imply that its conception of ethics, its value systems, and its mode of reasoning transcend social and cultural particularities" (1990).

Embedded within the new end-of-life practices are unexamined assumptions that stem from specific Western traditions. Innovations in health care ethics that emphasize advance care planning for death or a patient's "right" to limit or withdraw unwanted therapy appear to presuppose a particular patient. This ideal patient has the following characteristics: (1) a clear understanding of the illness, prognosis, and treatment options that is shared with the members of the health care team; (2) a temporal orientation to the future and desire to maintain "control" into that future; (3) the perception of freedom of choice; (4) willingness to discuss the prospect of death and dying openly; (5) a balance between fatalism and belief in human agency that favors the latter; (6) a religious orientation that minimizes the likelihood of divine intervention (or other "miracles"); and (7) an assumption that the individual, rather than the family or other social group, is the appropriate decisionmaker. Underlying these assumptions—and the innovations in clinical practice, such as the Patient Self-Determination Act, which they have spawned—is a theoretical perspective that I will call, for the sake of simplicity, the "autonomy paradigm." I make the assumption that an emphasis on the principle of autonomy has characterized much bioethics discourse over the past 25 years.7

The idealized view of decisionmaking common within bioethics also assumes that health care providers offer real choices to patients at the end of life, rather than simply dictate patients' answers by how information is presented or how scientific facts about prognosis are framed. There is also the (questionable) assumption that patients and providers are equally powerful in the clinical relationship.8

Another theme in contemporary bioethics has been the overall relationship of grand-scale ethical theories (like the principle of autonomy) to more mundane matters, such as practical ethical judgments or decisionmaking (Jennings, 1990; Jonsen, 1991; Hoffmaster, 1992). There are many ways to frame this dichotomy; one may speak of the relationship between normative and descriptive inquiry, for example. The two activities yield quite different forms of knowledge. "Theory can be discussed and argued in serene and unspecific terms: read Sidgwick or Rawls, where five hundred pages can go by without a detail of the casuists' 'who, what, when, where, why, and how'?" as Jonsen notes (1991, pp. 14–15). Theory is "very loosely tethered to the ground and can float quite free" (Jonsen, 1991, p. 14). Attention to grand-scale theories precludes attention to the social context of clinical practice.

Empirical or descriptive research in bioethics aims to be grounded, seeking after the "who, what, when, where, why, and how." Recent shifts within academic bioethics have opened the door for empirical work by



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