Rigorous attention has been paid to moral distress among healthcare professionals, largely in high-income settings. More obscure is the presence and impact of moral distress in contexts of chronic poverty and structural violence. Intercultural ethics research and dialogue can help reveal how the long-term presence of morally distressing conditions might influence the moral experience and agency of healthcare providers. This article discusses mixed-methods research at one nongovernmental social support agency and clinic in Rio de Janeiro, Brazil. Chronic levels of moral (...) distress and perceptions of moral harm among clinicians in this setting were both violent, following Nancy Scheper-Hughes’ use of that term, and a source of exceptional and innovative care. Rather than glossing over the moral variables of work in such desperate extremes, ethnography in these settings reveals novel skills and strategies for managing moral distress. (shrink)

This paper presents an analysis of the applicability of a principalist approach for a global, or cross-cultural, bioethics. We focus especially on the principle of individual autonomy, a core value in ethical discourse. We echo some long-standing criticisms of other anthropologists, sociologists, and many medical ethicists that the individualistic approach to autonomy is a Euro-American value and cannot be ethically applied in all settings. As a remedy, we suggest an adaptation of Kleinman's Explanatory Model approach to questions of decisionmaking. We (...) argue that the analysis and resolution of ethical dilemmas might also benefit from forms of pedagogy that integrate anthropological and other social science perspectives, and the incorporation of ethnographic techniques in ethical practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Cultural Context of Post-traumatic Stress DisorderCarolyn Smith-Morris (bio)Keywordspost-traumatic stress disorder (PTSD), culture, medical anthropology, fight-or-flight responseIn his Clinical Anecdote, Dr. Christopher Bailey gamely imagines the evolutionary underpinnings of his patient's distressing lack of war wounds. As part of a careful and engaged discussion of care for his suffering patient, Dr. Bailey suggests that our evolved fight-or-flight response to the alarms of the African savannah may be at work (...) in Colin's distress. The fight-or-flight response is something of great interest to anthropologists, who rely on Darwin's theory of evolution to explain much in human experience. According to Dr. Bailey's application of the theory, Colin's visceral response to threat is protective in the presence of danger, but destructive (particularly to his mental health) in the absence of such challenges. So Dr. Bailey considers whether we may have an evolved “need” for threat, and that Colin's trauma is in part related to the lack of such threat in his wartime experience.According to Darwin's ideas, evolved traits may be adaptive but may also simply be random appearances that have not yet produced cause for evolutionary eradication. The fight-or-flight response, or any of the hypothalamic–pituitary–adrenal axis events initiated under either acute or chronic stress, is therefore occurring in Colin's reactions to everyday frustrations, to wartime exposures, and even during the stressful nontrauma of feeling “wimpy.” Dr. Bailey's idea about an evolved need for threat is tautological. That need is not biological, but cultural.Although post-traumatic stress disorder is medically real, it is an event that develops in a particular place and time. Likewise, gender roles that demand scar battles and trophies of a certain form are culturally determined. Culture is central to this anecdote: a culture-specific occurrence of post-traumatic stress disorder and culturally driven gender roles for men, especially warriors. Stress is indeed present in Colin's life: our postindustrial culture's separation from everyday death and violence make episodes like war and combat all the more shocking or traumatic; the lack of social recognition for his service also seems to be one of Colin's stressors. Both the shock of warfare and the trauma of his social invisibility are as vivid to his evolutionarily informed body as is the presence of a crouching lioness in the room. So it is the host of cultural expectations, and his inability to mobilize social and cognitive resources to respond to them, that is wounding Colin. Talk therapy should draw out these cultural details [End Page 235] and, as Dr. Bailey has already begun to do, emplot Colin into a more heroic (his)story of his service to our nation.Related ArticlesFeature Article: Clinical Anecdotes: A Painful Lack of WoundsCommentary: The Nature of Proof in PsychiatryCommentary: Truth and Healing a Veteran's DepressionCommentary: Inappropriate RegretCommentary: The Cultural Context of Post-traumatic Stress DisorderCommentary: Explication or Explanation?Commentary: The Importance of What Psychiatrists Care AboutCommentary: Mourning or MelancholiaResponse: A Painful Lack of ConnectionCarolyn Smith-Morris Carolyn Smith-Morris is an Associate Professor in the Department of Anthropology at Southern Methodist University in Dallas, Texas. Her work focuses on chronic disease and the health impacts of culture change and acculturative stress in North America. She is engaged in several research programs among migrating Mexican workers, among poor African-Americans in Dallas, and for the Gila (pronounced Hee-la) River Indian Community of Southern Arizona, a tribe that suffers from the highest recorded rates of type 2 diabetes in the world. She also holds a research fellowship with the Foundation for Community Empowerment, serves on the Board of the Society for Medical Anthropology, and is a fellow in the Society for Applied Anthropology. She published Diabetes Among the Pima in 2006 and has several articles detailing her applied research on diabetes, reproduction, health care ethics, and end-of-life care. She can be contacted via e-mail at: [email protected], C. 2009. A painful lack of wounds. Philosophy, Psychiatry, & Psychology 16, no. 3:223–224. [End Page... (shrink)