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Time Is Short, Social Relations Are Complex: Bioethics as Typology Industry

Perhaps the central focus of American bioethics has been to push against medical paternalism on the grounds that it impedes the autonomy of patients— that is, their ability to make choices of their own volition. This preoccupation with autonomy has been criticized from both within and outside the field based on its atomistic view of the patient and corresponding lack of attention to how the patient is enmeshed in intimate social relations and broader cultural, political, and economic processes. Bioethics has responded to these critiques by trying to expand its moral scope, but it has maintained its concern for how patient autonomy might be violated. Paternalistic clinicians are now not the only parties who can be deemed guilty of infringing on the patient’s right to follow their preferences. Bioethicists commonly worry the patient must be protected from their family and even from themselves. This issue’s target articles walk the narrowing tightrope of a still intensely autonomy-focused bioethics: They promote a moral imperative to provide care according to patient and family preferences while debating how clinicians should determine whether the preferences patients and families express are authentic. Moore and colleagues examine “ambivalent” situations—when patients do not articulate definitive preferences, or their stated preferences change over time and/or in consultation with family and clinicians (Moore et al. 2022). The authors reason that by identifying the mental state underlying a patient’s ambivalence, clinicians can efficiently decode what the patient truly wants. Caruso Brown’s attention is directed toward ascertaining and giving voice to the authentic preferences of pediatric patients’ family members (Caruso Brown 2022). She argues that when family members are embedded in hierarchical kinship arrangements, clinical personnel may have difficulty differentiating their agreement with one another from deference to one another. To make discerning their authentic preferences easier, she keys in on certain familial, sociocultural, and demographic characteristics as indicators of the potential for marginalization of important decision makers. In addition to their concern with parsing the authenticity of patient and family preferences, the two target articles share a second key characteristic. They both lay out typologies meant to aid clinicians in inferring the authenticity of patient and family preferences amid social complexity and a time-constrained clinical environment. These typologies are clinically expedient. They are designed to facilitate the “efficient biomedical consumption” (Holmes and Ponte 2011) of complex situations to arrive at decisions in a timely fashion so that clinical workflow can be maintained— what Kondrat, in his astute commentary in this issue, calls “clinical impatience” (Kondrat 2022). We want to reflect more here on this drive to provide typologies for practitioners, both because it is common in bioethical work on medical decision making and because it has important ramifications for how the topic is approached. Typologies, of course, consist of types. They encourage us to typify things in certain ways as we move through the world. What is typification, exactly? Let us imagine a hiker walking through the woods. He encounters a tree with damaged bark alongside the trail. He takes little note of it, treating it as a singular tree that happens to be the worse for wear, and walks past (Kockelman 2005). A second hiker approaches and encounters the same tree. She surmises that the way the bark has been peeled from the tree is consistent with damage done by bears when they feed on sapwood. In