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This book explores the moral lives of mental health clinicians serving the most marginalized individuals in the US healthcare system. Drawing on years of fieldwork in a community psychiatry outreach team, Brodwin traces the ethical dilemmas and everyday struggles of front line providers. On the street, in staff room debates, or in private confessions, these psychiatrists and social workers confront ongoing challenges to their self-image as competent and compassionate advocates. At times they openly question the coercion and forced-dependency built into the current system of care. At other times they justify their use of extreme power in the face of loud opposition from clients. This in-depth study exposes the fault lines in today's community psychiatry. It shows how people working deep inside the system struggle to maintain their ideals and manage a chronic sense of futility. Their commentaries about the obligatory and the forbidden also suggest ways to bridge formal bioethics and the realities of mental health practice. The experiences of these clinicians pose a single overarching question: how should we bear responsibility for the most vulnerable among us?

As genetic technologies move out of research laboratories and into public life, there arise enormous debates about their proper use and interpretation. The ramifying debates about genetic technologies are driven by larger questions about inclusion and diversity in American society, and not surprisingly, contemporary debates over claims of identity and of social connection have very high stakes.

According to these norms, any restriction on the individual's voluntary will is ethically problematic; hence, accepting and giving gifts is unethical because it imposes long-term mutual obligations on what should be a short-term decision that the individual alone should make. [...]an acknowledgment would also sharpen the contribution of their style of ethics consultation to the cultural diversity of U.S. mental health care. [...]two conceptual oppositions haunt many of the arguments in this essay. [...]the culture, practice and discursive forms of ethical thinking are enduring topics of interest to moral philosophy as well as medical anthropology.

This article investigates the ambivalence of front-line mental health clinicians toward their power to impose treatment against people’s will. Ambivalence denotes both inward uncertainty and a collective process that emerges in the midst of everyday work. In their commentaries about ambivalence, providers struggle with the distance separating their preferred professional self-image as caring from the routine practices of constraint. A detailed case study, drawn from 2 years of qualitative research in a U.S. community psychiatry agency, traces providers’ response to the major tools of constraint common in such settings: outpatient commitment and collusion between the mental health and criminal justice systems. The case features a near-breakdown of clinical work caused by sharp disagreements over the ethical legitimacy of constraint. The ethnography depicts clinicians’ experience of ambivalence as the complex product of their professional socialization, their relationships with clients, and on-going workplace debates about allowable and forbidden uses of power. As people articulate their ethical sensibility toward constraint, they stumble over the enduring fault lines of community psychiatry, and they also develop an ethos of care tailored to the immediate circumstances, the implicit ideologies, and the broad social contexts of their work.

Recent disputes about human population genetics research have been provoked by the field's political vulnerability (the historic imbalance of power between the geneticists and the people they study) and conceptual vulnerability (the mismatch between scientific and popular understandings of the genetic basis of collective identity). The small, isolated groups often studied by this science are now mobilizing themselves as political subjects, pressing sovereignty claims, and demanding control over the direction and interpretation of research. Negotiations between the geneticists and the people asked to donate DNA have resulted not only in explicit bioethics protocols but also in diffuse anxiety over the incommensurability between expert and non-expert views about genetic evidence for identity claims. This article compares two disputes over genetics research: the Human Genome Diversity Project and the use of genetics to prove identity claims among the Melungeons of Tennessee. The case studies illustrate \"bioethics in action\": how particular controversies and interests drive the production of bioethics discourses and techniques (such as informed consent protocols). They also illustrate some limits on the usual apparatus of bioethics in overcoming this science's multiple vulnerabilities.

The experience of futility among frontline clinicians in community psychiatry is produced by the temporal structuring of their work. All health care providers share the disposition to intervene in the course of disease. Specific notions about the course of severe mental illness are woven into the mission of Assertive Community Treatment (ACT) as well as the treatment plan, a key paperwork tool used to stage daily activities. The treatment plan demands a narrative of progress that ACT workers often find impossible to supply. The gap between the ideal of progress and the realities of practice produce distinctive kinds of demoralization. Drawing from an ethnography of a single ACT team in the United States, this article explores how clinicians encounter, articulate, and attempt to resolve such experiences of futility. It explores their practical strategies to reframe the time horizons of work and thereby restore the sense of their own therapeutic power.

Issue Title: The Practice of Constraint in Psychiatry: Emergent Forms of Care and Control

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.

I examine the growth of Pentecostalism in the Haitian diaspora through both a neo-Weberian framework and the argument, derived from Walter Benjamin, that the cultural translation of religious doctrine should resonate with the original and not merely substitute scholarly categories for sacred meanings. Haitian migrants to Guadeloupe, French West Indies, appropriate Pentecostalism to produce a transnational enclave in the face of marginality and displacement. Using Christian idioms, they defend themselves against denigrating stereotypes and articulate sentiments of loss and remembrance of the Haitian homeland. Their theology of sin, salvation, and the spirit therefore overlaps with anthropological frameworks about the production of community. These two languages complement each other, and each provides a partial theory to explain the need for moral separationism as well as its likely effects. Examining this complementary relationship suggests both the specificity of Haitian Pentecostalism and the limits of Benjamin's literary model for ethnographic interpretation.