The coproduction of moral discourse in U.S. community psychiatry

Anthropologists often criticize the discipline of bioethics because its remote, abstract theories fail to capture how front-line clinicians experience and resolve moral uncertainty. The critique overlooks, however, the ways that everyday, emergent moral discourse is influenced--over time and through several mediations--by formal ethical notions. High-order ethical pronouncements become sedimented into the conditions of work, illustrated in this article by a two-year ethnographic study of Assertive Community Treatment (ACT), a popular mode of outpatient psychiatric services. ACT clinicians' moral unease when they break the confidentiality of patients is connected to high-order debates, dating back 35 years, about ensuring patients' autonomy without abandoning them. These debates originally spurred the invention of ACT, and they get braided into today's moral discourse through several mediations: regulatory paperwork, the mandates and micropolitics of staff-patient interactions, and the idealized self-image of front-line staff. This article shows how everyday moral talk is coproduced by both the immediate contexts of clinical work and the categories of formal bioethics.