SHE Pod Season 3 Episode 5: Claire Hooker on the Legacy of Miles Little

12:07AM May 27, 2022

Speakers:

Kathryn MacKay

Claire Hooker

Keywords:

miles

symposium

people

paper

corruption

virtue

qualitative research

ethics

commentaries

bioethics

medicine

scholarship

claire

inquiry

patient

centre

virtuous

legacy

themes

doctors

Hello, and welcome to the SHE Research Podcast. I'm your host Kathryn McKay. And today I'm joined by Claire Hooker to discuss 'A Symposium from the Journal of Bioethical Inquiry: On the Legacy of Miles Little. Hi, Claire.

Hi, Kate.

Thanks for joining me.

Oh, thank you for having me. You are a co editor on this fantastic special Symposium of the Journal of bioethical inquiry.

Yes, I should notice... I should mention that the symposium, the legacy of Miles Little is guest edited by Claire, Ian Kerridge ,Wendy Lipworth, and me. And this is the most recent volume, an issue of the journal, people can find a link in this episode's notes. And today Claire and I are going to be discussing the symposium and the kind of reasons behind it and what it accomplishes. So, Claire, I guess, is the first sort of question for you. I think it might make sense to ask first of all, what the motivations were for putting together this symposium?

Yes, indeed, it does. So this symposium was published to honour the work and beyond published work, the lifetime contributions of Emeritus, Professor Miles Little. Miles was a an incredibly important foundational figure in starting bioethics in Australia, and also was the founder of the Centre for Values Ethics and Law in Medicine, which eventually became Sydney Health Ethics, where we both work. Over that period of time, I think there are a couple of key achievements that the symposium is there to, to recognise. And one of them is all of the things that are not visible in print, to the extraordinary amount of support in a very nurturing way in an intellectually nourishing way. That Miles provided to a couple of generations of scholars who have gone on to be the drivers of so much interesting inquiry and research in very diverse areas of bioethics and also diverse areas of healthcare practice. And especially at the centre of of via... through values, ethics and law in medicine, once Miles had stepped down, as its director, he remained for a really long time, very much present virtually every day in his office. And the office was there with its door wide open. And scholars had the extraordinary opportunity of anytime they had an idea they wanted to explore or a difficult part in a paper that they needed to tease apart or an area of interest that they just wanted to think their way around at an initial inquiry level. They didn't have to wait. They could go right in and find an interlocutor of the most extensive, rich philosophical and literary knowledge who always had something to say that was relevant and who provided that important space for thinking one's way through the complexities of an issue in a... with an air of leisure with no sense of pressure and with a sense of that being an incredibly valuable activity for its own sake. And that piece of nurture, as I say, will never be able to be recognised in publications or into particular outcomes, but was the very substance of a kind of flourishing of bioethics in Australia. And of course, the other thing is that Miles was a very prolific and elegant writer himself, and produced a very large number of papers over decades and decades, both as a medical practitioner, a surgeon of note, and as a philosopher, a poet, a humanities scholar and a bio ethicist and it's great to step back and cast one's eye over the arc of the entire earth of the scholarship and see what kinds of thoughts and ideas it provokes us to recognise and understand the legacy and continuing impact of as we move forward. Is that your own impression of it?

Absolutely. Absolutely. That is Yeah, and I'm glad that you mentioned that Miles was a poet as well as a philosopher and a surgeon. An interesting combination of skills and interests and he had such a, and has, such a unique and interesting view on the world and on human interactions, and interpersonal relationships. And it's fascinating to me.

I agree. And to my mind, these are hallmarks of a lot of the domains of practice and these latter days inquiry that exist, where bioethics and the medical humanities intersect and meet, which is, I think, driven by doctors very passionate interest in understanding and coming to terms with the complexity of patient experience. And that ring those two sides together. So for me, you can't separate out the surgeon from the philosopher from the poet, they are intrinsic to each other, and they provide a depth to any area that fell more within one or other of those categories.

Yeah. So how did you go about choosing the papers out of Miles's extensive set of work for this symposium?

It would have been an impossible task. And I in particular, I'm terrible at spending too much time agonising over which out of a rich multitude one should limit oneself to, so we asked Miles. We asked miles, which five favourite papers over his entire career. And it was telling and lovely that the selection represented papers from 1974, right up to 2018.

So the papers that present the kind of... the key papers of Miles's that we've represented in the journal, and I'm going to name them all here. 'Vascular Amputees: A Study in Disappointment'. 'Liminality: A Major Category of the Experience of Cancer Illness', 'Discourse, Communities, and the Discourse of Experience', 'Pragmatic Pluralism: Mutual Tolerance of Contested Understandings between Orthodox and Alternative Practitioners in Autologous Stem Cell Transplantation', and 'An Archaeology of Corruption in Medicine'. And these are really different topics varied, you know, a whole range of different sorts of issues. Is there anything that ties them together, do you think?

Yes, I do. And there are two, perhaps three, very, very important characteristic themes in Miles's scholarship that tie them together. And perhaps you can add your own thoughts on this Kate. But the first of them is the fact that once Miles had discovered qualitative research as a means of accessing patient experience and beginning to actually explore and understand and have some systematic engagement with the range of patient's own responses, he... that drove so much of his scholarship and this is something that Chris Jordan's comments on in his contribution to this symposium. So that 1974 paper, 'Vascular Amputees: A Study in Disappointment', was one of the number of papers that Miles published in the 70s that were quite humbly responding to critiques of medicine as causes of distress rather than cure, or as leaving people in very difficult circumstances. And that Miles was under the impression that it was the first piece of qualitative research published in The Lancet. And while that's not quite true, it was certainly extremely early and at a time before that, methodology was recognised. So, from there, Miles went on to lead and participate in a huge number of qualitative research projects that examined all kinds of aspects of patient experience, particularly in relation to cancer patients. Hence, the paper later on that you mentioned, in relation to autologous stem cell transplants, which would be in that series and one of the enduring legacies of Myles' work is his recognition of survivorship as a social phenomenon, and of the challenges and distresses that are involved in survivorship. His publication, 'Surviving Survivorship' was you know, an extremely seminal moment I think in not only in in cancer studies, but in what we can actually learn through qualitative methodologies that take patient experiences really seriously or and or that invite patients in as our collaborators in research. So qualitative research was one theme. Another is Miles's keen, philosophical and acutely conceptual interest in and deep passionate aesthetic love of language. And his sense that I... which I share, be interesting to hear your own comments on this, that it is impossible actually to address matters of ethics without also considering matters of language. And for Miles the ethical and values oriented issues that completely coloured and constructed issues in medical practice and understanding patient experience came through the media of language. And that language was structured by as he referred to, in that paper with Chris Jordan's discourse communities, by people who developed and then shared common languages that enabled understanding and exploration of particular areas, but also then tended to generate their own outsiders or their own, their own or perhaps more importantly, their own insiders, their own capacities to be part of a tribe or part of a culture that shared these common understandings. Would you think there were other themes that cut across all of this?

Well, I think that I would, I would just add to the second one that you noted there, about Miles's deep love for language. And, and for communication and for story, I think, because one of the one of the themes that I see connecting these papers together, is the idea of narrative, and the disruption to narrative that can happen through illness, and even through cure, you know, so quotation marks around "cure". Because I think that this is a similar, you know, this story links the Vascular Amputees paper with the Cancer Illness paper, and with Discourse, Communities paper, and I also see links to the Archaeology of Corruption and Medicine, partly because I see that paper as being largely about virtue and about vice, and about the narrative that's built around medicine as a practice, and where we find it breaking down. So I think that Miles has had a really a scholarly and a practitioners focus on dialogue, and creating conversation and how to have good conversation, and how to pay attention to story and how story is disrupted or changed by conversations that we have as sort of practitioners and patients or as scholars with one another. And that seems to draw a line through a whole lot of his different work. And I find it really interesting how it shows up in different places. So you mentioned earlier that he started the Centre for Values, Ethics, and the Law and Medicine and dialogue and conversation was a really core part of the beginning of that centre, in fact, so not just in his scholarly work, but also as a colleague, he made a central place for that kind of conversation with people, as you said, informally, just kind of coming into his office, but also with some formal structures that are there in the in the centre as well, that survivednow in Sydney Health Ethics. So I see that as being really central to all of this as well.

Yes, I too think of it as dialogical inquiry. And and you mentioned that you saw the Archaeology of Corruption paper as being essentially about virtue. And of course, virtue ethics and the virtues of a doctor were was something that Miles was deeply interested in, he was interested in those questions of can one educate doctors to be more virtuous? What would that look like? And another major contribution, I think of his work was the development of a notion of so-called values based medicine. And whilst thinking through that his articulation of the concept of phronesis so practical wisdom as been a hallmark of a virtuous practitioner, as a scholar of such areas. So what what did you say in your own article that responded to Miles' is paper and what do you make of those themes in his work?

Well, I found reading his paper on corruption in medicine, really enlightening, because up until reading this paper for a response in this symposium, I hadn't done very much research in the corruption literature. And it turns out that the corruption literature is quite connected to literature on virtue, but from the point of view of vice. And I really hadn't done very much research around vice, or corruption as such. So that was really fascinating to me, it gave me a window into this project that I was undertaking on virtue and a literature that I hadn't considered before. And in this paper, Miles and his co authors are specifically interested in thinking about corruption and how it can be prevented. And they think that corruption, they argue that corruption is a necessary result, let's say, of certain kinds of social entities like it's just a psychological fact of humans that because our capacity to build institutions is necessarily limited, we are flawed, we build flawed constructions of all kinds, by nature. There will be cracks in them that can be exploited by people who are psychologically inclined to exploit these things. And that's what they think kind of in a nutshell, creates corruption and the opportunities for corruption.

I note that we are saying this on the eve of a federal election, that really, perhaps, exemplifies everything you've just said.

Yes. And by the time this comes out, the election will have happened, we'll have seen the results. But my response to this is that I sort of take a different view of human nature. First of all, I think that I see no reason to assume that humans will, will always do vicious acts when the when the opportunity is presented, I think that by and large, humans are actually inclined to cooperate. So if we've got rules set up in such a way that it is especially enticing to cooperate, you know, we've set up an institution in a way that will reward that kind of cooperation, you really reduce the, the chances of someone, even with that kind of psychology, that kind of very self interested psychology, who might come along and exploit a crack in a way that would lead to corruption, you can entice them to cooperate in certain ways. And so I think that this connects to my interest in sort of structuring virtue, how do we, how do we actually structure our institutions such that it's more likely that people would be virtuous rather than vicious. So that's what I focused on, in my commentary, very brief kind of overview of how we might actually be able to resist corruption, if we set the rules of the game in such a way that cooperation and virtue is more likely to lead people to succeed in their various individual projects.

This really makes me think about Robert Merton's, well known original sociological formulation of science, which he suggested was just such an institution. And that rewarded, people who behaved according to his five norms, which are, they're not norms about cooperation as such, but they certainly reward people who are virtuous, if virtue in that context is defined by coming close to... to enacting those norms, and tried, I think, to set up a means by which it becomes less enticing to behave according to the counter norms that are also available for people the exact opposite of those things. And I often feel that Merton's work, you know, having been surpassed and discarded. Surpassed in the sort of 1970s and 1980s, was discarded too fast in terms of thinking about whether the degree to which science exemplifies a system where the rules that... that structures virtue, as he puts it did relatively well. And that that is central to some of its really rather extraordinary good function, all things considered. But that's the kind of little remark and conversation that Miles would have liked.

(laughs)

A little by way, where we were led somewhere unexpected to both of us in that. Were there elements of this symposium that similarly led you some somewhere unexpected? We've talked so far about how the symposium is there to represent Miles' earth, his work, his legacy, but actually one of the things that I find fantastic about the symposium and just as evocative of Miles's spirit is that all of the really impressive commentary pieces, don't just comment on you know, Miles's contribution and what this idea was in the past, they take whatever that idea is and apply it in a completely new context, which is exactly the sort of scholarship that Miles wanted to foment.

Yeah. I agree. I think that the commentaries that the people who we invited to, to, to reflect on Miles's work, really, really took it in the spirit that Miles would have loved, which was incredibly constructive and critical. And building something forward. And even the papers from the 1970s felt fresh. You know, it didn't feel like I was reading a dated piece of work, I felt like I was reading something that has contemporary traction, and pull. And the commentaries on these really demonstrated that I think that even the ideas from 'A Study of Disappointment or Liminality', are, in some ways, still finding their feet, they're still so important. And they're still so powerful, and able to be taken in different directions as the authors, the various authors actually demonstrated. So, I mean, I felt like the commentaries on Miles's work reestablished how important Miles's work was.

Yeah, so I was just thinking that one of my favourites in there, so the two responses to the paper on Pragmatic Pluralism, Mutual Tolerance of Contested Understandings between Orthodox and Alternative Practitioners in Autologous Stem Cell Transplantation. So, you know, this paper opened up the difficult issues around what you do with complementary and alternative medical practitioners who can, who, who, you know, whose offerings are often just incredibly threatening to a doctor who's already trying so hard to provide a defensible therapeutic pathway amidst the... amidst uncertainty. So I really relate to that at that level. But, you know, what happened with that paper was to have this, you know, sort of fantastically, no holds barred response from Paul Komesaroff who's such a elegant commentator anyway, on the rich qualities of the ethics of interactions in clinical spaces, you know, who had that whole concept of micro ethics as being, you know, the core of clinical ethics practice it's all about what happens in those little moments that occur between people, and who, and who just actually, you know, dealt deals with that anxiety by facing it by naming it and confronting it and saying, actually, it's really good if we disagree, it's gonna make us anxious.

(laughs).

But it's about having multiple understandings is and and knowledges that are not in fact bedded down that remain contested, is actually a source of both, as it were good ethics in social interaction, and good epistemology in the clinic itself, and that they should be allowed to be tolerated. So that that was a great response. And then for you know, Miles's only very recently completed PhD student, Dr. Sean Gallagher, to take up material that was in that original paper to look at how emotion gets constructed in or out of qualitative research as a kind of ethical challenge was, you know, just again, fantastically in the traditions of inquiry that Miles had established.

Yeah, agreed. I think we're kind of coming to our time, Claire. So I wanted to ask you a final question, which is, what do you hope that the legacy of the symposium on the legacy of Miles Little will be?

Oh, okay, so first of all, I as you know, I cannot separate contemporary scholarship from history.

(laughs).

I helped I hope it helps people understand contemporary scholarship in bioethics, because they will suddenly see where it has come from. And I think the symposium, the symposium did not set out to do that. But people's commentaries often constructed that and I personally found it super useful to see how important issues of contemporary bioethical discussion came from doctors wrestling with survivorship and wondering about the limits of quality of life research and trying to grapple with what a values based or virtue oriented medicine would be like, and I know all those things will look old those ideas in a way but that understanding where that comes from was really good for me. And it also reinforced to me, the value to my mind the inseparability of other bioethics that recognises those roots that that that all of those ideas were brought into practice. So on the one hand, I hope its legacy is that it it contextualises and grounds people, I mean, obviously, I want people to remember Miles. But that's a secondary consideration to what this can offer. And then into the future. I want it to encourage people to be playful, bold, creative and linguistically rich in their and conversationally and diologically oriented in their approach to scholarship. And I think actually, the whole journal does that. And the whole journal was itself, in many ways an outcome of you know what, what Miles did at the centre, and often contains quite provocative and confronting articles. And I hope this symposium continues in that tradition. Do you yourself have a hope?

Well, I think that a part of what comes through in this symposium is Miles's lasting spirit of curiosity, and passion, and humility. And those are values that I hold very dear, that I hope deeply to instantiate in my own work and in my own life. And I think that that if the... if it inspires people to maintain an attitude of curiosity, and that kind of openness, that willing to explore and talk to people and listen, that Miles, so very much embodies in in his life and in his work, then that would be an incredible legacy. And I think that this hopefully just provides a taste of Miles's work to people who perhaps haven't encountered it before. And that it might, as you say, inspire people and it might inspire people even in terms of scholarship, and in terms of research and things that they might think further about. So I hope that it will be multiply, inspiring for people in terms of emulating the kind of life and kind of scholar that Miles was, and also in terms of pursuing some of these really difficult, challenging and important questions that he worked on in his life.

Maybe so, thank you Kate.

Thank you, Claire. Thanks so much for joining me on the podcast. And thank you everyone so much for listening to this episode of the SHE Research Podcast. You can find the symposium that we were discussing today linked in this episode's notes, along with the transcript of our discussion. SHE Pod is hosted by me, Kathryn McKay, and produced by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor or wherever you get your podcasts of quality. Thanks again for listening. Bye.