Performable Case Studies in Ethics Education

12 Pages·2017·0.18 MB·English

healthcare
ConceptPaper
Performable Case Studies in Ethics Education
RichardRobeson1andNancyM.P.King2,*
1 DepartmentofCommunication,andBioethicsFaculty,GraduateSchoolofArtsandSciences,
WakeForestUniversity,Winston-Salem,NC27109,USA;[email protected]
2 DepartmentofSocialSciencesandHealthPolicy,WakeForestSchoolofMedicine,CenterforBioethics,
HealthandSocietyandGraduatePrograminBioethics,WakeForestUniversity,Winston-Salem,
NC27109,USA
* Correspondence:[email protected];Tel.:[phone]
AcademicEditors:IanWalshandHelenNoble
Received:2August2017;Accepted:8September2017;Published:12September2017
Abstract: Bioethics education often includes the study of short stories, novels, plays, and films,
because such materials present case examples that can highlight relevant issues and questions
especiallyvividlyforawiderangeofstudents. Inaddition,creativewritingiswidelyusedinthe
educationofhealthprofessionalstudentsandincontinuingeducationsettingsforhealthprofessionals.
There are very few academic or professional disciplines that do not use case studies, but the
casestudyindialogicformhasnotbeenstandardpracticeforthousandsofyears. Dramaticarts
casuistry—thecreationandperformanceofshortcasestudiesdesignedspecificallytoraisebioethics
issues for discussion—represents an application of literature and the medical humanities that is
bothuniqueanduniquelyvaluable. Thisessaydescribesthedevelopmentandhistoryofacourse
that has been successfully taught to medical students and graduate bioethics students, in which
theclassresearches,writes,andperformsacasestudydesignedtoelicitreflectionanddiscussion
aboutatopicandsetofbioethicsissuesofcurrentinteresttobothacademicandgeneralaudiences.
Themodelisalsosuitedtothepresentationanddiscussionofexistingcasestudies,bothliveandvia
on-demandaudio.
Keywords: medicalhumanities;bioethics;casestudies;interdisciplinaryteaching;ethicsteaching;
readers’theater;narrativemedicine
1. IntroductionandBackground
InthePlatonicDialogue“Euthyphro”[1], thetitlecharacter, onhiswaytocourttoprosecute
his own father for impiety, by chance encounters Socrates, who presses Euthyphro to explain his
unwaveringcertaintyofthedefendant’sguilt. Euthyphro’sresponse—namely,thatthere’sonlyone
way to interpret the evidence—causes Socrates to ask a question that is, so to speak, the center of
gravity of the Dialogue: even if there is only one way to read the evidence, a proposition which
is extremely doubtful, by what mental, spiritual, or intellectual apparatus can you be certain that
youknowthatoneundeniablycorrectinterpretation? Thisisafundamentalquestionthatattends
ethical issues, and it has remained so in the more than three thousand years since the Dialogues
werecomposed;evenasourscienceandourscientificrhetorichavebecomeevermoresophisticated.
ThePlatonicDialogue,andespeciallythe“Euthyphro,”isinmanywaystheidealmodelforwhat
wecallthePerformableCaseStudy(PCS);thatis,acasestudyindialogicform: betweenthepoles
ofmoralabsolutismandmoralrelativism,thereexiststheopportunitytointerrogateanethicalissue
frommorethanoneperspective,withoutsuccumbingtowhatjournalistandauthorEricAlterman
calls“on-the-one-handism”[2]. Thispaperdescribesthedevelopmentanduseofperformablecase
studiesinbioethicseducationinNorthCarolina,bothinsideandoutsideacademia.
Healthcare2017,5,57;doi:10.3390/healthcare5030057 www.mdpi.com/journal/healthcare
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In1989–1990,theDepartmentofSocialMedicine,UniversityofNorthCarolina(UNC)-Chapel
HillSchoolofMedicine,introducedaradicallynewpedagogicalstrategyintoitspreclinicalcurriculum
forsecond-year(MSII)medicalstudents. “MedicineandTheater”engagedissuesinbiomedicalethics,
researchethics,thephysician–patientrelationship,andrelatedtopicsthroughthedevelopmentand
presentationofdramaticliterature.
Medicalandotherhealthprofessionaleducationhaslongincorporatedethicsteachinginboththe
classroomandclinicalsettings.Inthe1970sand1980s,educationinthemedicalhumanities—including,
for example, history and literature—began to augment medical ethics education as a means of
increasingstudents’sensitivityandresponsivenesstotheneedsandinterestsofpatients.TheLiterature
andMedicinearenaofthemedicalhumanitiesmakessophisticateduseofliterarygenresdeemed
noteworthybyvirtueoftheauthors’renownortopicalcurrency,includingfiction,creativenonfiction,
pathography,patienthistories,andevencaselaw,statutes,scholarlybioethicsliterature,andinformed
consentdocuments.
Discussion of fiction and poetry, plays, and films addressing bioethics issues has been
standardfareinhealthprofessionaleducationformanyyears. Forexample,NewYorkUniversity
(NYU)’sLiterature,Arts,andMedicinedatabase[3]beganin1993andprovidesextensiveinformation
andvaluableresourcesforuseinteaching. Shortstories,suchasthephysician-poetWilliamCarlos
Williams’“TheUseofForce”[4],andfilmslikeWhoseLifeisitAnyway?[5],Wit[6](bothofwhich
wereoriginallystageplays),GATTACA[7],TheDoctor[8],andmanyothers,havebecomestandard
educationalfareinmanyuniversitiesandmedicalschools,ashavenovelssuchasNeverLetMeGo[9]
aswellasnewworkslikeInternalMedicine[10]. CollectionssuchastheSocialMedicineReader[11]
include short stories, creative nonfiction essays, and poetry chosen to stimulate the discussion
of bioethics issues and questions in the classroom. Collections of adapted [12] and original [13]
shortreaders’theaterpieceshavebeenpublished. Moreover,studentstodayoftenwritetheirown
short stories or poetry for a literary magazine or bioethics blog, and many such literary outlets
are based in medical, graduate, and even law schools. Indeed, writing narratives about “critical
incidents”—difficultorotherwisememorableclinicalexperiences—hasbecomequitecommon,notonly
duringclinicaleducation,butasanexerciseforpracticingphysicians,nurses,andotherhealthcare
providers[14].
“MedicineandTheater”wasunique,however,inrequiringclassesofmedicalstudentstocreate
anoriginaldramaticwork(case)tobothreflectandprovokethecarefulargumentrequiredinbioethics
analysisandpedagogy. In2010,webroughttheMedicineandTheatermodeltotheGraduateProgram
inBioethicsatWakeForestUniversity(WFU),and,inamodifiedform,toundergraduatestudentsinthe
DepartmentofCommunication. Nowcalled“PerformableCaseStudies”,thiscoursemodelengages
studentsfromabroadrangeofdisciplinesinresearching,writing,presenting,anddiscussingshort
casestudiesindialogicformthataredesignedtoprovokethoughtfulconsiderationanddiscussion.
Whenstudentscreatedialogiccasestudies,theylearntoemploythesegenrestoposequestionsto
audiencesandeachotherthroughcreationandperformance. Engagingatonceinanalysis,synthesis,
performance,andcriticalreflectionopensuparangeofperspectivesonbioethicsissuesthatnoother
typeofcoursecanachievealone. Dramaticartscasuistry,aswehavetermedtheprocessasawhole,
thusmoveswellbeyondanyothermodeofethicsinquiryasameansofengagingstudentsinsustained
andcreativemoralreflection.
To understand drama as a means of promoting public reflection and discourse on important
societal questions is to return to a theatrical model that places the dramatic dialogue at or
near the beginning of literary casuistry, which we know today through the plays of the Greeks,
includingAeschylus,Aristophanes,Euripides,andSophocles,aswellasphilosophicworks,suchas
the Dialogues of Plato. What is forgotten in contemporary education is that these plays were
intended to be accessible and to stimulate public engagement. It should not be surprising that a
departmentcalled“SocialMedicine”,devotedtoamultidisciplinaryapproachtoeducatingmedical
students to understand the social and cultural context of health care by means of the medical
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humanitiesandsocialsciences,wouldrecognizethevalueofacoursesuchasMedicineandTheater.
Nonetheless,thedisciplinarysegregationandsequestrationofexpertknowledgethathascharacterized
academiainrecentcenturies(i.e.,increasingspecialization,or“siloing”)hasrenderedmanyuniversities
(and students) skeptical about the possibility and value of such a course. Only recently has the
resurgence of interest in creativity studies, interdisciplinary teaching and scholarship, and the
importanceofnarrativebeguntostandagainstthislonghistory[15]. Evenmultidisciplinaryfields,
suchasbioethicsandcommunication,mayattimesneedremindersthattheartsandhumanitiesplay
anessentialroleinteachingandlearningabouthealth,illness,andhealthcare[16].
2. HistoryofPerformableCaseStudies
WhatisnowPerformableCaseStudiesbeganlifein1988asanextracurricularenrichmentactivity
formedicalstudentsatUNC-ChapelHill,fundedbytheNorthCarolinaHumanitiesCouncil(NCHC)
asacommunityoutreachactivity,designedtostimulateengagementanddiscussionbetweenhealth
care professionals and students and the general public about a broad range of ethical and social
issuesarisingfromthephysician–patientrelationshipandtheroleofmedicineinsociety. Thefirst
“stagedreading”wasanadaptationofWilliamCarlosWilliams’shortstory“MindandBody”from
thecollectionTheDoctorStories[17]. Thiscollectionofshortfictionaboutmedicine,byanacclaimed
poetwhowasalsoaphysician,isfrequentlyusedinmedicalstudentteaching. Thestoriesaresparein
styleandhighlyevocative. Inaddition,theyareprimarilydialogue,andthereforeeasytoadapt.
Thepresentationmodelusedinthefirstprojecthaspersisted: ashortperformancefollowedby
adiscussionbetweenthereadersandtheaudience,moderatedbyascholarinmedicalhumanities
orbioethics. Thestagedreadingformat,inwhichtheperformersreadratherthanmemorizetheirlines
andminimaluseismadeofstagemovementandprops,wasexplainedina“curtainspeech”,aswas
theintegralroleofthepost-performancediscussion. “MindandBody”wasperformedfirstattheUNC
Student Union and subsequently in a popular Chapel Hill coffee shop with a performance area.
It was also adapted for radio, produced and directed by Robeson, with a cast of professionals,
andbroadcastin1990on”Soundings”,anationallysyndicatedradioprogramemanatingfromthe
NationalHumanitiesCenterinResearchTrianglePark,NorthCarolina(NC),followedbyadiscussion
withphysician–ethicistDr. EricCassellaboutthephysician–patientrelationship[18].
“MindandBody”—achallengingandambiguousstoryinwhichaphysiciantries,withuncertain
success,tounderstandandmeettheneedsofanewpatient—spurredvigorousaudiencediscussion.
It was abundantly clear that this presentation model worked for audiences. Williams’ publisher,
after seeing the text of the adaptation and the videotape of the Student Union performance
and discussion, was, moreover, delighted to provide a broad permission to adapt the stories in
TheDoctorStoriesforeducationaluses.
“Mind and Body” also made clear how well the performable case studies model worked for
the healthprofessionalsand students serving asreaders, in three ways. First, because the staging
was minimal and no memorization was required, rehearsals could easily incorporate discussion.
Thereadersthusundertooktheirownexplorationofthecharactersandthestory,examineddifferent
points of view about the issues addressed, and developed questions they wished to discuss
withaudiences.Second,thereaders,likeactorseverywhere,hadtheopportunitytoexaminecharacters
from the inside, and often gained significant insights from portraying someone like the patient in
thestory. Andthird,discussingthesamereadingwithdifferentaudiences—especiallyafterhaving
discusseditamongthemselvesinrehearsal—alwaysresultedinvaluablenewmutuallearning.
The success of the first performable case study led to a collaboration between NCHC and
UNC-Chapel Hill (both the medical school and the graduate school), East Carolina University
(the medical school), and Duke University (the medical school), in a successful application to the
NationalEndowmentfortheHumanitiesfora3-yearExemplaryAward(1990–1992)toprovidesupport
for traveling readers’ theater companies from the participating universities. A repertoire of case
studies,adaptedfromthe20thcenturyliterarycanon,wasdevelopedbyartisticdirectorsfromeach
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university,andacoordinatorhelpedtoadvertise,plan,schedule,andfacilitateperformance/discussion
sessions on evenings and weekends around the state. The venues included public libraries; area
colleges,communitycolleges,anduniversities;medicalsocietymeetings;andretirementcommunities.
NCHC, upon receiving notice of the success of the application, also learned that this project was
consideredthemostinnovativeofanyduringthatfundingcycle,hencethedesignation“Exemplary”.
After several years of pursuing performable case studies as a means of addressing medical
ethics issues solely in an extracurricular capacity, particularly with students, faculty, and in some
cases staff of the medical school as readers, the time was ripe to incorporate the model into the
curriculumformedicalstudents. And,oncetheoutreachmodelbecameapartofthecurriculumas
“MedicineandTheater”,itwassoonapparentthatthemodel’spedagogicalvaluecouldbeenhanced
byworkingfromoriginalsourcesratherthancreatingadaptationsfromthecanon. Adaptationsmust
beginfrompredeterminednarratives,whichalsotypicallyofferalimitedandpredeterminedrange
ofinterpretations. Theworkofidentifyingdifferinglinesofethicalinquirywhencreatinganoriginal
case study, particularly when even the facts of the case may be in dispute, is by definition more
intellectuallyandcreativelydemanding.
Since 1988, Richard Robeson, working alone, with medical or graduate students, or in
collaborationwithNancyKingandothercolleagues,hascreatedmorethantwodozenperformable
case studies, almost all of which have been presented as staged readings, with discussion, in a
variety of classroom and community settings. This body of work includes materials as diverse as
adaptationsofexistingscripts(e.g.,GeorgeBernardShaw’sTheDoctors’Dilemma[19];HenrikIbsen’s
AnEnemyofthePeople[20]),adaptationsofshortstories(e.g.,numerousworksfromWilliamCarlos
Williams’ collection The Doctor Stories, as well as stories by Wendell Berry and Perri Klass); and
original works based on court cases and news stories raising significant bioethics issues, such as
theactivitiesofDr. JackKevorkian; organtransplantation; medicalandresearchdecision-making;
andenvironmentaljustice. Theseworkshavebeendevelopedandusedintheclassroom,asmedical
grandrounds,inpublichumanitiesprojects,aseducationalmaterialsinpublichealthresearch,asradio
readings,andinconferencesettings.
The“MedicineandTheater”courseconfrontedawiderangeoftopics,fromtakingafreshlookat
someofbioethics’earliestissues(e.g.,theTuskegeesyphilisstudy)tosomethatremainemblematicof
thediscipline’sconcerns(e.g.,surrogatedecision-making;faith-basedtreatmentrefusal)toothersthat
itisonlybeginningtoconsider(e.g.,ethicalissuesinsportsmedicine). Itssubsequentiterationsince
2010as“PerformableCaseStudies”intheGraduatePrograminBioethicsatWakeForestUniversityhas
addressedasimilarlyvariedsetofissuesthroughcasestudiesinvolving,forexample,militaryresearch,
genepatentingandgenetictesting,andthenonconsensualdrugtestingofpregnantwomen.
3. ProcessandProducts
The PCS model is in some respects a laboratory, in others a workshop. Although the topics
andsubject/issueareaschangewitheachsemester’scourseoffering,theprocessbywhichcasesare
developedhasremainedconsistentsincetheearly1990s. Casedevelopmentisaccomplishedduringa
single12–14-weeksemesterinthreephasesofroughlyequallength,describedinthecoursesyllabus
asfollows:
PhaseOne: DiscussionandAnalysis. Thisisapproximatelyfiveclasssessions. Wewilldiscuss
andanalyzethecontextualandbackgroundmaterial,andtheperspectivesrepresentedbystakeholders,
scholars,andreporters. Duringthisphase,wewillidentifylinesofbioethicalinquiry,whichinturn
willinform(1)students’targetedadditionalresearch;and(2)thecreationofprincipals(characters)in
thecasetobeconstructed.
Phase Two: Targeted Research. This is approximately three class sessions. Each student will
doresearchspecificallyintendedtoinformandadvancetheworkofconstructingthecase,present
theirresearchandanalysistotherestoftheclass, andfieldquestionsregardingtheresearchitself
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and its applicability to the bioethics framework. Additional presentation time may be necessary,
dependinguponthefinalclasssize.
PhaseThree: CaseStudyConstruction(Writing). ItisintendedthatthisPhasetakeplaceentirely
duringclasssessions,andwillcovertheremainderofthesemester. Atthisjuncture,charactershave
been revealed via the framing of bioethics issues. The engagement of characters with each other
andtheircircumstances(e.g.,patients-subjects,healthcareproviders/researchers,familymembers,
investors,reporters,etc.)willbethesubstanceofthecasestudy.Theclasswilldivideintowritingteams,
accordingtowhichcharactersinteractinagivensetting,inagivenclassperiod. Theseinteractions
willbefacilitatedbythefacultyinstructor. EachsessionofPhaseThreewillbeginwithareviewofthe
previoussession’swriting,andwillendwithareviewofthecurrentsession’swriting[21].
The writing process, which begins approximately two-thirds of the way into the semester,
is facilitated via the intra- and inter-group dynamics of as many as four writing teams, whose
membershipschangeaccordingtothescene,dialog,andcharacterinteractionsofagivenwritingsession.
Circulatingbetweenwritingteamsduringclasssessions,thefacultyinstructorisabletoworkwith
eachteam,providingon-the-spotmonitoring,prompting,andeditorialsuggestions,bothtoensure
narrative continuity and to maintain a proper balance between character, narrative, and issues.
Scripts are crafted to highlight questions and tensions, in order to promote lively and nuanced
post-performance discussion. The classprepares listsof audience discussionquestions and drafts
framingmaterials(eventintroduction, andguidelinesfordiscussionfacilitators)toensurethatall
participantsunderstandthenecessarycomplementarityofperformanceanddiscussion. Everyaspect
ofeveryreadingthuspointstowarddiscussion. Moreover,discussionisdesignedinthecourseand
managed in each presentation not only to build on the case presented, but also to incorporate the
experiencesandperceptionsofdiverseaudiences,whoseinsightshavethecapacitytogreatlyenrich
theinterpretationanddiscussionoftheissues.
Oneofthepremieradvantagesofthisapproachtobioethics/medicalhumanitiespedagogyis
itsusefulnessinengagingstudentsfromabroadrangeofeducationalanddisciplinarybackgrounds.
AnMSIIclass,forexample,willnecessarilyrepresentstrongbackgroundsinthelifesciences,evenif
somemighthavehadahumanitiesorsocialsciencedisciplineastheirmajorundergraduatecourse
ofstudy. TheGraduatePrograminBioethicsatWakeForestUniversity,however,notonlyshowsa
similar breadth of disciplinary backgrounds, but also has a student population that includes fully
credentialledphysicians,nurses,physicianassistants,andpracticingattorneys,aswellascurrentand
future medical, law, and divinity students, and others with undergraduate backgrounds in STEM
disciplinesaswellasthehumanitiesandsocialsciences.Althoughthereareoftensignificantdifferences
indisciplinarybackgroundandcareerexperiencewithinagivenclass,orfromoneclasstoanother,
thelearningobjectivesforstudentsareconsistent,regardlessoftopicorissuearea. ThePCSsyllabus
statestheseobjectivesas: (1)Carefulandthoroughresearch. (2)In-depthanalysisanddiscussion,
withaparticulareye/eartowardimpliedmeaningsorinterpretations;andacontinualalertnessto
thepossibilityoftheexistenceofapriorquestion,andawillingnesstoraiseit—ortohaveitraisedto
you—ifsuchbethecase. (3)Clearlyexpressedandwell-renderedargumentsinwrittenandoralform.
(4) The ability to craft a complex but succinct narrative with no deliberate intent to bias how the
narrativewillbeinterpreted. (5)Theabilitytoworkcollaboratively.
Itisexpectedneitherthateveryoneshouldagreeonallpointsatasemester’sbeginning,northat
everyone should agree at the semester’s end. Furthermore, it is not required that the case itself
representthehomogenizationoftheperspectivesandanalysesthatemergeasthesemesterunfolds.
Rather,itisunderstoodthatdivergencesofopinionandinterpretationwillenrichnotonlytheprocess
butalsotheendresult.
This pedagogical method works equally well with all student cohorts, not only because of
thescholarlyimperativesthatattendbioethicsinquiryregardlessofmethod,butalsobecausethis
particularmethod,asmentionedpreviously,allows(evendemands)arecognitionthatcomplexethical
issuesarenotbinary,butmultifaceted.
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ProfessorRobesonandhisstudentshaveresearchedandwritten13originalcasestudiestodate.
Each of those created by bioethics graduate students has been presented, with discussion, as a
campus-wideeventsponsoredbytheWakeForestUniversityCenterforBioethics,Health,andSociety.
Inaddition,in2011,“TheBurialSociety”,aPCSabouttheTuskegeeSyphilisStudythatwascreated
in the Medicine and Theater course in 1994, was presented [22] as part of a scholarly visit by
JamesJones,tocommemoratethe30thanniversaryofthepublicationofhisclassichistoricalanalysis
BadBlood[23]. StudentsintheDepartmentofCommunicationhavealsoread,studied,andanalyzed
severalperformablecasestudieswritteninpreviousyears,andthenmadeaudiorecordingsunder
ProfessorRobeson’sdirection.
One example of the breadth and versatility of this creative process is provided by “Whose
Right?—A Neurofamilial Tangle”. The case that formed the basis of the work of the class was a
familycontroversythatarosewhenthewifeofaretiredphysicianwithdementiaallegedlyconsulted
Dr. JackKevorkianonherhusband’sbehalf. Thecouple’sadultchildrendividedoverwhatwasbest
fortheirfather,andanumberoflegalproceedingsensued.
The class was provided by Richard Robeson with newspaper clippings detailing the court
proceedingsandinterviewswithfamilymembers. NancyKingcompiledresourcesaboutend-of-life
decisions,capacitytoconsent,surrogatedecision-making,andthedistinctionsbetweenwithholding
treatment, physician-assisted suicide, and euthanasia. Under Professor Robeson’s guidance,
the students wrote a performable case study that, by exploring family dynamics, raised important
questionsabouthowtointerpretpatients’wishes;therelationshipbetweenautonomyandbestinterests,
anddifferentinterpretationsofeach;thecomplexentanglementbetweenemotionandreasoninfamily
decision-making;andthelimitsofthelawinend-of-lifeissues.
Thecasestudy,whileshort,isvividandsurprisinglynuanced. Thisisattributableinnosmall
measuretotheaforementionedtri-phasicprocess. Bythetimethatthecaseconstructionisbegun,
thestudents,havingspenttwo-thirdsofasemesteridentifyinganddiscussingthesalientethicalissues,
have also identified (or imagined) stakeholders who represent those issues. From this point,
theessentialwritingtaskistoengagetheissueorcircumstanceasthestakeholder. Itisoftenthecase
thatastudent’sindividualunderstandingoftheissuesisquiteatoddswiththoseofthestakeholder
thestudenthaselectedtorepresent. Giventhatmostofthestudentswhohavetakenthiscourseover
theyearsexpecttoworkinclinicalethicsorbiomedicalcaregivingsettings,theabilitytoidentifywith
a challenging or unfamiliar ethical position has both immediate and enduring value. The writing
teamsvaryfromoneclasssessiontoanother,dependinguponwhichelementsofthenarrativearcare
beingdeveloped.
It is also critically important that the lines of dialogue be spoken aloud as they are written.
Having the dialogue develop as spoken language helps to ensure that it is conversational,
andembodyingthecharactercansometimesresultinexchangesthatarecompletelyunplanned.
“WhoseRight?—ANeurofamilialTangle”,thoughbaseduponawell-documentedcourtcase
duringtheheightofDr. JackKervorkian’sinfamy[24],focuseslessuponthelitigationthanuponthe
dynamicswithinafamily—inwhichthepatientandthreeofhisfouradultchildrenarephysicians,
and the fourth is married to a physician—who have drastically differing views on the scope and
meaningofspousalloyalty,andtheprecisenatureofthedutytoone’sparents. AsEvelyn,themother,
conflictedoveradecades-oldpromisemadetohusbandPhil,confidesinKaren,hernon-physician
daughter[25]:
EVELYN: Karen, I’m just not sure what to do anymore. Taking care of your father has
becomesodifficult.I’mreallytornbetweenwhatIknowhewantsandwishingthingscould
bethewaytheywerebefore. ButIknowtheycan’t. Hewon’tgetbetter... onlyworse....
KAREN:Maybeweshouldthinkaboutgettinganursetohelpyoulookafterhim.
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EVELYN:It’snotthatImindtakingcareofhim... thatwasn’tactuallywhatIwasthinking
of.... I’ve been wondering about this doctor in Michigan ... this doctor who ....... helps
peoplewhoareterminallyill. Dr. Rubenstein. Haveyouheardofhim?
KAREN:Mom,youcan’tbeserious. Inthefirstplace,Dad’snotterminallyill
...
EVELYN:Alongtimeago,Imadeapromisetoyourfather. IpromisedhimIwouldn’tlet
hislifeendlikeyourgrandmother’sdid. Ithinkthetimehascometomakeadecision.
KAREN:You’vealreadycontactedDr. Rubenstein,haven’tyou?
EVELYN:Notyet.
Thedialoguehereemergedfromthepositionsthatthestudentsdeterminedwereheldbythese
twostakeholders,basedontheirresearch,discussion,andwritingwork. Intheclassroom,whereother
writing teams are working at the same time, similar exchanges are taking place. Thus, the rest of
theclassisunawarethattheselinesarebeingdeveloped,untiltheendoftheperiod,whenallofthe
session’sworkissharedbybeingreadaloud.
Theperceivedethicalimperativesamongfamilymembersaresufficientlydistinctthatthemoral
highground,asitwere,isdifficulttodiscern. Andthis,ofcourse,isthereasonthatacasestudyin
thisformhassuchpower,bothasnarrative,andasstimulustomultiplelinesofbioethicalinquiry.
Forexample,Hank,indenouncinghismotherforevenentertainingtheideaofphysician-assisted
deathforhisfather,irrespectiveofanypacttheymadedecadesago,impliesanexistinganimustoward
hismother,whichalsoraisesaquestion: towhatifanyextentarehisreasonsrelevanttowhatheseeks
toaccomplish,namely,preservinghisfather’slife[26]?
EVELYN:HANK:Mom,I’mreallyconcernedaboutDad. Ijustgotdonetalkingtohim
andheseemssuicidal!
EVELYN:Whatdoyoumean?
HANK:Youwouldn’tbelievethethingshesays: “Idon’twanttogoonlikethis”;“Mylife
isn’tworthliving.”
EVELYN:Hank,thesethingsaren’tnew. Whyareyousurprised?
HANK:I’mnotsurprisedatallathim! I’msurprisedatyou. Howcanyoujustsitthere
likeIjustsaid“Thesoup’sready”? IjusttoldyouyourhusbandwantstokillhimselfandI
thinkyoushouldbedoingmore.
EVELYN:I’mdoingthebestIcan. Youaren’there. Youdon’tseehim. Hesaidbeforehe
gotsickthathe’dratherdiethanlivethelifehe’slivingnow.
HANK:Andyousupporthistakinghisownlife?
EVELYN:Well,inhiscondition,it’sunlikelyhecould.
HANK:Youwouldn’tactuallyconsiderhelpinghim,wouldyou?
EVELYN:[Looksdown.]
HANK:Well,wouldyou?
EVELYN:Youdon’tunderstand–EverydayItakecareofhim. It’ssohard....
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HANK:Hard? Hardforyou? Whatabouthim? Whataboutus? Ifit’ssohard,whydon’t
youjustcallupDr. RubensteinandhavehimputDadoutofyourmisery?
EVELYN:[Fidgets.]
HANK:Ican’tbelieveyou’reareactuallyconsideringit.
EVELYN:Iknowwhatyourfatherwouldhavewanted.
HANK:Tokillhimself?!! OrshouldIsay,tohaveyoukillhim? MyGod,Mom,howcan
youbesoheartless? Myfather,yourhusband,issick;andone-day-too-manygoingtothe
grocerystoreforhimandyoudecidetokillhim! LifeisGod’sgreatestgift,Mom;andno
ideal,howevergloriousorhoweverselfish,isworththetakingofitANDIFYOUTHINK
there’sachanceinhellyou’dgetawaywithit,you’vegotANOTHERTHINKCOMING!
In this, as in all Performable Case Studies, the ending does not resolve the conflicts or
ethicalconundrums. A case study in whatever form can be considered to most properly be the
beginningofadiscussion,ratherthanadeclarationofacertainpointofview. Thedialogicformmakes
multidimensionalitymuchmorereadilyavailable,andsubsequentlycarrieswithititsownethical
imperativetofullyexploitthiscapability.
InadditiontoitsperformancebytheMedicineandTheaterstudentsin1997,“WhoseRight?”
wasalsoperformedbybioethicsscholarsandteachersfromacrossthenationatthe1999Bioethics
SummerRetreat,in2002bymembersoftheCharlotte,NC-basedBioethicsResourceGroup,andin
2008byWakeForestUniversitylawstudents. Discussionsineachinstancefocusednotonlyonthe
issuesthemselves,butalsoonthepedagogicalusesoftheperformablecasestudyandtherelationships
between the issues depicted in the case study and the experiences and perceptions of the readers
andaudiences.
Responses and reactions from audiences during discussion have been varied, and continue
to be so, according to the backgrounds and disciplinary predispositions of both academic and
outreachaudiences. ThethesisquestionsthatinformthedevelopmentofeachPCSandthequestions
that prompt discussion following presentations are not intended to elicit particular responses.
Forexample,“UnquantifiableRisk”,aPCSthatinquiresintoxenotransplantationasapossiblesource
oforgansforhumantransplantation,alsoraisesthequestion: whatdowemeanwhenwesaythat
there is an “organ shortage”? Likewise, a readily available point of departure in discussing the
TuskegeeSyphilisStudyistheundeniablepresenceofaninstitutionallyracistagenda,nottomention
ahighlysuspect(atbest)researchquestion. Butquiteadifferentveinofanalysisisavailableifthe
thesisquestion,andthusthedevelopmentofthecasestudyandplanningforaudiencediscussion,
concernswhattheTuskegeesubjectshaveincommonwithclinicalresearchsubjectsingeneral.
Inaddition,manystudentsinthecoursehavechosentoexamineadditionalaspectsofthecase
studytheyhelpedtobuildthroughcreativewritingintheirfinalpapers,thuscontinuingtoexplore
case issues such as the complexity and ambiguity offamily decision-making about the end-of-life
issuesaddressedin“WhoseRight?”.
The feasibility and effectiveness of the performable case study model can be extended to
additional settings, both in and outside the classroom, by essentially working backwards: first
engagingparticipantsinaconcertreading,thendiscussingtheissuesaddressedbythecasestudy,
howthetheatricalformatinfluencesidentificationanddiscussionoftheissues,andtherelationship
betweenresearchintoscientific,policy,andethicalissuesandtheircreativeuseinwritingcasestudies.
(See Table 1 for a complete list of performable case studies, including their creation and uses.)
For example, the case study “Unquantifiable Risk” addresses issues raised by the prospect of
xenotransplantation,including: thebalancingofrisksofharmandpotentialbenefits;theuncertainties
offirst-in-humanxenotransplantation;theblurringoflinesbetweenresearchandtreatment;andthe
processesofrecruitmentandconsentwhenpatientsarealsoresearchsubjects. Thecasestudywas
Healthcare2017,5,57 9of12
researched,developed,andpresentedbyProfessorRobesonandMSIIstudentsatUNC-ChapelHill
in1997–1998,andstudiedandrecordedbystudentsintheDepartmentofCommunicationatWFU
in2012. Theissuesposedhavenotchangedintheinterveningyears.
Table1.PerformableCaseStudies1988–2016.Subject/IssueAreasandSettings.
MedicineAndTheater—MSII,UNCChapelHillSchoolofMedicine
Adaptations*
Year Title(author) Theme(s)
1989–90 TheDoctor’sDilemma(G.B.Shaw) Resourceallocation
1990–91 EnemyofthePeople(HenrikIbsen) Publichealth/biohazard
1991–92 TheDoctorandtheDevils(DylanThomas) Researchethics
Original**
TheGeorgetownCollegeCase–faith-based
1992–93 TheDanceofPower
treatmentrefusal
USPublicHealthServiceSyphilisStudyat
1993–94 TheBurialSociety
TuskegeeUniversity
Dr.ChristianBarnaard/thefirstsuccessful
1994–95 AleaJactaEst(TheDieisCast)+
humanhearttransplant
1995–96 DutytoRescue? McFallvs.Shimp–bonemarrowdonorrefusal
1996–97 WhoseRight?ANeurofamilialTangle Alzheimer’sdisease/physician-assisteddeath
Xenotransplantation–imaginingthefirst
1997–98 UnquantifiableRisk
permanentanimal-to-humanorgantransplant
There-introductionoftheteratogenfornew
1998–99 ThalidomideonTrial
medicaluses
Faith-basedtreatmentrefusalcomplicatedby
1999–00 ConsciousDecision
criminalchargesofproximatecause
Confluenceofbioethics,high-profile
2000–01 DrawnandQuartered
intercollegiateathleticsandgenderequity
NCHumanitiesCouncil/NationalEndowmentfortheHumanitiesExemplaryAwardProject
Adaptations***
Trust,mistrustandempathyinthe
1988 MindandBody(WilliamCarlosWilliams)
physician-patientrelationship
1991 AFaceofStone(WilliamCarlosWilliams) Overcomingphysicianprejudice
1992 OldDocRivers(WilliamCarlosWilliams) Ruralmedicine,physiciansubstanceabuse
Deathanddyinginaclose-knitrural
1993 ThatDistantLand(WendellBerry)
community
1994 Invasions(PerriKlassandSarahKlemmer) Patients,physiciansandprivacyinthehospital
NationalInstituteofEnvironmentalHealthSciences/UNCSchoolofPublicHealth—ExchangeProject
Original****
Conservation,EnvironmentalJustice,Eminent
2002 Lost:Sanctuary
Domain
Thesameissue(disasterrelief/publichealth)fromthreedifferentideological,disciplinaryandstakeholderperspectives
2003 ACertainMeasure Displacedfloodvictim
2004–05 FallTowardGrace Low-senioritycountyhealthdept.staffer
2005 AMatterofEngagement Publichealthschoolacademicians
PerformableCaseStudies—M.A.inBioethics,WakeForestUniversity
MyriadGenetics,Inc.,genepatenting,women’s
2011 CameraObscura
health
Fergusonv.CityofCharleston,involuntarydrug
2012 ADefiningError
screening/arrestatprenatalclinics
UnitedStatesv.Stanley,USGovt.hallucinogen
2015 Incident-ToService
experiments
Third-partlitigationfinancingindustry;
2016 PerhapsALevelField
unethicalsurgicalinnovation
CommunicationEthics/Bioethics:AnInterface—DepartmentofCommunications/M.A.inBioethics,WakeForestUniversity
UnquantifiableRisk(ForElectronicand Xenotransplantation(cf.above),biotechnology,
2012
DigitalMedia) transhumanism
CameraObscura(ForElectronicandDigital MyriadGenetics,Inc.,genepatenting,women’s
2013
Media) health
*AdaptationsbyRichardRobesonwithKarynTraut,students,andNancyKing.**Performablecasestudiesby
RichardRobesonwithstudents. ***AdaptationsbyRichardRobeson. ****PerformablecasestudiesbyRichard
Robeson.+GrandRounds,Dept.ofFamilyMedicine,UNCHospitals.
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4. Conclusions
ThePCSmodelgrewoutofrecognitionofthevalueofcase-basedteachinginthemultidisciplinary
fieldofbioethics,combinedwithacommitmenttotheintersectionofartandscholarship,andshapedby
theimperativeoffosteringeffectivecommunicationbetweenhealthcareprofessionalsandthepublic.
Bioethicspedagogy,increasinglypopularbothinandbeyondhealth-relatededucation,isitselfeclectic.
Atitsbest,itmakesuseofavarietyofdisciplinaryperspectives,thoughthereisageneraltendencyto
prioritizephilosophyandWesternclassicalphilosophicalreasoning. Whatismostimportantabout
bioethicseducation—aboutanyethicseducation,forthatmatter—isitsinculcationofhabitsofcritical
moralreflection,especiallytheabilityandwillingnesstoquestionone’sownviewpointandtofoster
productivereflectionanddiscussioninothers. Yetmucheducationinvolvingliteratureandnarrative
fallsshortofpromotingcriticalreflection. Instead,theauthor’sperspectiveisthoughtfullychallenged
only in rare circumstances; as a result, the narrator—whether doctor or patient—risks becoming
unassailable,andthenarrativerisksbecomingpropaganda: thatis,aworkmeanttodisallownuance
orthepossibilityofalternateinterpretations.
In signal contrast, the process of creating performable case studies from contemporary cases
treatstheworkasastimulusforcriticalreflection. Studentwritersdevelopcharacterswhosevoices
are complex and whose viewpoints are plausible and will stand up to many-faceted discussion.
Student readers gain insights from representing views different from their own, and grow to
understand and appreciate others’ experiences, in at least a small way, through this process.
Students also learn from discussion with audiences, both academic and non-academic. How the
audience experiences the story—what they bring to it and what they take from it—is an essential
component of the performance/discussion combination. Indeed, the PCS model is based on
understanding the engagement with audiences as ethics education outreach for them, and as one
componentofethicseducationforstudentsinthecourse.
Catharsis, as Aristotle teaches us in the “Poetics”, is one of the principal currencies of
dramatic art: an emotional release, “purgation” (sometimes translated as “purification” [27])
through“pityandfear”[28]. Totheextentthatdistinctionsbetweenartandreligionexistedinthe
GreeceofAristotle,heacknowledgescatharsisasanartisticconceit. Acasestudy,bycontrast,isa
stimulustocriticalreflectionandanalysis.Andwhileacasestudyindialogicformdoesnotdiscourage
orsubvertanemotionalconnectiontothefactsorpersonsunderconsideration,itsprimaryfunctionis
not—norcanitbe—toinduceacatharticexperience. Thisisacrucialdistinctionbetweenadialogic
casestudyandexpressly“theatrical”models,includingreader’stheater.
DistinguishingthePCSmodelfromtraditionalformsoftheaterisimportantforotherreasons
aswell. First,ithelpstodemocratizethePCSprocessandproducts,bymakingitclearthatstudents
and faculty both without and with theatrical experience and expertise can readily work together
in producing, presenting, and discussing case studies. Second, it helps to reassure students who
mayatfirstnotconsiderthemselvessufficientlycreativeorextrovertedtoparticipateinthecourse.
Hesitantstudentsinvariablycometoappreciatetheprocessandtotakeprideintheproduct.
The depth, scope, and flexibility of active engagement with ethics represented by this course
provides a pedagogical model that can be adapted effectively for any ethics education curriculum;
and that, in addition, incorporates community outreach that is both engaging and educational.
Bioethics, or the ethics of health care and science, is a naturally attractive subject for dramatic arts
casuistry because its case examples are vivid, complex, and compelling. However, many other
manifestationsofethicsinsocietyarejustasapropos,makingthiseducationalmodelextremelyversatile.
Anydiscipline,whetheracademic,professional,oroutreach-based,thatcustomarilyutilizesthecase
studyasapedagogical,developmental,ororganizationaltool,canbenefitfromthismodel. Professor
Robesonhasemployeditinpublichealthandenvironmentaljusticecontexts,andaspartofaleadership
training conference. Similarly important ethical issues arise—and are the focus of educational
innovation—inbusinessandentrepreneurship,inlawandeconomics,andinlaboratoryscience.