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Enacting Deliberation:
A workshop-based method of applied medical ethics
Susan S. Stocker
Moral Agency Theater (MAT) workshops is based on Augusto Boal’s
theater method, which operationalizes the collaborative deliberation that
Aristotle says is ingredient to moral action. By staging their moral
dilemmas and then finding better alternatives, healthcare practitioners can
effectively deliberate about what to do and how.
Moral dilemmas in the clinic include: how to negotiate the patient’s interests
sometimes against those of the patient’s family members or friends, how and
what to say to a colleague whose error caused an adverse event, or how to give
a patient or the parents of a child bad news. It is often not obvious in the
moment exactly how to do what seems best.
Martha Nussbaum characterizes Aristotle’s “virtuous agent” as being someone
“on whom nothing is lost” (Nussbaum 1992, 84). What kind of learning can take
us from clueless to a virtuoso level of attentive responsiveness? Freshly
deliberating about the particulars of each situation is what develops within us a
repertoire of improved responsiveness. MAT workshops provide opportunities
for practitioners to embody their deliberation about the situations that most
concern them.
Practicing Moral Agency: what to do and how
MAT workshops begin with various warm-up theater games. More than
icebreakers, they thematize human desire and power differentials. Then, MAT
participants divide into small groups, in which each person describes an incident
of regret or distress in the clinic. Their stories will be drawn upon to create what
Boal calls “Forum Theater” scenarios where each group stages a moral dilemma
centered around the protagonist whose dilemma it is. Boal transposes those
watching and listening into “spect-actors” because anyone can stop the action at
any point, replacing the protagonist to try an alternative. The so-called “joker”
(workshop facilitator; Boal prefers the term “difficultator”) urges those in the
scenario stay in character while those watching and listening evaluate each
intervention. Precisely because participants pose their own recognizable
quandaries, they are invested in finding successful alternatives; hence, they are
cheered when an intervention works well.
Then, as they collaborate about what actions would be better than those of the
ineffective protagonist, they help each other make their choices deliberatively,
with care. It is all about acting well, so we go on asking the practical questions of
how, when, where, and to what extent we should act. For Aristotle, if one acts in
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the right way, at the right time, in the right amount, and makes a habit of this, one
becomes a virtuoso human being, a person “on whom nothing is lost”.
The premise of inviting interventions is that, too often, we have talked ourselves
out of the agency we do have. Good, but failed, intentions do not make a
difference in the world. Our MAT workshops demonstrate how interior
appraisals are made visible by being actually tried out—to see if they might work
better. For the joker says, if you are satisfied with what the protagonist does,
then do nothing; but if you think we could do better, try something else.
In Forum Theater, we are invited to intervene because, as Boal puts it,
possibilities:
…are presented to be destroyed and replaced by others…new
alternatives which are not substitutes for real action, but
rehearsals, pre-actions which precede…the actual action…then
to be practiced in real life (Boal, 1995, 72).
Very often, when something works in an intervention, successive interventions
will try and build upon it, adding strategies to extend this promising direction.
Working with experienced practitioners confirms how unobvious moral agency is,
for scenarios regularly draw forth multiple interventions before even clearly better
alternatives are found. When a superb solution happens, often the antagonist is
at a loss for words.
Even more important than coming to a solution, says Boal, is to achieve a good
debate. “Even if one does reach a solution, it may be good for the person who
has proposed it, or good within the confines of the debate, but not necessarily
useful or applicable for all the participant in the forum.” (Boal, 259).
Supporting Moral Resources
Katarina Swahnberg
and Barbro Wijma, at Linköping University’s Gender and
Medicine program, invited me to implement this theater method to prevent abuse
in health care (AHC) by supporting the moral resources of healthcare
practitioners. Prompted by their research findings about gynecological patients
across the Nordic countries documenting that “the overall prevalence of any
lifetime experience of AHC was 13-28%” (Swahnberg, Schei, et.al., 2007, 354),
I gave MAT workshops to doctors, midwives, and nurses in a Swedish obstetrics
ward. In my subsequent report, “Staging the Moral Imagination in the Healthcare
Setting”, I enumerate a variety of the practitioners’’ “moral resources”. In addition
to moral agency practice, here are two more:
1. Moral Regret
2. Moral Distress
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We do well to support--and take care not to diminish--the moral resources of our
practitioners. Rather than being negative, moral regret and moral distress can
motivate us, prompting our reflection and learning. Making good use of these
two resources, participants practice their moral agency, Boal says, in the “second
world” of theater for the “first world” of living.
1) Moral Regret
When I regret having done something, this is a moral resource. Those who do
not regret what they have done cannot learn from their mistakes. To avoid regret
– and because acting well is often not obvious – we deliberate about what to do
and how.
· Deliberation is necessary because every situation is different
· Deliberation turns into choice
· Our choices, over time, form our character
2) Moral Distress
Moral distress can also teach us. Mary C. Corley defines moral distressas "the
painful psychological disequilibrium that results from recognizing the ethically
appropriate action, yet not taking it, because of such obstacles as the following:
lack of time, supervisory reluctance, an inhibiting medical power structure,
institution policy, or legal considerations" (Corley, et. al., 2001, 250-251).
Being constrained by such “obstacles” is distressing.
In staged scenarios, where our values are on the line, MAT workshops replicate
the immediacy of the need to embody a good response. Such moral agency
practice helps us improve our ability to be responsive, thereby making
constructive this use of this distress, this regret.
Outcomes Research
Already a practicing OBGYN, Anke Zbikowski (another project member), wrote
her dissertation, Counteracting Abuse in Health Care from a Staff
Perspective: Ethical Aspects and Practical Implications, concluding that moral
learning occurs as a result of "Forum Theater" (Boal's term), w
hich she calls Forum Play (PF). She writes,
In study III...an increase in the staff’s ability to act in situations
with a moral dilemma was confirmed, even one year after the
intervention. The findings of study IV suggest that FP has the
potential to develop a response ability, enabling staff to become
active in AHC situations. The power to intervene when
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witnessing AHC was emphasized (Zbikowski, 2014, abstract).
She concludes, moreover, that in order for the staff to appreciate AHC, they must
understand it from the patient’s point of view. But to see this, they also have to
address “structural aspects such as power imbalances between professionals”
(Zbikowski. 2014, abstract). Boalian theater always thematizes power
differentials and the respective desires of each person in the scenario that bring
them into conflict. For other evaluations of Boal’s theater work, see:
http://www.theatreoftheoppressed.org/en/index.php?nodeID=45.
Conclusion
“Forum Theater” in MAT workshops combine reflection and action, supporting the
moral resources of practitioners and developing and their responsive
sensibilities. Practicing matters because our choices accumulate into making us
into a person with a certain kind of character--enhancing or degrading it by the
choices we make and fail to make.
Bibliography
Boal, A & Jackson, , A. (translator), Games for Actors and Non-Actors Alike, New
York: Routledge, 2002.
Corley, M.C., et al., Development and evaluation of a moral distress scale.
Journal of Advanced Nursing, 33, 250256.2001, 250-251.
Nussbaum, M., Love's Knowledge: Essays on Philosophy and Literature, Oxford:
Oxford University Press, 1992.
Stocker, S., “Staging the Moral Imagination in the Health Care Setting”,
Linköping: Linköping University Press, 2014, revised edition.
m.
Swahnberg, K., Schei B., Hilden, M., Halmesmäki, E., Sidenius, K.,
Steingrimsdottir, T., Wijma, B.. “Patients’ experiences of abuse in health care: a
Nordic study on prevalence and associated factors in
gynecological patients.” Acta Obstetrics and Gynecology Scandinavia 86.3
(2007): 349- 56.
Tronto, J., Caring Democracy. Markets, equality and justice. New York: New
York/London: Routledge, 2013.
Zbikowski, A., "Counteracting Abuse in Health Care form a Staff Perspective:
Ethical Aspects and Practical Implications", Linköping: Linköping University
Press, 2014.
