects and people, which, I had imagined, would generate ethical ideas and tension. As I reflected on the hospital space, my perception reflected two misunderstandings of space. First, I understood space to be like a neutral container prior to the things that come to fill it. Reducible to the observed world, space is a demarcated and passive zone into which the human may venture. Second, I envisioned ethics as occurring in a separate, mental space that is applied to the neutral physical place and space. The realm of ethics, then, is a cognitive space imposed onto and through the neutral material world.1 Scott Stonington (2012) has noted that implying that ethics occurs in abstract, mental space carried by persons is common in western biomedical ethics. He writes, ‘‘[P]lace is important for clarifying roles, but the ethics of the situation are due to the people involved, not to the place itself’’ (p. 837). Confounding the tendency to think of ethics as brought into spaces and places, the centrality of the hospital in US health care delivery has afforded a degree of uniformity and shared focus in ethical reflection, making it even easier to overlook the ethical significance of space itself. This issue of HEC Forum is about ethical issues that arise with the delivery of health care in places other than the urban hospital—in the home, the virtual world, long term care, rural settings, etc. By place, I mean the material qualities, setting, and location of health care delivery. The various places in which health care is delivered are also distinct spaces. By space, I mean not only physical and geographical qualities, but also the ideas, activities, and symbols that form, result from, and function within places.2 All places are spaces, but spaces far exceed any particular place. Space includes the ideas that helped map out the space, the practical ordering of the space, and the symbolic meaning of the space and its objects. This paper examines the relationship of space and ethics. Although usually unrecognized, space itself immanently normalizes ideas, thoughts, and actions. Conversely, ideas, thoughts, and actions also normalize space. Thus, I will argue that our thoughts, actions, habits, intentions, ideologies, and values—in short, our ethics—produce and are produced by spaces. Reflecting on the spaces of health care, which always arise 1
According to Lefebvre (1991), an ethics that is primarily situated in mental space resembles sentiments of math, science, and philosophy as influenced by Descartes’ division of the res cogitans and res extensia. Kant separated space from the empirical and historical world, denoting it an a priori that functions in the realm of consciousness and reinforcing Platonism over the Aristotelian importance of categories and teleology. For Kant, space is a cognitively understood condition for the possibility of pure reason, or of morality. ‘‘From a philosophy of space revised and corrected by mathematics,’’ Lefebvre writes, ‘‘the modern field of inquiry known as epistemology has inherited and adopted the notion that the status of space is that of a ‘mental thing’ or ‘mental place’’ (p. 3). Lefebvre argues that different logic has been developed in various mental spaces, and logical theories are then applied to the world in a way that appears untouched by ideology or experience. He writes, ‘‘In an inevitably circular manner, this mental space then becomes the locus of a ‘theoretical practice’ which is separated from social practice and which sets itself up as the axis, pivot or central reference point of Knowledge’’ (p. 6).
2
Many scholars, like Stonington, who have written about place are discussing what I understand as space. I distinguish place and space to highlight that space is not merely location.
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out of particular places but far exceed the locality and materiality of those places, will help us understand how we are normatively formed and how we may more comprehensively create ethical cultures in non-acute places of health care delivery. To make this argument, I will first unpack Henri Lefebvre’s theory of space. Second, I will explore the way that space informs and is informed by both an ethics of character and an ethics of action. In the first two sections, I will describe the ICU space both to illustrate the content I discuss and to serve as a point of relief for the third section. In the third section, I will reflect on the way that non-acute health care spaces immanently produce and are produced by normative values.
Lefebvre on the Production of Space As noted by Doreen Massey (1992, p. 66), space is a common word, often used as if its meaning is clear; however, space has many meanings and interpretations, which are neglected and oversimplified. I begin with Lefebvre’s view of space because it challenges the kind of decontextualization and mental/physical binary that often is presumed in thinking about ethics. Inasmuch as we understand mental and physical spaces as independent, space functions as a neutral and transparent concept, and thus ‘‘goes hand in hand with a view of space as innocent, as free of traps or secret places’’ (Lefebvre 1991, p. 28). In response, Lefebvre strives to articulate a unitary theory of space that integrates physical/perceived, mental/conceived and social/lived aspects of space and describes how space is actually produced. Space is not simply the physical, but also cognitive and social dimensions entangled with materiality. Lefebvre argues that a unified theory of perceived, conceived, and lived space must begin with recognition of the act of its production. Production is not simply a construction or manufacturing, but an ongoing and dynamic process that integrates materials, ideas, and interactions. Building on Hegel’s vision of production,3 Lefebvre suggests that the mental and physical as well as the ideal and real are subsumed in and by a social space, or lived space. Merrifield notes, ‘‘in Lefebvre’s hands, space becomes re-described not as a dead, inert thing or object, but as organic and fluid and alive; it has a pulse, it palpitates, it flows and collides with other spaces. And these interpenetrations—many with different temporalities—get superimposed upon one another to create a present space’’ (Merrifield 2000, p. 171). Space is not a thing or an a priori, but a dynamic, evolving product that in turn produces infinitely new spaces. Lefebvre specifies that the perceived/conceived/lived triad translates into three moments of production: spatial practice (perceived), representations of space (conceived), and representational spaces, or spaces of representation (lived).4 Spatial practice is the way that a space is used and ordered. Spatial practice ‘‘secretes’’ a space. The spatial practice of the ICU involves the construction and layout of the unit that leads to a certain order, the reliance on technology, the material dimensions and 3
Lefebvre writes, ‘‘In Hegelianism, ‘production’ has a cardinal role: first, the (absolute) Idea produces the world; next, nature produces the human being; and the human being in turn, by dint of struggle and labour, produces at once history, knowledge and self-consciousness’’ (p. 68).
4
For a helpful discussion of Lefebvre’s ideas, see Watkins (2005).
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positioning of technology, and the way that people perceive and move around each other. Spatial practice involves the people who carry supplies in and out of the unit, and the designated areas that require a badge for entry. Spatial practice includes the usual route by which corpses are led out of the ICU toward the morgue. It incorporates the families of patients and the ordering of ICU rooms and units affects how families and friends gather around a patient or participate in a care conversation. Representations of space are the maps, models, plans, or designs used by agents and institutions to produce spaces. They are abstract and mental constructs. Although the machinery used in ICU spatial practices may cause a patient to lose prominence within the room, designs of newer ICU spaces have conceived of ways to ‘‘hide’’ the chaos of the room, enclosing the tools of medicine (IV drips, machines, etc.) behind cupboards and panels. Similarly, while the spatial practice of transporting a corpse may occur in a planned route, that route and the location of the morgue has been carefully conceived in advance to avoid areas that patients and families frequent. Thus, representations of space are enacted through spatial practices. Most importantly, representations of space that aim to obviate the technological dependence of medical care or minimize encounters with the dead body are not neutral abstract constructs. On the contrary, they are ethically-laden ideas which are enacted through material construction and engrained in spatial practices. Representational space (or more clearly, ‘‘space of representation’’ or ‘‘lived space’’) is ‘‘space as directly lived through its associated images and symbols, and hence the space of ‘inhabitants’ and ‘users’…’’ (Lefebvre 1991, p. 39). Spaces of representation overlap physical space and use objects symbolically. The chaos of the ICU room is not only reflective of the actions taken and patterns of movement, but it also symbolizes the chaos of the patient’s body. The symbolic spaces within which we live reflect our ideas, feelings, and actions. Thus, Lefebvre writes, the space of representation ‘‘is alive: it speaks. It has an affective kernel or centre: Ego, bed, bedroom, dwelling, house; or: square, church, graveyard. It embraces the loci of passion, of action and of lived situations…’’ (Lefebvre 1991, p. 42). Experiences that patients, families, employees, administrators, and clinicians have in the hospital and the ICU are a dynamic exchange that encompasses spatial practices and representations. The ICU room is not simply the result of a plan and the place where spatial practice occurs; it is also a lived space, wherein the ventilator manipulated in a spatial way and for a functional purpose also has a symbolic meaning. To clinicians, a corpse covered by a blanket in an ICU room is not simply an object to transport by a designated procedure, but also a symbol of failure or finitude. Curtains are symbols of privacy, whereas sliding glass doors of an ICU room are symbols of surveillance.5 Cleaning an empty ICU room is a spatial practice, 5
An interesting example of a values conflict embedded in the evolution of hospital space and design has to do with the movement from large open patient wards to small private rooms. Verderber and Fine (2000) offer an interesting account of this history. Critics of moving away from large wards and towards separate rooms, most notably Florence Nightingale, saw the open ward as allowing for higher quality nursing care. A debate intensified in the mid-twentieth century. A movement towards semi-private wards occurred first. Strategies of clustering groups of patients emerged, and patient preferences for private rooms gained recognition and persuasive power. Patients prioritized the value of privacy, whereas Nightingale and others prioritized the ease and quality of care.
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but it is also symbolic and anticipatory of the stream of patients who arrive because of the realities of illness. Family meeting rooms are important to the spatial practices of decision making and they are made possible through representations of space conceived in the building, renovating, or labeling of a facility. But, these rooms also have symbolic meaning—they are spaces that signify conflict, resolution, frustration, hope, exchange, or even the role of and need for a clinical ethicist. Spatial practice, representations of space, and spaces of representation are, ultimately, dynamically interrelated and interdependent. Health care design and architecture and their scholarly literature are probably the best illustration of how spatial practice comes to help revise and improve the representations of space that undergird the construction of health care settings. Of course, major architectural decisions have a significant effect on the spatial patterns of patients, families, and employees. However, smaller design decisions, such as with flooring or desk layout, also can transform the lived space of the hospital. Niesen (2004), for example, suggests that as patients are moved by bed, ceiling lights can be very uncomfortable. This experience of movement and construction in the hospital has spurred new models that use side or indirect lighting to ease the light sensation for patients being transported. Similarly, Collignon (2008) notes that as hospitals struggle to care for extremely obese patients, they turn to design experts for improvements in the facility’s capacity to accommodate these patients. Spatial practices and challenges to those practices help to spur revision in the literal models used to construct the spaces of health care. The title of Carpman and Myron’s last book (2001) illustrates the way that architects shape health care spaces: Design that Cares. The construction and design of health care buildings can transform the lived spaces, enabling or disabling certain kinds of goals or interactions. Lived space is an inseparable synthesis of ideas, materiality, and actions. Each moment in the production of space is transformed by other bordering, intersecting, overlapping, and preceding spaces and results in many new spaces. Representations of space are constructed in relation to remembered and projected spatial practices and other lived spaces. In short, spaces necessarily transform and borrow from each other. For example, the space of the ICU imports and subsumes elements of other spaces, such as the spaces of science, anatomy, or economics. Historically, the construction of hospitals has been shaped by economic factors and business strategies. For example, Ahuja (2012) shows that Albert Kahn, who designed Ford Motor Company’s burgeoning automotive plant, used his knowledge of the factory to design the University of Michigan’s hospital. The representation of space from the factory came to shape the models undergirding the hospital. Crucially, the importation of factory space carried not only architectural qualities but also the values of efficiency, quality, and volume as well as a production mentality.6 In the 6
Illustrating this point, Ahuja cites a 1932 speech by Kahn, who said that building a hospital ‘‘requires knowledge of industrial processes for after all the same principles underlying the proper functioning of a manufacturing plant apply to the planning of a hospital building… Every department must be so coordinated as to cause all to operate jointly with maximum efficiency and for the greatest good’’ (pp. 403–404). Ahuja summarizes, ‘‘The University of Michigan’s new hospital provided a striking endorsement of efficiency as an institutional value that, importantly, it was willing to promote publicly. Its design resonated with an industrial model and supported an operational approach that maximized inhospital productivity’’ (p. 426).
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sharing of these spaces, the hospital subsumed an economically focused space that supported and cultivated values of efficiency and quality.7 In short, economic spaces come to shape the conception of the ICU, underlying both its construction and the way that people are taught to move and care for people. Many contemporary ICUs are constructed in a circular model, so as to maximize clinicians’ surveillance of patients and thus their response time when distress occurs. In the lived space of the ICU, the nurses’ station can even symbolize the need to observe as well as the importance of multi-tasking. The ICU space also has an effect on patients and families. Similarly, the ICU space also intersects with the space of the anatomy lab. Epistemologically, the dead body of anatomical dissection is the foundation on which future clinicians learn how to treat patients (Bishop 2011). The dead body becomes a kind of model that instructs spatial practices and symbolism in the anatomy lab. In the lived space of the anatomy lab, medical students develop ways of moving and interacting with the dead body, and they learn that this body teaches them how to treat patients. The space of the anatomy lab, however, then bumps into the ICU space, informing the way that physicians interact with patients (their spatial practice) as well as the symbolism such interactions convey. In short, clinicians carry the space of the anatomy lab into their clinical practices, and the anatomy lab and dissection practices shape the way that clinicians understand and interact with patients. The anatomy lab is just one example of the spaces that contribute to the production of ICU space. The space of the ICU carries all the spaces in which caregivers learned how to be caregivers. Thus, Lefebvre emphasizes that space is social and produced. He writes, ‘‘(Social) space is a (social) product’’ (p. 26). Lefebvre uses parenthesis to make two points: First, all space is produced. Second, space and its production are inherently social. Space carries the imprints of many people, ideas, actions, and habits, and such factors shape the ongoing production of a space and the events, actions, ideas, relationships, and institutions that evolve alongside and within that space. Thus, space ‘‘serves as a tool of thought and of action’’, and it ‘‘is also a means of control, and hence of domination, of power; yet…it escapes in part from those who would make use of it’’ (p. 27). In other words, space always precedes and exceeds people and institutions that try to control it. Lefebvre describes space: (Social) space is not a thing among other things, nor a product among other products: rather, it subsumes things produced, and encompasses their interrelationships in their coexistence and simultaneity—their (relative) order and/or (relative) disorder. It is the outcome of a sequence and set of operations, and thus cannot be reduced to the rank of a simple object. At the same time there is nothing imagined, unreal or ‘ideal’ about it as compared, for example, with science, representations, ideas or dreams. Itself the outcome of past actions, social space is what permits fresh actions to occur, while suggesting others and prohibiting yet others. Among these actions, some serve 7
There are many critiques of the hospital and the procedures of the ICU. One recent article that was published while I wrote this paper is ‘‘Efficient, Compassionate, and Fractured: Contemporary Care in the ICU.’’ I found this paper helpful and insightful. See Bishop et al. (2014).
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production, others consumption (i.e., the enjoyment of fruits of production). Social space implies a great diversity of knowledge (p. 73). (Social) space is complex and dynamic, and it bridges the gap between the real and the abstract, between practice and thought. It is not itself a singular object, but includes objects, their meaning, political and social forces, ideologies, intentions, and relationships. Considering this complexity, it is impossible to ‘‘produce a space with a perfectly clear understanding of cause and effect, motive and implication’’ (p. 37). Spaces exceed all particular intentions active in the production of space, and no person or institution holds or retains true control over any space. Whereas Lefebvre discusses the meaning of space as mapped onto large-scale projects like urban development, I am interested in the ways that his theory of space helps unpack more limited and particular spaces—the spaces adjacent to, around, and in which health care is delivered. And, in the same way that Lefebvre understands all space as socially produced and socially suggestive, I will suggest that all space is also morally produced and morally suggestive.
Space as a Normative Factor Between Being and Doing The question of interest for this paper is how, where, and when space is value-laden and of interest for ethics. All too often, as Jack Glaser points out, we misperceive ethics as dealing with a small and dramatic slice of issues. Glaser writes, We have the impression, as a society, that ethical decisions are few, dramatic, far between and happen with a solemn awareness that ‘this is an ethical issue’. [Hospital ethics committees] run the risk—unwittingly and unwillingly—of reinforcing these distortions of ethical reality. Since no other forum gets the title ‘ethics’ we can be deceived into thinking that ethics happens—only, best, exclusively—here where it is announced in the title. The fact is that most ethics, ethical deliberation, ethical decision-making takes place elsewhere. Most ethics happens anonymously, without being recognized and named as such. Major ethical decisions of individuals & institutions usually go by another name: ‘management decision,’ ‘financial decision,’ ‘long-range plan’. So, while ethics committees do deal with ethical reality, they deal only with a small fraction of a day’s ethical decision-making. Most of it happens elsewhere (Glaser 1989, pp. 275–276). Glaser’s insight about hospital ethics committees applies to ethics in all areas of clinical care. Reflecting on ethics in homecare, outpatient offices, telemedicine, long term care, and other non-acute settings, ethics should not be relegated to quandaries that rouse attention and disagreement. In fact, I push Glaser’s point further: not only does ethics happen anonymously and throughout all aspects of health care affairs, but our values and ethics are present and formative prior to any certain dilemma or situation that occurs. Without being recognized and named as ethics, the spaces in which health care is delivered already contain and cultivate values.
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Drawing from Lefebvre’s description of space and Glaser’s insight about ethics, it becomes clear that ethics is inscribed into space and space inscribes ethics into the people who interact in and as part of that space. Put differently, moral ideas always already present themselves to us through space. Space is particularly powerful in absorbing and inscribing ethics because it does so on multiple levels—in social space, ethics is carried and inscribed in physical, intellectual, and symbolic ways. Without our knowing, we are saturated in the values of the spaces in which we live, and this saturation leads us to think, act, and feel in certain ways. Space leads all of us to take on certain habits, and even to develop certain identities. Lefebvre’s best example of this point is the space of a religious cloister or monastery. Monastic space imports centuries of ideas, intentions, and aims— representations of space. Monasteries are built to normalize spatial practices in relation to living and deceased members, and the rhythms of prayer are reflected in columns, arches, and geographic location. The architecture reflects the development of theological and spiritual ideas that have been in practice for centuries, and living amidst that architecture in the space of the monastery reproduces those ideas, encouraging certain postures, gestures, and practices. The patterns, sounds, walls, and rooms of the monastery instruct when to move and how to position the body. In turn, these practices also shape thoughts, beliefs, and ideas. For example, many monasteries have long corridors that circumvent courtyards. As inhabitants walk these corridors, they have no outward visibility. Instead, their vision is drawn to the interior courtyard, which is often open, light, and luscious. While inhabitants are closed off from society, their movement through the hallways cultivates a sense of looking onto an interior openness. Similarly, the movements and postures of kneeling and prostration in worship cultivate not only reverence, but a sense of smallness and humility given the whole of the monastery and the aesthetic beauty of its church. Even the exterior of the monastery is part of the monastic space. An illustrative example is the Mete´ora, in Greece. The Mete´ora is a group of monasteries, each built on a separate natural rock pillar, with dramatic cliffs on all sides. When built, accessing Mete´ora required long ladders strung together and the use of basket lifts for supplies. Set apart from and towering above the nearby city, the location of the community intended to make entry difficult. The geography of the Mete´ora cultivated persistence, courage, and faith in the process of ascending the walls. This space led monks not only to undertake the precarious journey necessary to enter the monastery, but also helped them develop identities as people set apart from society, located between heaven and the rest of earth and tasked with the challenging spiritual endeavors. Walking the patterns of the monastery, practicing postures of worship, and maintaining a distance from society cultivate experiences, which, over time, lead to habits of thinking and acting and eventually to character traits. The relation between identity and action is circular, and it is always mediated by, rerouted by, inscribed by, or in tension within the monastic space. In health care, as in the monastery, space mediates character and action. The ICU space is not simply a neutral location, but, in fact, promotes certain habits, practices, representations, and ideals. The ICU room, for example, is often a chaotic area wherein monitors hold a prominent place and are often ordered for ease of visibility.
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Clinicians can observe the patient’s vital signs from afar. Accordingly, caregivers are led into habits of focusing on monitors and numbers as the source of the most relevant information, rather than looking first at a patient. Over time, such habits may creep into character, leading towards character traits that neglect attending to patients themselves. These habits also spur the arrangement of the room and the unit in a way that eases the visibility of monitors, which in turn perpetuates this sort of orientation towards the screens and monitors. Space cultivates practices, and practices cultivate identity and character. In turn, the identity and action produced within spaces also then contribute to the ongoing production of spaces. We develop as humans only within space, and the values formative in the production of spaces have profoundly formative effects on what we do and who we are. Glaser worked in the Catholic tradition, and a foundational insight from Catholic moral theology (and the Aristotelianism that shaped it) is illustrative of this point. As Richard Gula (1989, p. 7) notes, ‘‘actions are always expressions of a person’’. The people we are and the actions we perform, however, never occur outside of space. They are formed by and contribute to the spaces in which they occur. Ethics occurs in all three dimensions of space—space as it is conceived, perceived, and lived. Ethically neutral spaces do not exist; a new space always builds on various preceding values, even if changing or shifting the meaning or implications of those values. Therefore, the perceived, conceived, and lived dimensions of spaces always contribute to the production and application of values. As the places of health care delivery expand, new health care spaces are produced and that production will inevitably influence patients and clinicians. Consider the simple example of an outpatient office. The spatial placement of the office in a certain geographical area, for example, leads to trends in the qualities of both patients and employees. The spatial practice of the office includes having patients check-in upon arrival and enter a waiting area. It also includes separating patients and having the physician move between patients, who again wait in separate rooms. This spatial practice reflects a multitude of values and intentions. It presumes the values of privacy and confidentiality. It promotes efficiency and reduces delivery costs by gathering patients around the doctor (instead of the older model of making home-visits), and it embeds expectations that patients will wait to speak with the physician. These spatial practices secrete ideas about how people ought to act. Clinicians become accustomed to patients waiting for them, as they attend to a line of patients. Perhaps this spatial practice might lead some clinicians to develop a symbolic understanding of their work as a kind of production-line. This symbolism may not only shape actions, but also seep into character. Space sits at the cusp of being and doing. Spaces normalize our actions, and such actions come to form and reform our identity. Whereas Lefebvre emphasizes that all space exists and coheres only in its social nature, my emphasis is that the production of social space is always the production of value-laden space that carries and inscribes ethics. No space is silent on values or neutral in relation to our actions and identity. Spaces subtly but immediately convey values and transmit power dynamics and ideologies. Yet, space never fully normalizes thought and action. Thoughts and actions always exceed space and therefore can serve as an impetus for spatial transformation and the production of new spaces. While the ICU may encourage
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certain character traits—both good and bad—clinicians always have the ability to overstep the formative influence of the ICU space. Thinking about ethics in the non-acute context means not only thinking about ethics in places like the physician’s office or the rural health center, but also ethics in the new spaces that emerge in those places. The home and the long-term acute care facility are not just different places than the hospital. Because of the spatial practices in each place, because they are conceived of and planned differently, because they hold radically different symbolic meaning, and because they lead us to think and act in different ways, they are in fact different (although overlapping and colliding) spaces. In what remains of this paper, I will explore how attending to space might contribute to ethical reflection.
Home Space and Virtual Space As I noted previously, space exceeds place because it encompasses more than location and material. It includes ideology, symbolism, practice, thought, relationships, interior design, and patterns of movement and action. Health care delivery occurs in spaces, and the discourses and practices of ethics always constitute and are constituted by such spaces. As we contribute to, act within, and respond to the production of space, character and identity are also inscribed and reformed. Health care spaces differ between specialties, buildings, rooms, organizations, clinicians, payment structures, and patients. They differ between cities, states, and countries. Since every space could be unpacked separately, I have chosen two examples in the production of the (ethical) spaces involved in contemporary health care delivery. The contemporary return to home health care produces a new space, wherein the lived space of the home and the spatial practices of medicine are overlaid upon one another. The lived space of a person’s home, laden with symbolism, carries preferences, aesthetics, and spatial practices. A patient’s bed, for example, may not only differ according to function, but also according to meaning. In the hospital, the bed is symbolic of illness and need. The spatial practices surrounding the hospital bed are, in large part, those of caregivers who treat the patient. The room is organized according to the bed, and the head of the bed is oriented towards the door not only for convenience, but to increase efficiency and monitoring, to facilitate acknowledgment of the patient, and to allow the patient to view the people who enter the room. Clinicians approach the bed with ease, and they often stand at the foot of the bed to speak to the patient. The bed is mobile, and can transport the patient for a scan. In the space of the home, however, the bed entangles different spatial practices and symbolic meanings. The placement of the bed reflects the spatial patterns of the residents of the home and the limits envisioned in the design of the home. The bed might be a symbol of passion, love, affection, or intimacy. It might be a symbol of violence, lust, or aggression. It may be a symbol of loss and loneliness, following the memory of a lover who is no longer present. A clinician delivering care does not remove the symbolic meaning of the lived space of the home, but ventures into it, adds fragments from the space of medicine, and leads to the production of a new
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space. In home health care, the spatial practices of the clinician occur in a place where the patient has long established her own spatial practices and symbolic meaning. Thus, the space of the home has implications for the actions of the clinician. Whereas the clinician may approach the ICU bed with authority and intent, knowing the room well and rearranging it when necessary, the caregiver in the home risks offending the patient if she is too confident and assuming. Whereas a patient may be comfortable disrobing in a hospital room, she may be horrified by the same action done in her own bedroom with the presence of a caregiver. Whereas a patient may appreciate the presence of a clinician at the bedside in the hospital, it may make her uncomfortable in the home. Clinicians indifferent to the realities of the lived space of the home may cultivate habits in which they fail to recognize the particularities of patients and spaces, and thus fail to become humble and respectful caregivers. In the production of homecare spaces, the perceived-conceived-lived space of the patient’s home blend with perceived-conceived-lived spaces of health care. In this production, there is a risk of imposition and even of violation. And yet, the production of a new space is unavoidable with the delivery of health care in the home.8 Second, the growing reliance on telemedicine and virtual sites for caregiver and patient communication also produces new spaces that, like all spaces, will form character and shape action. As Speilberg (1998) reminds us, virtual communication replays old patterns in new ways. Previously, physicians sometimes wrote letters containing medical information. The development of the telephone transformed communication between patients and physicians, making it more direct and instantaneous. The rise of virtual communication has transformed communication yet again, making encounters more immediate and convenient. The space of telemedicine and electronic communication can be financially efficient, reducing cost, increasing revenue, and improving patient satisfaction (Pitt 2015). Telemedicine carries with it the value of minimizing the time and expense of health care affairs. It offers an alternative communication venue for patients who have been shown to feel intimidated by some in-person conversations or topics (Borowitz and Wyatt 1998, p. 1323). Electronic communication with health care professionals also cultivates a sense that the doctor is accessible for a quick question, which a person may not be willing to ask at the expense and time of an ordinary in-person consultation. The opportunity for a patient to email her physician is a symbol of that physician’s availability within the virtual space of health care. She will be present for the patient in her times of need, and this presence may help to sustain the 8
The space of the home and health care delivery also collide in long term care facilities, such as the nursing home. Young (2005, pp. 155–170), for example, reflects on the way that nursing homes have failed to cultivate the spatial elements of home. In many cases, residents cannot develop habits of their own, control who enters their areas, arrange their belongings, or maintain objects that have acquired meaning throughout time. She emphasizes the way that the ordinary aspects of home support and enact personal identity. When people lack the opportunity to develop a space, including the arrangement of objects, the patterns of movement, and the meaning of objects and activities, the dominating space of health care precludes them from thriving in their own lived space. Spaces inevitably collide when the places of home and health care overlap; however, careful ethical reflection can improve the production of a home health care space, whether that occurs in a house, apartment, or communal facility.
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relationship between the patient and physician over time. The continuity of this relationship enabled by a virtual space of health care delivery might then contribute to the physician’s sense of what it means to be a good and attentive clinician. Timely responses and consistent accessibility become part of the way that the physician acts, and over time, part of her identity as a caregiver. In spite of the increased availability of clinicians, however, virtual health care services could create a distance between the patient’s experience and the clinical encounter. Whittaker and Cox (2015, p. 53) write, ‘‘Today’s telehealth disrupts the intimacy customarily associated with the relationship between caregivers and patients’’. As the space of telemedicine allows more clinical encounters to occur exclusively in the virtual realm, it carries the risk of creating a distance between touch and care. It could lead to the assumption that adequately conveying information can be done without being present for a patient’s reaction. For the sake of efficient information sharing, test results that are highly distressing to a person but have no actionable medical indications may be delivered via a secure email system, leaving patients alone when receiving distressing results. In the process, caregivers are not always confronted with the responsive anxiety of patients, which may subtly cause a clinician to lose touch with patients’ experiences. Moreover, in such moments of communication, there may be a subtle suggestion that physicians are not responsible for comforting the patient in an emotional response, but only for explaining results, illustrating options, and sharing information.9 As the locus of health care shifts away from the hospital, spaces are blurred and new spaces are produced. The material, ideological, and interpersonal components of these spaces are suggestive of actions and subtly formative for character. New ethical dilemmas arise in the delivery of health care in non-acute places. Those spaces must also receive attention, so that we think not only about ethical dilemmas but also about the way spaces themselves shape how we act, how we should act, and what kinds of people we are becoming.
Conclusion I think back to the day where I stood in the empty space of the hospital under construction: I realize that at a time when I was more conscious of space than ever before, I overlooked the relation of ethics and space. When I stood in the vacant hospital, I reflected on how the already constructed building before me would soon become the space wherein a medical ethic was at work. What I failed to notice was that ethics—in fact, not one ethic, but a variety of conflicting ethics—had already 9
Notably, some effort has been made to proactively address the way that telemedicine will shape the patient-physician relationship. Mercy Health, for example, has noted that in leveraging new technology, there must be an emphasis on remaining true to the patient-physician relationship (Hale et al. 2015). The production of spaces of non-acute health care delivery is always colliding with other spaces, including ICU spaces. Lefebvre is critical of what he calls abstract space. Abstract space is real space, but it tends towards homogenization. When space is abstract, people tend to downplay or erase distinction, particularity, and difference, leading to a kind of spatial interchangeability and homogeneity that overlooks the non-neutrality of space and fails to account for the interplay between the perceptive and conceptive, the real and the ideal.
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been at work in the idea of constructing the hospital, in the decisions about the hospital’s structure and layout, in the spatial patterns involved in other health care endeavors, and in the placement of the hospital itself. The production of space long preceded and anticipated the patients, incubators, ventilators, and family meeting rooms that so often are involved in the activities and dilemmas that we identify as ethical. Space is not simply a container to be filled with stuff, such that when the stuff arrives, so too does ethics. Ethics is always already inscribed into space, and spaces convey, limit, and expand our values and moral imagination. There is a risk that ethical reflection on non-acute health care settings will fail to account for spatial particularity, uncritically importing the tendencies of moral thinking about hospital care.10 The purpose of this issue is to draw attention to the diversity of places within which health care is delivered. The purpose of this paper is to note that within the places of health care delivery there is also a multiplicity of health care spaces. Lefebvre notes that ideologies always lurk in the production of space. If moral reflection presumes a uniformity of space, we could usurp ethical particularities with ideological overgeneralizations and thus risk cultivating tendencies of imposition or insensitivity. The production of ethical space is always particular to the places of health care delivery, but its production begins long before the patient and caregiver meet. In fact, the spaces of health care have been under development for centuries and will continue long after—indefinitely after—the spaces of health care delivery become functional. Whereas Lefebvre talks about (social) space, I have discussed the way that space shapes our character, thoughts, and behaviors and has implications for how we think we ought to act. Ethics scholarship must attend not only to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by (ethical) space itself.
References Ahuja, N. K. (2012). Fordism in the hospital: Albert Kahn and the design of old main, 1917–25. Journal of the History of Medicine and Allied Sciences, 67(3), 398–427. Bishop, J. P. (2011). The anticipatory corpse: Medicine, power, and the care of the dying. Notre Dame: University of Notre Dame Press. Bishop, J. P., Perry, J. E., & Hine, A. (2014). Efficient, compassionate, and fractured: Contemporary care in the ICU. Hastings Center Report, 44(4), 35–43. Borowitz, S. M., & Wyatt, J. C. (1998). The origin, content, and workload of e-mail consultations. JAMA, 280(15), 1321–1324. Carpman, J. R., & Grant, M. A. (2001). Design that cares: Planning health facilities for patients and visitors (2nd ed.). San Francisco: Wiley. Collignon, A. (2008). Strategies for accommodating obese patients in an acute care setting. Washington, DC: American Institute of Architects: Academy Journal. 10 On this point, Lefebvre is critical of what he calls abstract space. Abstract space is real space, but it tends towards homogenization. When space is abstract, people tend to downplay or erase distinction, particularity, and difference, leading to a kind of spatial interchangeability and homogeneity that overlooks the non-neutrality of space and fails to account for the interplay between the perceptive and conceptive, the real and the ideal.
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HEC Forum Glaser, J. (1989). Hospital ethics committees: One of many centers of responsibility. Theoretical Medicine, 10(4), 275–288. doi:10.1007/BF00489649. Gula, R. M. (1989). Reason informed by faith: Foundations of catholic morality. Mahwah: Paulist Press. Hale, T., & Moore R. (2015). Mercy Virtual connects with a new model of care. Health Progress, 96(1), 13–17. Lefebvre, H. (1991). The production of space (Donald Nicholson-Smith Trans.). Oxford: Blackwell. Massey, D. (1992). Politics and space/time. New Left Review, 65–84. Merrifield, A. (2000). Henri Lefebvre: A socialist in space. In M. Crang & N. Thrift (Eds.), Thinking space. London: Routledge. Niesen, J. (2004). Lighting design for healthcare facilities: A common-sense approach. Washington, DC: American Institute of Architects: Academy Journal. Pitt, A. (2015). Connected care is essential to telemedicine’s success. Health Progress, 96(1), 5–12. Spielberg, A. R. (1998). On call and online: Sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. JAMA, 280(15), 1353–1359. Stonington, S. D. (2012). On ethical locations: The good death in Thailand, where ethics sit in places. Social Science and Medicine, 75(5), 836–844. Verderber, S., & Fine, David J. (2000). Healthcare architecture in an era of radical transformation. New Haven: Yale University Press. Watkins, C. (2005). Representations of space, spatial practices and spaces of representation: An application of Lefebvre’s spatial triad. Culture and Organization, 11(3), 209–220. Whittaker, S, and Johnny Cox. Use Catholic tradition to guide telehealth. Health Progress, 96(1), 51–55. Young, I. M. (2005). On female body experience: ‘‘Throwing like a girl’’ and other essays. Oxford: Oxford University Press.
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New Places and Ethical Spaces: Philosophical Considerations for Health Care Ethics Outside of the Hospital Rachelle Barina1
Springer Science+Business Media Dordrecht 2015
Abstract This paper examines the meaning of space and its relationship to value. In this paper, I draw on Henri Lefebvre to suggest that our ethics produce and are produced by spaces. Space is not simply a passive material container or neutral geographic location. Space includes the ideas on which buildings are modeled, the ordering of objects and movement patterns within the space, and the symbolic meaning of the space and its objects. Although often unrecognized, space itself is value-laden, and its values are suggested as people interact within that space. By reflecting on the spaces of health care, we will see that we not only must attend to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by spaces. These values influence our moral imagination and shape us as people. Keywords space
Non-acute care health care ethics Bioethics Henri Lefebvre Social ‘‘(Social) space is a (social) product’’ (Lefebvre 1991), p. 26. ‘‘The space of a (social) order is hidden in the order of space’’ (Lefebvre 1991), p. 289.
The spaces of hospitals and medical offices have designated purposes, and objects fill the spaces accordingly. Unused space is uncommon. As soon as a vacant space is noticed, it is usually given a purpose and filled with objects accordingly. When I toured a hospital in the midst of its construction, the space of the hospital peaked my & Rachelle Barina [email protected] 1
Albert Gnaegi Center for Health Care Ethics, Saint Louis University, Salus Center 3545 Lafayette Ave., St. Louis, MO 63104, USA
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interest. Strolling through the halls, I began to imagine how the empty, vacant space would become a functional hospital. And, I assumed that ethical considerations would arise when beds and machines were added and occupied and staff began to care for patients. Today, that space is full of all kinds of objects and people, which, I had imagined, would generate ethical ideas and tension. As I reflected on the hospital space, my perception reflected two misunderstandings of space. First, I understood space to be like a neutral container prior to the things that come to fill it. Reducible to the observed world, space is a demarcated and passive zone into which the human may venture. Second, I envisioned ethics as occurring in a separate, mental space that is applied to the neutral physical place and space. The realm of ethics, then, is a cognitive space imposed onto and through the neutral material world.1 Scott Stonington (2012) has noted that implying that ethics occurs in abstract, mental space carried by persons is common in western biomedical ethics. He writes, ‘‘[P]lace is important for clarifying roles, but the ethics of the situation are due to the people involved, not to the place itself’’ (p. 837). Confounding the tendency to think of ethics as brought into spaces and places, the centrality of the hospital in US health care delivery has afforded a degree of uniformity and shared focus in ethical reflection, making it even easier to overlook the ethical significance of space itself. This issue of HEC Forum is about ethical issues that arise with the delivery of health care in places other than the urban hospital—in the home, the virtual world, long term care, rural settings, etc. By place, I mean the material qualities, setting, and location of health care delivery. The various places in which health care is delivered are also distinct spaces. By space, I mean not only physical and geographical qualities, but also the ideas, activities, and symbols that form, result from, and function within places.2 All places are spaces, but spaces far exceed any particular place. Space includes the ideas that helped map out the space, the practical ordering of the space, and the symbolic meaning of the space and its objects. This paper examines the relationship of space and ethics. Although usually unrecognized, space itself immanently normalizes ideas, thoughts, and actions. Conversely, ideas, thoughts, and actions also normalize space. Thus, I will argue that our thoughts, actions, habits, intentions, ideologies, and values—in short, our ethics—produce and are produced by spaces. Reflecting on the spaces of health care, which always arise 1
According to Lefebvre (1991), an ethics that is primarily situated in mental space resembles sentiments of math, science, and philosophy as influenced by Descartes’ division of the res cogitans and res extensia. Kant separated space from the empirical and historical world, denoting it an a priori that functions in the realm of consciousness and reinforcing Platonism over the Aristotelian importance of categories and teleology. For Kant, space is a cognitively understood condition for the possibility of pure reason, or of morality. ‘‘From a philosophy of space revised and corrected by mathematics,’’ Lefebvre writes, ‘‘the modern field of inquiry known as epistemology has inherited and adopted the notion that the status of space is that of a ‘mental thing’ or ‘mental place’’ (p. 3). Lefebvre argues that different logic has been developed in various mental spaces, and logical theories are then applied to the world in a way that appears untouched by ideology or experience. He writes, ‘‘In an inevitably circular manner, this mental space then becomes the locus of a ‘theoretical practice’ which is separated from social practice and which sets itself up as the axis, pivot or central reference point of Knowledge’’ (p. 6).
2
Many scholars, like Stonington, who have written about place are discussing what I understand as space. I distinguish place and space to highlight that space is not merely location.
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out of particular places but far exceed the locality and materiality of those places, will help us understand how we are normatively formed and how we may more comprehensively create ethical cultures in non-acute places of health care delivery. To make this argument, I will first unpack Henri Lefebvre’s theory of space. Second, I will explore the way that space informs and is informed by both an ethics of character and an ethics of action. In the first two sections, I will describe the ICU space both to illustrate the content I discuss and to serve as a point of relief for the third section. In the third section, I will reflect on the way that non-acute health care spaces immanently produce and are produced by normative values.
Lefebvre on the Production of Space As noted by Doreen Massey (1992, p. 66), space is a common word, often used as if its meaning is clear; however, space has many meanings and interpretations, which are neglected and oversimplified. I begin with Lefebvre’s view of space because it challenges the kind of decontextualization and mental/physical binary that often is presumed in thinking about ethics. Inasmuch as we understand mental and physical spaces as independent, space functions as a neutral and transparent concept, and thus ‘‘goes hand in hand with a view of space as innocent, as free of traps or secret places’’ (Lefebvre 1991, p. 28). In response, Lefebvre strives to articulate a unitary theory of space that integrates physical/perceived, mental/conceived and social/lived aspects of space and describes how space is actually produced. Space is not simply the physical, but also cognitive and social dimensions entangled with materiality. Lefebvre argues that a unified theory of perceived, conceived, and lived space must begin with recognition of the act of its production. Production is not simply a construction or manufacturing, but an ongoing and dynamic process that integrates materials, ideas, and interactions. Building on Hegel’s vision of production,3 Lefebvre suggests that the mental and physical as well as the ideal and real are subsumed in and by a social space, or lived space. Merrifield notes, ‘‘in Lefebvre’s hands, space becomes re-described not as a dead, inert thing or object, but as organic and fluid and alive; it has a pulse, it palpitates, it flows and collides with other spaces. And these interpenetrations—many with different temporalities—get superimposed upon one another to create a present space’’ (Merrifield 2000, p. 171). Space is not a thing or an a priori, but a dynamic, evolving product that in turn produces infinitely new spaces. Lefebvre specifies that the perceived/conceived/lived triad translates into three moments of production: spatial practice (perceived), representations of space (conceived), and representational spaces, or spaces of representation (lived).4 Spatial practice is the way that a space is used and ordered. Spatial practice ‘‘secretes’’ a space. The spatial practice of the ICU involves the construction and layout of the unit that leads to a certain order, the reliance on technology, the material dimensions and 3
Lefebvre writes, ‘‘In Hegelianism, ‘production’ has a cardinal role: first, the (absolute) Idea produces the world; next, nature produces the human being; and the human being in turn, by dint of struggle and labour, produces at once history, knowledge and self-consciousness’’ (p. 68).
4
For a helpful discussion of Lefebvre’s ideas, see Watkins (2005).
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positioning of technology, and the way that people perceive and move around each other. Spatial practice involves the people who carry supplies in and out of the unit, and the designated areas that require a badge for entry. Spatial practice includes the usual route by which corpses are led out of the ICU toward the morgue. It incorporates the families of patients and the ordering of ICU rooms and units affects how families and friends gather around a patient or participate in a care conversation. Representations of space are the maps, models, plans, or designs used by agents and institutions to produce spaces. They are abstract and mental constructs. Although the machinery used in ICU spatial practices may cause a patient to lose prominence within the room, designs of newer ICU spaces have conceived of ways to ‘‘hide’’ the chaos of the room, enclosing the tools of medicine (IV drips, machines, etc.) behind cupboards and panels. Similarly, while the spatial practice of transporting a corpse may occur in a planned route, that route and the location of the morgue has been carefully conceived in advance to avoid areas that patients and families frequent. Thus, representations of space are enacted through spatial practices. Most importantly, representations of space that aim to obviate the technological dependence of medical care or minimize encounters with the dead body are not neutral abstract constructs. On the contrary, they are ethically-laden ideas which are enacted through material construction and engrained in spatial practices. Representational space (or more clearly, ‘‘space of representation’’ or ‘‘lived space’’) is ‘‘space as directly lived through its associated images and symbols, and hence the space of ‘inhabitants’ and ‘users’…’’ (Lefebvre 1991, p. 39). Spaces of representation overlap physical space and use objects symbolically. The chaos of the ICU room is not only reflective of the actions taken and patterns of movement, but it also symbolizes the chaos of the patient’s body. The symbolic spaces within which we live reflect our ideas, feelings, and actions. Thus, Lefebvre writes, the space of representation ‘‘is alive: it speaks. It has an affective kernel or centre: Ego, bed, bedroom, dwelling, house; or: square, church, graveyard. It embraces the loci of passion, of action and of lived situations…’’ (Lefebvre 1991, p. 42). Experiences that patients, families, employees, administrators, and clinicians have in the hospital and the ICU are a dynamic exchange that encompasses spatial practices and representations. The ICU room is not simply the result of a plan and the place where spatial practice occurs; it is also a lived space, wherein the ventilator manipulated in a spatial way and for a functional purpose also has a symbolic meaning. To clinicians, a corpse covered by a blanket in an ICU room is not simply an object to transport by a designated procedure, but also a symbol of failure or finitude. Curtains are symbols of privacy, whereas sliding glass doors of an ICU room are symbols of surveillance.5 Cleaning an empty ICU room is a spatial practice, 5
An interesting example of a values conflict embedded in the evolution of hospital space and design has to do with the movement from large open patient wards to small private rooms. Verderber and Fine (2000) offer an interesting account of this history. Critics of moving away from large wards and towards separate rooms, most notably Florence Nightingale, saw the open ward as allowing for higher quality nursing care. A debate intensified in the mid-twentieth century. A movement towards semi-private wards occurred first. Strategies of clustering groups of patients emerged, and patient preferences for private rooms gained recognition and persuasive power. Patients prioritized the value of privacy, whereas Nightingale and others prioritized the ease and quality of care.
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but it is also symbolic and anticipatory of the stream of patients who arrive because of the realities of illness. Family meeting rooms are important to the spatial practices of decision making and they are made possible through representations of space conceived in the building, renovating, or labeling of a facility. But, these rooms also have symbolic meaning—they are spaces that signify conflict, resolution, frustration, hope, exchange, or even the role of and need for a clinical ethicist. Spatial practice, representations of space, and spaces of representation are, ultimately, dynamically interrelated and interdependent. Health care design and architecture and their scholarly literature are probably the best illustration of how spatial practice comes to help revise and improve the representations of space that undergird the construction of health care settings. Of course, major architectural decisions have a significant effect on the spatial patterns of patients, families, and employees. However, smaller design decisions, such as with flooring or desk layout, also can transform the lived space of the hospital. Niesen (2004), for example, suggests that as patients are moved by bed, ceiling lights can be very uncomfortable. This experience of movement and construction in the hospital has spurred new models that use side or indirect lighting to ease the light sensation for patients being transported. Similarly, Collignon (2008) notes that as hospitals struggle to care for extremely obese patients, they turn to design experts for improvements in the facility’s capacity to accommodate these patients. Spatial practices and challenges to those practices help to spur revision in the literal models used to construct the spaces of health care. The title of Carpman and Myron’s last book (2001) illustrates the way that architects shape health care spaces: Design that Cares. The construction and design of health care buildings can transform the lived spaces, enabling or disabling certain kinds of goals or interactions. Lived space is an inseparable synthesis of ideas, materiality, and actions. Each moment in the production of space is transformed by other bordering, intersecting, overlapping, and preceding spaces and results in many new spaces. Representations of space are constructed in relation to remembered and projected spatial practices and other lived spaces. In short, spaces necessarily transform and borrow from each other. For example, the space of the ICU imports and subsumes elements of other spaces, such as the spaces of science, anatomy, or economics. Historically, the construction of hospitals has been shaped by economic factors and business strategies. For example, Ahuja (2012) shows that Albert Kahn, who designed Ford Motor Company’s burgeoning automotive plant, used his knowledge of the factory to design the University of Michigan’s hospital. The representation of space from the factory came to shape the models undergirding the hospital. Crucially, the importation of factory space carried not only architectural qualities but also the values of efficiency, quality, and volume as well as a production mentality.6 In the 6
Illustrating this point, Ahuja cites a 1932 speech by Kahn, who said that building a hospital ‘‘requires knowledge of industrial processes for after all the same principles underlying the proper functioning of a manufacturing plant apply to the planning of a hospital building… Every department must be so coordinated as to cause all to operate jointly with maximum efficiency and for the greatest good’’ (pp. 403–404). Ahuja summarizes, ‘‘The University of Michigan’s new hospital provided a striking endorsement of efficiency as an institutional value that, importantly, it was willing to promote publicly. Its design resonated with an industrial model and supported an operational approach that maximized inhospital productivity’’ (p. 426).
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sharing of these spaces, the hospital subsumed an economically focused space that supported and cultivated values of efficiency and quality.7 In short, economic spaces come to shape the conception of the ICU, underlying both its construction and the way that people are taught to move and care for people. Many contemporary ICUs are constructed in a circular model, so as to maximize clinicians’ surveillance of patients and thus their response time when distress occurs. In the lived space of the ICU, the nurses’ station can even symbolize the need to observe as well as the importance of multi-tasking. The ICU space also has an effect on patients and families. Similarly, the ICU space also intersects with the space of the anatomy lab. Epistemologically, the dead body of anatomical dissection is the foundation on which future clinicians learn how to treat patients (Bishop 2011). The dead body becomes a kind of model that instructs spatial practices and symbolism in the anatomy lab. In the lived space of the anatomy lab, medical students develop ways of moving and interacting with the dead body, and they learn that this body teaches them how to treat patients. The space of the anatomy lab, however, then bumps into the ICU space, informing the way that physicians interact with patients (their spatial practice) as well as the symbolism such interactions convey. In short, clinicians carry the space of the anatomy lab into their clinical practices, and the anatomy lab and dissection practices shape the way that clinicians understand and interact with patients. The anatomy lab is just one example of the spaces that contribute to the production of ICU space. The space of the ICU carries all the spaces in which caregivers learned how to be caregivers. Thus, Lefebvre emphasizes that space is social and produced. He writes, ‘‘(Social) space is a (social) product’’ (p. 26). Lefebvre uses parenthesis to make two points: First, all space is produced. Second, space and its production are inherently social. Space carries the imprints of many people, ideas, actions, and habits, and such factors shape the ongoing production of a space and the events, actions, ideas, relationships, and institutions that evolve alongside and within that space. Thus, space ‘‘serves as a tool of thought and of action’’, and it ‘‘is also a means of control, and hence of domination, of power; yet…it escapes in part from those who would make use of it’’ (p. 27). In other words, space always precedes and exceeds people and institutions that try to control it. Lefebvre describes space: (Social) space is not a thing among other things, nor a product among other products: rather, it subsumes things produced, and encompasses their interrelationships in their coexistence and simultaneity—their (relative) order and/or (relative) disorder. It is the outcome of a sequence and set of operations, and thus cannot be reduced to the rank of a simple object. At the same time there is nothing imagined, unreal or ‘ideal’ about it as compared, for example, with science, representations, ideas or dreams. Itself the outcome of past actions, social space is what permits fresh actions to occur, while suggesting others and prohibiting yet others. Among these actions, some serve 7
There are many critiques of the hospital and the procedures of the ICU. One recent article that was published while I wrote this paper is ‘‘Efficient, Compassionate, and Fractured: Contemporary Care in the ICU.’’ I found this paper helpful and insightful. See Bishop et al. (2014).
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production, others consumption (i.e., the enjoyment of fruits of production). Social space implies a great diversity of knowledge (p. 73). (Social) space is complex and dynamic, and it bridges the gap between the real and the abstract, between practice and thought. It is not itself a singular object, but includes objects, their meaning, political and social forces, ideologies, intentions, and relationships. Considering this complexity, it is impossible to ‘‘produce a space with a perfectly clear understanding of cause and effect, motive and implication’’ (p. 37). Spaces exceed all particular intentions active in the production of space, and no person or institution holds or retains true control over any space. Whereas Lefebvre discusses the meaning of space as mapped onto large-scale projects like urban development, I am interested in the ways that his theory of space helps unpack more limited and particular spaces—the spaces adjacent to, around, and in which health care is delivered. And, in the same way that Lefebvre understands all space as socially produced and socially suggestive, I will suggest that all space is also morally produced and morally suggestive.
Space as a Normative Factor Between Being and Doing The question of interest for this paper is how, where, and when space is value-laden and of interest for ethics. All too often, as Jack Glaser points out, we misperceive ethics as dealing with a small and dramatic slice of issues. Glaser writes, We have the impression, as a society, that ethical decisions are few, dramatic, far between and happen with a solemn awareness that ‘this is an ethical issue’. [Hospital ethics committees] run the risk—unwittingly and unwillingly—of reinforcing these distortions of ethical reality. Since no other forum gets the title ‘ethics’ we can be deceived into thinking that ethics happens—only, best, exclusively—here where it is announced in the title. The fact is that most ethics, ethical deliberation, ethical decision-making takes place elsewhere. Most ethics happens anonymously, without being recognized and named as such. Major ethical decisions of individuals & institutions usually go by another name: ‘management decision,’ ‘financial decision,’ ‘long-range plan’. So, while ethics committees do deal with ethical reality, they deal only with a small fraction of a day’s ethical decision-making. Most of it happens elsewhere (Glaser 1989, pp. 275–276). Glaser’s insight about hospital ethics committees applies to ethics in all areas of clinical care. Reflecting on ethics in homecare, outpatient offices, telemedicine, long term care, and other non-acute settings, ethics should not be relegated to quandaries that rouse attention and disagreement. In fact, I push Glaser’s point further: not only does ethics happen anonymously and throughout all aspects of health care affairs, but our values and ethics are present and formative prior to any certain dilemma or situation that occurs. Without being recognized and named as ethics, the spaces in which health care is delivered already contain and cultivate values.
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Drawing from Lefebvre’s description of space and Glaser’s insight about ethics, it becomes clear that ethics is inscribed into space and space inscribes ethics into the people who interact in and as part of that space. Put differently, moral ideas always already present themselves to us through space. Space is particularly powerful in absorbing and inscribing ethics because it does so on multiple levels—in social space, ethics is carried and inscribed in physical, intellectual, and symbolic ways. Without our knowing, we are saturated in the values of the spaces in which we live, and this saturation leads us to think, act, and feel in certain ways. Space leads all of us to take on certain habits, and even to develop certain identities. Lefebvre’s best example of this point is the space of a religious cloister or monastery. Monastic space imports centuries of ideas, intentions, and aims— representations of space. Monasteries are built to normalize spatial practices in relation to living and deceased members, and the rhythms of prayer are reflected in columns, arches, and geographic location. The architecture reflects the development of theological and spiritual ideas that have been in practice for centuries, and living amidst that architecture in the space of the monastery reproduces those ideas, encouraging certain postures, gestures, and practices. The patterns, sounds, walls, and rooms of the monastery instruct when to move and how to position the body. In turn, these practices also shape thoughts, beliefs, and ideas. For example, many monasteries have long corridors that circumvent courtyards. As inhabitants walk these corridors, they have no outward visibility. Instead, their vision is drawn to the interior courtyard, which is often open, light, and luscious. While inhabitants are closed off from society, their movement through the hallways cultivates a sense of looking onto an interior openness. Similarly, the movements and postures of kneeling and prostration in worship cultivate not only reverence, but a sense of smallness and humility given the whole of the monastery and the aesthetic beauty of its church. Even the exterior of the monastery is part of the monastic space. An illustrative example is the Mete´ora, in Greece. The Mete´ora is a group of monasteries, each built on a separate natural rock pillar, with dramatic cliffs on all sides. When built, accessing Mete´ora required long ladders strung together and the use of basket lifts for supplies. Set apart from and towering above the nearby city, the location of the community intended to make entry difficult. The geography of the Mete´ora cultivated persistence, courage, and faith in the process of ascending the walls. This space led monks not only to undertake the precarious journey necessary to enter the monastery, but also helped them develop identities as people set apart from society, located between heaven and the rest of earth and tasked with the challenging spiritual endeavors. Walking the patterns of the monastery, practicing postures of worship, and maintaining a distance from society cultivate experiences, which, over time, lead to habits of thinking and acting and eventually to character traits. The relation between identity and action is circular, and it is always mediated by, rerouted by, inscribed by, or in tension within the monastic space. In health care, as in the monastery, space mediates character and action. The ICU space is not simply a neutral location, but, in fact, promotes certain habits, practices, representations, and ideals. The ICU room, for example, is often a chaotic area wherein monitors hold a prominent place and are often ordered for ease of visibility.
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Clinicians can observe the patient’s vital signs from afar. Accordingly, caregivers are led into habits of focusing on monitors and numbers as the source of the most relevant information, rather than looking first at a patient. Over time, such habits may creep into character, leading towards character traits that neglect attending to patients themselves. These habits also spur the arrangement of the room and the unit in a way that eases the visibility of monitors, which in turn perpetuates this sort of orientation towards the screens and monitors. Space cultivates practices, and practices cultivate identity and character. In turn, the identity and action produced within spaces also then contribute to the ongoing production of spaces. We develop as humans only within space, and the values formative in the production of spaces have profoundly formative effects on what we do and who we are. Glaser worked in the Catholic tradition, and a foundational insight from Catholic moral theology (and the Aristotelianism that shaped it) is illustrative of this point. As Richard Gula (1989, p. 7) notes, ‘‘actions are always expressions of a person’’. The people we are and the actions we perform, however, never occur outside of space. They are formed by and contribute to the spaces in which they occur. Ethics occurs in all three dimensions of space—space as it is conceived, perceived, and lived. Ethically neutral spaces do not exist; a new space always builds on various preceding values, even if changing or shifting the meaning or implications of those values. Therefore, the perceived, conceived, and lived dimensions of spaces always contribute to the production and application of values. As the places of health care delivery expand, new health care spaces are produced and that production will inevitably influence patients and clinicians. Consider the simple example of an outpatient office. The spatial placement of the office in a certain geographical area, for example, leads to trends in the qualities of both patients and employees. The spatial practice of the office includes having patients check-in upon arrival and enter a waiting area. It also includes separating patients and having the physician move between patients, who again wait in separate rooms. This spatial practice reflects a multitude of values and intentions. It presumes the values of privacy and confidentiality. It promotes efficiency and reduces delivery costs by gathering patients around the doctor (instead of the older model of making home-visits), and it embeds expectations that patients will wait to speak with the physician. These spatial practices secrete ideas about how people ought to act. Clinicians become accustomed to patients waiting for them, as they attend to a line of patients. Perhaps this spatial practice might lead some clinicians to develop a symbolic understanding of their work as a kind of production-line. This symbolism may not only shape actions, but also seep into character. Space sits at the cusp of being and doing. Spaces normalize our actions, and such actions come to form and reform our identity. Whereas Lefebvre emphasizes that all space exists and coheres only in its social nature, my emphasis is that the production of social space is always the production of value-laden space that carries and inscribes ethics. No space is silent on values or neutral in relation to our actions and identity. Spaces subtly but immediately convey values and transmit power dynamics and ideologies. Yet, space never fully normalizes thought and action. Thoughts and actions always exceed space and therefore can serve as an impetus for spatial transformation and the production of new spaces. While the ICU may encourage
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certain character traits—both good and bad—clinicians always have the ability to overstep the formative influence of the ICU space. Thinking about ethics in the non-acute context means not only thinking about ethics in places like the physician’s office or the rural health center, but also ethics in the new spaces that emerge in those places. The home and the long-term acute care facility are not just different places than the hospital. Because of the spatial practices in each place, because they are conceived of and planned differently, because they hold radically different symbolic meaning, and because they lead us to think and act in different ways, they are in fact different (although overlapping and colliding) spaces. In what remains of this paper, I will explore how attending to space might contribute to ethical reflection.
Home Space and Virtual Space As I noted previously, space exceeds place because it encompasses more than location and material. It includes ideology, symbolism, practice, thought, relationships, interior design, and patterns of movement and action. Health care delivery occurs in spaces, and the discourses and practices of ethics always constitute and are constituted by such spaces. As we contribute to, act within, and respond to the production of space, character and identity are also inscribed and reformed. Health care spaces differ between specialties, buildings, rooms, organizations, clinicians, payment structures, and patients. They differ between cities, states, and countries. Since every space could be unpacked separately, I have chosen two examples in the production of the (ethical) spaces involved in contemporary health care delivery. The contemporary return to home health care produces a new space, wherein the lived space of the home and the spatial practices of medicine are overlaid upon one another. The lived space of a person’s home, laden with symbolism, carries preferences, aesthetics, and spatial practices. A patient’s bed, for example, may not only differ according to function, but also according to meaning. In the hospital, the bed is symbolic of illness and need. The spatial practices surrounding the hospital bed are, in large part, those of caregivers who treat the patient. The room is organized according to the bed, and the head of the bed is oriented towards the door not only for convenience, but to increase efficiency and monitoring, to facilitate acknowledgment of the patient, and to allow the patient to view the people who enter the room. Clinicians approach the bed with ease, and they often stand at the foot of the bed to speak to the patient. The bed is mobile, and can transport the patient for a scan. In the space of the home, however, the bed entangles different spatial practices and symbolic meanings. The placement of the bed reflects the spatial patterns of the residents of the home and the limits envisioned in the design of the home. The bed might be a symbol of passion, love, affection, or intimacy. It might be a symbol of violence, lust, or aggression. It may be a symbol of loss and loneliness, following the memory of a lover who is no longer present. A clinician delivering care does not remove the symbolic meaning of the lived space of the home, but ventures into it, adds fragments from the space of medicine, and leads to the production of a new
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space. In home health care, the spatial practices of the clinician occur in a place where the patient has long established her own spatial practices and symbolic meaning. Thus, the space of the home has implications for the actions of the clinician. Whereas the clinician may approach the ICU bed with authority and intent, knowing the room well and rearranging it when necessary, the caregiver in the home risks offending the patient if she is too confident and assuming. Whereas a patient may be comfortable disrobing in a hospital room, she may be horrified by the same action done in her own bedroom with the presence of a caregiver. Whereas a patient may appreciate the presence of a clinician at the bedside in the hospital, it may make her uncomfortable in the home. Clinicians indifferent to the realities of the lived space of the home may cultivate habits in which they fail to recognize the particularities of patients and spaces, and thus fail to become humble and respectful caregivers. In the production of homecare spaces, the perceived-conceived-lived space of the patient’s home blend with perceived-conceived-lived spaces of health care. In this production, there is a risk of imposition and even of violation. And yet, the production of a new space is unavoidable with the delivery of health care in the home.8 Second, the growing reliance on telemedicine and virtual sites for caregiver and patient communication also produces new spaces that, like all spaces, will form character and shape action. As Speilberg (1998) reminds us, virtual communication replays old patterns in new ways. Previously, physicians sometimes wrote letters containing medical information. The development of the telephone transformed communication between patients and physicians, making it more direct and instantaneous. The rise of virtual communication has transformed communication yet again, making encounters more immediate and convenient. The space of telemedicine and electronic communication can be financially efficient, reducing cost, increasing revenue, and improving patient satisfaction (Pitt 2015). Telemedicine carries with it the value of minimizing the time and expense of health care affairs. It offers an alternative communication venue for patients who have been shown to feel intimidated by some in-person conversations or topics (Borowitz and Wyatt 1998, p. 1323). Electronic communication with health care professionals also cultivates a sense that the doctor is accessible for a quick question, which a person may not be willing to ask at the expense and time of an ordinary in-person consultation. The opportunity for a patient to email her physician is a symbol of that physician’s availability within the virtual space of health care. She will be present for the patient in her times of need, and this presence may help to sustain the 8
The space of the home and health care delivery also collide in long term care facilities, such as the nursing home. Young (2005, pp. 155–170), for example, reflects on the way that nursing homes have failed to cultivate the spatial elements of home. In many cases, residents cannot develop habits of their own, control who enters their areas, arrange their belongings, or maintain objects that have acquired meaning throughout time. She emphasizes the way that the ordinary aspects of home support and enact personal identity. When people lack the opportunity to develop a space, including the arrangement of objects, the patterns of movement, and the meaning of objects and activities, the dominating space of health care precludes them from thriving in their own lived space. Spaces inevitably collide when the places of home and health care overlap; however, careful ethical reflection can improve the production of a home health care space, whether that occurs in a house, apartment, or communal facility.
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relationship between the patient and physician over time. The continuity of this relationship enabled by a virtual space of health care delivery might then contribute to the physician’s sense of what it means to be a good and attentive clinician. Timely responses and consistent accessibility become part of the way that the physician acts, and over time, part of her identity as a caregiver. In spite of the increased availability of clinicians, however, virtual health care services could create a distance between the patient’s experience and the clinical encounter. Whittaker and Cox (2015, p. 53) write, ‘‘Today’s telehealth disrupts the intimacy customarily associated with the relationship between caregivers and patients’’. As the space of telemedicine allows more clinical encounters to occur exclusively in the virtual realm, it carries the risk of creating a distance between touch and care. It could lead to the assumption that adequately conveying information can be done without being present for a patient’s reaction. For the sake of efficient information sharing, test results that are highly distressing to a person but have no actionable medical indications may be delivered via a secure email system, leaving patients alone when receiving distressing results. In the process, caregivers are not always confronted with the responsive anxiety of patients, which may subtly cause a clinician to lose touch with patients’ experiences. Moreover, in such moments of communication, there may be a subtle suggestion that physicians are not responsible for comforting the patient in an emotional response, but only for explaining results, illustrating options, and sharing information.9 As the locus of health care shifts away from the hospital, spaces are blurred and new spaces are produced. The material, ideological, and interpersonal components of these spaces are suggestive of actions and subtly formative for character. New ethical dilemmas arise in the delivery of health care in non-acute places. Those spaces must also receive attention, so that we think not only about ethical dilemmas but also about the way spaces themselves shape how we act, how we should act, and what kinds of people we are becoming.
Conclusion I think back to the day where I stood in the empty space of the hospital under construction: I realize that at a time when I was more conscious of space than ever before, I overlooked the relation of ethics and space. When I stood in the vacant hospital, I reflected on how the already constructed building before me would soon become the space wherein a medical ethic was at work. What I failed to notice was that ethics—in fact, not one ethic, but a variety of conflicting ethics—had already 9
Notably, some effort has been made to proactively address the way that telemedicine will shape the patient-physician relationship. Mercy Health, for example, has noted that in leveraging new technology, there must be an emphasis on remaining true to the patient-physician relationship (Hale et al. 2015). The production of spaces of non-acute health care delivery is always colliding with other spaces, including ICU spaces. Lefebvre is critical of what he calls abstract space. Abstract space is real space, but it tends towards homogenization. When space is abstract, people tend to downplay or erase distinction, particularity, and difference, leading to a kind of spatial interchangeability and homogeneity that overlooks the non-neutrality of space and fails to account for the interplay between the perceptive and conceptive, the real and the ideal.
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been at work in the idea of constructing the hospital, in the decisions about the hospital’s structure and layout, in the spatial patterns involved in other health care endeavors, and in the placement of the hospital itself. The production of space long preceded and anticipated the patients, incubators, ventilators, and family meeting rooms that so often are involved in the activities and dilemmas that we identify as ethical. Space is not simply a container to be filled with stuff, such that when the stuff arrives, so too does ethics. Ethics is always already inscribed into space, and spaces convey, limit, and expand our values and moral imagination. There is a risk that ethical reflection on non-acute health care settings will fail to account for spatial particularity, uncritically importing the tendencies of moral thinking about hospital care.10 The purpose of this issue is to draw attention to the diversity of places within which health care is delivered. The purpose of this paper is to note that within the places of health care delivery there is also a multiplicity of health care spaces. Lefebvre notes that ideologies always lurk in the production of space. If moral reflection presumes a uniformity of space, we could usurp ethical particularities with ideological overgeneralizations and thus risk cultivating tendencies of imposition or insensitivity. The production of ethical space is always particular to the places of health care delivery, but its production begins long before the patient and caregiver meet. In fact, the spaces of health care have been under development for centuries and will continue long after—indefinitely after—the spaces of health care delivery become functional. Whereas Lefebvre talks about (social) space, I have discussed the way that space shapes our character, thoughts, and behaviors and has implications for how we think we ought to act. Ethics scholarship must attend not only to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by (ethical) space itself.
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