Life and Death in Intensive Care. Joan Cassell. Philadelphia: Temple University Press. 2005. 233 pp.
Reviewed By: Liz Nickrenz, University of Chicago Department of Comparative Human Development
Psychological anthropologists have increasingly attended to teaching hospitals as rich sites for examining processes of socialization into competing worldviews. Within high-stakes, affectively-charged interactions, medical practitioners learn and invent strategies to balance differing models of mind and body, conflicting epistemological value systems, and often nearly incompatible role demands (Mattingly 1998; Luhrmann 2000). Joan Cassell contributes to this literature with her ethnographic study of the competing moral and financial economies guiding medical practice around end-of-life decisions in a surgical intensive care unit (SICU) in a prestigious Midwestern academic medical center, where surgeons, nurses and intensivists (doctors specializing in intensive care) struggle to collaborate on the care of patients on a contested boundary between life and death.
Cassell examines the conflicts that arise when these three groups of medical professionals negotiate with each other and with grieving families about the decision to shift from “heroic measures,” the extensive and often brutal techniques used to prolong the life of a patient in critical condition, to “comfort care” and the concomitant acknowledgement of death’s imminence. To explore why such conflict so often interferes with compassionate care in these negotiations, Cassell employs Lorraine Daston’s (1993) concept of “moral economies,” defined as “webs of affect-saturated values” within which medical practitioners weigh the costs and benefits of actions having to do with the terms on which life ought to be conducted. Cassell describes in detail three particular moral economies, the systemic and institutional conditions that perpetuate and support them within particular professions, and the moments when they come into conflict: the caring ethic of nurses, the “covenantal” ethic of surgeons in which life must be saved at any cost, and the ethic of intensivists, focused on allocation of scarce resources and attention to quality of life.
Wound throughout the book is Cassell’s critique of a fourth economy, the “ethic of billable hours” (p. 151), which devalues processes which cannot be measured and counted in favor of revenue-generating “value units” of clinical productivity, reimbursable by insurance companies and Medicare. Cassell argues that while moral economies can co-exist in conflict with one another, the ethic of billable hours is not a web of affect-saturated values at all but in fact the absence of such values, and as such is radically incompatible with the moral economies of ethical medical practitioners, threatening to nullify the sense of mission and personal commitment that these moral values provide. Complementing her work in the Midwestern medical center are brief excursions to a community hospital in Texas and ten weeks in an ICU in Auckland, New Zealand, providing a glimpse at alternative models within which life-or-death questions are addressed within radically different constraints.
Cassell has a keen eye for the details that shape the lives of her doctor subjects: speech conventions governing weekly medical staff case reviews, the kind of relationships doctors perceive themselves as having with patients under differing degrees of sedation, the miscommunications and discontinuities that arise when responsibility for a patient’s care is frequently shifted. Many pieces of the puzzle will be familiar to readers interested in health care: managed care reimbursement policies put hospitals under financial squeezes, doctors in contemporary practice struggle to forge coherent and continuous relationships with their patients, the emphasis on quantifiable units over dynamic processes changes the experience and practice of medicine in sometimes undesirable ways. What Cassell contributes is a new conceptualization of how these pieces all fit together uneasily to form an uneasy site for dealing with death and loss.
From the perspective of psychological anthropology, there are moments in the book when the contributions individuals make to their own socialization are given too little weight in relation to the impact of structural forces upon them, as shared pressures bring homogeneous groups to identical endpoints. The moments when Cassell attends to the interaction of individual characteristics with social and organizational forces over time are far stronger; her case study of the professional development of two doctors-in-training, one brilliant but heartless, the other warm and communicative but not academically gifted, elegantly demonstrates the interactional processes through which “values filter down from above” (p. 152) creating a system where prestige is rewarded over compassion.
Cassell’s critique of evidence-based medicine would be more effective if she had taken advantage of her opportunity to explore what it is that makes “evidence in this narrow sense” (p. 39) compelling to doctors as well as to uncertain young trainees. Although Cassell argues in favor of clinical intuition, defined as knowing things without necessarily knowing how one knows them (p. 198), over the illusion of statistical certainty, some of the book’s own stories hint at the dark side of intuition unbridled by strategies for systematically checking one’s own knowledge sources against other observations and perspectives. In one particularly disturbing case, racism and cultural stereotyping inform the decision of the New Zealand medical staff to remove the ventilator of a quadriplegic Indian man in an arranged marriage, arguing that his quality of life was not worth preserving even before his condition deteriorated; in another, a surgeon emotionally blackmails a family into agreeing to prolonged, painful and expensive treatment for a patient with a minimal chance of survival on the grounds that she has “seen patients like this survive”(p. 196). In both cases, a critical look at how one knows what one knows would lead to more compassionate patient care. There is a moral valence to the search for certainty and for greater predictive powers, one that would have been well-suited to Cassell’s astute analysis of such affect-saturated webs of knowledge and practice.
Overall, Life and Death in Intensive Care is an effective, important examination of the way in which institutions teach consistent but unspoken value systems through their policies, priorities and practices, as well as a powerful call for reform. Cassell effectively integrates perspectives from anthropology and medical sociology to ensure that her final point is driven home: individual hearts and institutions must work together to relieve the confusion, indignity and horror of death in the SICU, just as they now work together, however unintentionally, to perpetuate it.
Daston, Lorraine
1995 The Moral Economy of Science. Osiris 10: 3-26.
Luhrmann, T.M.
2000 Of Two Minds: The Growing Disorder in American Psychiatry. New
York: Alfred A. Knopf.
Mattingly, Cheryl
1998 Healing Dramas and Clinical Plots: The Narrative Structure of
Experience. Cambridge: Cambridge University Press.
