Safe as Houses: investigating OTs’ ethical development

Jani GrisbrookeUniversity of Southampton

Daily Ethics

• Your best friend (female) has acquired a designer label outfit and asks you if it makes her look fat. Sadly, it does.

• What do you tell her, and more importantly, why?

Approaches to Daily Ethics

• Deontology• Consequentialism• Virtue

Ethics and law

• Should fox hunting with dogs be banned?• Should cannabis be available in chemist

shops?

Why OTs recommend

• Interested in how people do their valued occupations and carry out valued roles

• Look at this in social dimension• Look at this in physical dimension• Look at this in spatial dimension• Consider foreseeable future – time dimension• Look at this in design of objects in use• Look at this in analysis of task

Why ethics

Negotiation between world views:•Personal ethics•Professional values•Service user values•Organisational norms

2 strands to follow

• Personal ethics a matter for the individual• Professional ethics a matter for the

community of practice

Choosing a design

• Tapping into reflective CPD groups• Individual interviews• Ethical approval

CPD sessions

Would one of you like to begin by telling the story of an adaptation case which you had to wrestle with or felt uncomfortable about?

Starting the interviews

• How do you think you developed a sense of fairness?

Analysing the data

• Literary critical approach• Close reading• Identifying characteristics of ethical

reasoning within dialogical practice• Identifying ethical qualities within

Bildungsroman

Group dialogue in practice

• Mix of deontological, consequentialist and virtue ethics approaches

• Practical reasoning – phronesis (Sen)• Contextualised view (Gilligan)• Dialogical practice changing reasoning

(Wenger, Bakhtin)

Individuals

• No problem articulating ethical development• All had rationales to ground articulation• Each one specific to the person and life story• Each one had an ethical ‘flavour’ – truth,

justice, kindness• Still developing through dialogue - not

finished (unfinalized)

Acting with virtue

• Bildungsroman - education for living well• Aristotelian development of character• Political framework, countering injustice,

promoting justice• Religious framework, fidelity, truth• Discomfort with ‘virtue’ perhaps

misunderstanding the nature of it?

Empathy in practice

• A notable feature in both group and individual transcripts

• Accounts for imaginative leap into the world of the other

• Necessary for clinical reasoning to occur• Accounts for some of the emotional labour• Necessary for assessment and

implementation

Empathy is

• Clear sighted not fuzzy• Accounts for ability to move alongside client

and stand back for professional judgement• Operated for colleagues as well• Accounts for depth of dialogical exchange• Able to act as a whole self but also as

disparate parts which might belong to others (wave and particle)

So what?

• Dialogue IS practice therefore time needed for community practice

• Empathy as a virtue is a skill and a value and appears to underpin clinical reasoning

• Practical reasoning describes OT ethical practice better than application of universalist principles

Narrative reasoning

The OT’s task is to take the episodes of action within a clinical encounter and structure them into a coherent plot. A plot is what gives unity to an otherwise meaningless succession of one thing after another…When a therapeutic process has been successfully emplotted, it goes somewhere, it is driven and shaped by a ‘sense of an ending’.

(Mattingly, p246)

Unfinalizability (Mattingly/Bakhtin)

• Good stories are never only open to one reading but allow for interaction with multiple readers – what does it mean, how does it end, could it end another way?

• Good clinical emplotment is unfinalized by the therapist, allowing the person to interpret and drive the plot forward himself

• Are task driven management plots completely finalised – eligibility established, service provided ‘end of’… ?

Implication for professionals• Keeping to the professional bounds of narrative but

remaining imaginatively open and unfinalized requires professional accountability for the process within the community of practice

• That’s why supervision is so important • New therapists need another more experienced

narrative reasoner• Experienced therapists need another experienced

therapist• All therapists need dialogical opportunities to open

their practice to each other

References• Gilligan C (1977) In a different voice: women’s conception of

self and morality. Harvard Educational Review 47 (4) 418-517 • Mattingly C (1998) Healing Dramas and Clinical Plots. The

Narrative Structure of Experience. New York: Cambridge University Press

• Mattingly C, Hayes Fleming M (1994) Clinical Reasoning. Forms of Inquiry in a Therapeutic Practice. Philadelphia: FA Davis

• Ryan SE, McKay EA (1999) Thinking and Reasoning in Therapy. Narratives from Practice. Cheltenham: Stanley Thornes

• Sen A (2009) The Idea of Justice. London: Allen Lane/Penguin• Wenger E (1998) Communities of Practice. Learning, Meaning

and Identity. Cambridge: Cambridge University Press