Choosing not to help: The ethical challenge of beneficence for clinicians conducting ethnographic research

Abstract

For clinicians conducting ethnographic research, conflict can arise between the clinical understanding of beneficence, meaning to apply skills and knowledge for people towards whom there is a duty of care, and enacting beneficence through research, which can sometimes allow researchers to withhold assistance in the interests of generating data which may have a broader beneficent effect when applied. As a nurse and ethnographic researcher, I present three reflections on my own fieldwork with people engaging in recovery from harmful methamphetamine use, to explore how beneficence can be enacted in constrained and complex circumstances. These reflections provide the basis for a discussion of how relational ethics can reveal the fabric of microethical actions and decisions which comprise clinical and research interactions, allowing practitioners to demonstrate a continuity between how they enact principles like beneficence both in the context of clinical work and in the field.

Introduction

Research, like everyday life, often generates ethical dilemmas in which it may be impossible to find agreement on what is right or wrong – National Health and Medical Research Council (2018).

Ethnographers that deal with issues of social justice think very carefully about these issues and are sometimes stuck managing tension between what is deemed ethically sound research practice and what is the morally right thing to do – Russell and Barley (2019).

It was the sixth month of fieldwork for my ethnographic PhD thesis on methamphetamine recovery, and I was on my way to visit Bridget, one of the participants. As an emergency nurse frequently managing patients experiencing harmful methamphetamine use, I wanted to understand the lives of these patients and discover what shaped their trajectories of use and recovery over time. Bridget was in her late thirties and lived in the suburbs of Brisbane, Australia, with her three children, current partner, and large labrador. Bridget’s partner had cheated on her, and she had found out shortly before I arrived that morning. This had contributed to her injecting methamphetamine after 4 days abstinence. When I arrived Bridget’s partner had left, and she was frantically rummaging around in his car for loose change. She immediately said we had to go to the supermarket to get iced coffee. I drove us there, and she surged around the large supermarket at speed picking up other basic groceries. After figuring out what she could buy with the coins she had found, she put what she could afford through the self-serve checkout and shoplifted an iced coffee as we walked out.

Her relationship was a few months old, and Bridget had been saying throughout that time that she was using methamphetamine less while her partner was around. I mentioned this as we got back to her house, which was a mistake. As we got out of the car Bridget screamed and threw her bag of groceries onto the ground, scattering milk, bread, and grapes over the grass. She sat on the ground outside her house crying, and continued to shout:

I know! You know that guy, who would do that, who would care enough about me, to do that-, god- that’s the whole fucking catalysm [sic] of it, that’s why I stick around, because I wonder if [his old personality] might come back, cos there’s this fucking dog, lying in my bed, fucking money hungry cheating fuck!

As we got into the house Bridget’s daughter eagerly started eating the grapes as she continued to rage about her partner. I had never seen her this upset. Bridget was a kind and thoughtful person, but with very little support around her. This betrayal was causing her to spiral, triggering her to use and endangering what little supports she did have. As an ethnographer I was there to observe Bridget’s day, and I felt compelled to hold back, to let her respond to events as naturalistically as possible. As a nurse, however, I felt compelled to try and help, to be empathetic, conciliatory, and offer advice; to be there for her on a day when she needed someone. Could I do both, or did I have to choose?

Doing Good

For researchers that are also clinicians, the ethical issues they encounter in fieldwork can be compounded by their possession of professional skills, knowledge, or resources that could be of some help to the participants. Despite entering the field purely as an ethnographer, I still felt bound during my research by the clinical ethics that govern my practise as a nurse. This includes specific issues such as mandatory reporting of issues of child safety, but also the broader principles of beneficence, non-maleficence, autonomy, and justice (Scott, 2017: 196). These basic principles are consistent across nursing, medicine, and allied health fields. The Australian National Health and Medical Research Council (2018) lists four similar components within its ethical framework: research merit and integrity, justice, beneficence, and respect.

Many situations in research and clinical care will entail all of these principles to varying degrees, and distinguishing between them in practise can be difficult. Beneficence is often characterised as the inverse of non-maleficence, with these two sometimes grouped together as a single injunction. I would argue, however, that beneficence is unique among these ethical ideals as it entails instrumental positive action and intervention, as opposed to the absence of harm (Persson, 2017). Justice, respect, autonomy, and non-maleficence can each be preserved or at least not actively reduced by practitioners withdrawing from a scene, by avoiding the assumption of responsibility for each of these components through relationships with patients or research participants. Beneficence, however, is more complex and impactful in its application. To be beneficent is to actively affect people’s lives. Much more is at stake. Without implying that it is ever the single factor at play, therefore, it is valuable to single out beneficence for particular scrutiny.

Beneficence was at the heart of my dilemma that morning with Bridget; however, the implementation of this principle can look very different in healthcare compared to research. In clinical practise, beneficence implies the realisation of valued outcomes from treatments, interventions, or service interactions. Research practise, however, can require non-intervention, particularly with qualitative methods that aim to explore naturalistic, real world behaviour. Unlike the focus of clinical nursing, it is accepted that the beneficence of a research project can be not directed towards the individual research participant, but towards the ‘wider community’ (National Health and Medical Research Council, 2018: 9). Furthermore, to involve oneself at a deeper relational level with a participant, such as by helping them materially, can mean disrupting the frame of your relationship, to contaminate the research field with favouritism and personality, or at least further complicate the process of knowledge production (Thomas, 2016). There is therefore no positive obligation on the researcher to step into the participant’s life to help them, to apply skills for their immediate benefit. For a nurse, meanwhile, that is precisely what beneficence means. A nurse is not obligated to look after anyone; however, once they have started, and a duty of care is established, then beneficence means using their knowledge and skills to help that individual if possible (Water et al., 2017). After conducting an hour-long qualitative interview, visiting people’s homes, making plans to see them again soon, and intentionally developing a relationship with them, it can certainly feel like a duty of care has been established. One of the hardest tasks during my own research was to sit in the face of people’s suffering, and not say or do the things I normally would in my nursing practise, to not kick into gear and start working to solve their various unsolvable problems. This did not need to be justified to the multiple human research ethics committees that had approved the study, but I did need to justify it to myself.

In this paper, I will discuss the challenges of integrating Australian research and nursing ethical frameworks, and articulate potential developments towards a process of relational ethics for clinicians conducting qualitative research, drawing on a series of reflections from my own ethnographic work with people using methamphetamine. There is rarely sufficient space in a journal article to address these issues when they are not the focus of the study. Extended ethical reflections were not included in the published findings from this research, and yet they give another valuable window into the participants’ lives. They are a form of ‘ethical overflow’ (Clancy, 2011: 114) that needs to be processed, without necessarily contributing to the study’s key findings (see Brookfield et al., 2021; Brookfield, et al., 2021a, 2021b, 2022). Developing a relational framework for ethics that attends to the unbroken stream of complex ethical moments which make up fieldwork can enable clinician researchers to negotiate the complexity of moral decision making in a way that is theoretically coherent, responsive to the context, and founded on equitable, mutually respectful relationships, helping to ensure that we are doing the right thing by someone like Bridget.

Ethical Ethnography

Ethnography is a research methodology defined by long term participant observation of individuals, communities, or cultures, to understand the naturalistic behaviour of people embedded in real world environments (Hammersley and Atkinson, 2007; Plows, 2018). The goal of this observation is to develop what Clifford Geertz (1973) called ‘thick description’, which includes detailed analysis of people and their interpretations of themselves, in order to help outsiders understand the ‘situated rationality’ of particular contexts (Parker, 2007).

The tension of if, when, and how researchers should intervene or participate in ethnographic contexts is an ongoing debate with potentially high stakes particularly for marginalised or vulnerable populations. Vanderstaay (2016) narrates how in his study of a young man using cocaine, by giving him a small amount of money he may have inadvertently contributed to a series of events resulting in murder. Desmond (2014: 267) contends meanwhile that ‘ethnography is what you do when you try to understand people by allowing their lives to mould your own as fully and genuinely as possible’. Ethical ethnography takes place somewhere on a tightrope between uncoordinated, potentially harmful participation from a position of power, what Irwin (2006: 169) refers to as ‘enacting structure’, and the injunction to not use the veil of fieldwork as ‘justification for turning one’s back on the suffering of human beings’ (Taylor, 1987: 299). Walking this tightrope requires constant re-evaluation of one’s own behaviour, intentions, and research aims.

The common challenges of applying standard procedural ethics to ethnography via institutional review committees have been well documented, such as the indeterminacy of who is and is not a participant; the challenge of obtaining informed consent in a fluid social environment; and trying to anticipate or control the risks and (more often) benefits different participants receive from being an ethnographic subject (Atkinson, 2009; Plows, 2018; Øye et al., 2016). Ethnographic fieldwork can be a ‘fluid, anarchic, and messy’ process (Alam, 2018: 59) which plays out in inherently and intentionally unpredictable ways. Some scholars bemoan, therefore, the ‘impoverished view of field research that is enshrined in current regulatory practice’ (Atkinson, 2009: 17). Despite the necessary role of ethics committees in regulating and governing the research practices which institutions enact, there is also a fundamental disconnect between the idealised topiary garden of ethical rectitude supposedly enshrined in principles such as beneficence, and the unruly wilderness of the field or clinic to which it must be applied.

The way ethics is deployed through institutional review committees is predicated on a certain understanding of the world as a stable, predictable phenomenon which can be reduced to a set of known and approved outcomes (Fry et al., 2007; Small et al., 2014). This perspective is mirrored to some degree throughout bioethics, which some argue has overemphasised various classic hypothetical thought experiments, and lost contact with how ethical issues and decisions are enacted in real world settings (Komesaroff, 1995; Marino, 2017; Nikku and Eriksson, 2006). The point of ethnography, meanwhile, is to attend closely to precisely these settings, and to resist seeing the world as a stable, normative, or justified set of conditions (Tolich and Fitzgerald, 2006). It is the difference between understanding research as exploring a rainforest versus solving a hedge maze.

Ethnographic research is dependent on interpersonal relationships, within which ethical or beneficent behaviour is a symbiotic and emergent process whose complexity can rarely be anticipated by procedural ethics processes. Relationships between researchers and participants entail complex and evolving expressions of both personal and professional identities, emotions, and beliefs (Miller and Boulton, 2007). Care must be taken by the ethnographer to shape the relationship in a way that serves the overlapping, yet distinct needs of the participant, researchers, and the research. The power imbalance in fieldwork relationships can be reduced but not eliminated, and bestows a significant responsibility on researchers (Griffin, 1996), particularly in forms of qualitative analysis that select which portions of often deeply personal information to present and scrutinise, and which to leave out. It is inevitably challenging therefore, to enact beneficence across such complex ethical terrain in a way that consistently aligns with multiple ethical frameworks the researcher may be subject to. In this paper, I reflect on some of these challenges as they relate to beneficence, and present a relational ethical approach incorporating the concept of microethics (Guillemin and Gillam, 2016; Komesaroff, 1995), which can assist future clinician researchers and help ensure that their perhaps well-meaning but also haphazard advances towards participants are as beneficent as intended.

Method

For my PhD research, I conducted qualitative interviews and ethnographic observation with a group of twelve participants recruited through outpatient recovery services in Brisbane, Australia. The research project was initially described to participants by a nurse at these services who would provide the project information and consent forms to the participant to read in their own time and obtain consent to provide their details to me as the principal researcher. I would then contact them via phone 24 hours later to discuss the project again and arrange a time and place to meet of their choosing to complete the consent process. At that time I would read the information and consent forms out loud to participants and complete the signing of the forms. I took care to give participants multiple opportunities throughout the project to withdraw their participantion and their data from the study at any time, making it clear there would be no consequences for them or their access to services.

Data collection was focused on activities related to drug use and recovery, and between 2018 and 2019, I visited participants’ homes, met their families, and accompanied them to see doctors, counsellors, parole officers, child safety services, and drug dealers. Data collection occurred over 6 months for each participant, with more formal semi-structured interviews conducted at the beginning, middle, and end of this time period. Participants were given a $50 supermarket voucher as compensation for each of the interviews, an amount consistent with standard university practise, and considered sufficient to be meaningful without being coercive or endangering informed consent. (Festinger and Dugosh, 2012; Ritter et al., 2003). Interviews and some participant observations were audio recorded with the participants’ consent. Via this process I compiled 30 interview transcripts and over 100,000 words of field notes. It was difficult to maintain contact with participants during the 6-month data collection period, with two participants being lost to follow-up, usually due to changing phone numbers and addresses. Follow-up processes of collaborating with participants on final manuscripts and quote selection was therefore unfortunately not part of this project. The research was approved by both the Queensland Health Metro North Hospital and Health Service and the University of Queensland Human Research Ethics Committees.

This paper provides reflexive analysis of three episodes that occurred during my fieldwork. Reflexivity is a critical process of reflection on not only the knowledge generated by a research project, but also how and why that knowledge was produced (Guillemin and Gillam, 2016). A reflexive researcher interrogates and brings forth the ways their own assumptions, biases, and beliefs may have shaped the research process, without allowing their own experience to intrude upon the narrative of the participants (Gullion, 2016). Reflexivity reminds the researcher to remain attentive to the ongoing reciprocal process between research subjects and the values and priorities of researchers and organisations. This process thereby provides an opportunity to analyse ‘ethically important moments’ in research practise, where small scale decisions are made that have ethical content, despite not placing the researcher on the ‘horns of a dilemma’ (Guillemin and Gillam, 2016: 265). These reflections aim to highlight how minor aspects of interpersonal interactions knit together to make up the ethical fabric of especially qualitative research practice, without standing out as clear binary ethical quandaries.

Reflections

Buying drugs with Bridget

It was a normal and quiet day at home for Bridget. She had arranged for someone to come round that day to mow the lawn and the grassy aroma pervaded the house. Her daughter was playing Fortnite in the front room. She planned to buy some methamphetamine later that day and said I could come with her. I had previously driven us both to visit doctors and shopping centres, which implied that we could also use my car today. The trip would otherwise entail catching two buses across town to a pub where her friend was waiting with the drugs. Bridget correctly anticipated that I might feel conflicted about this car ride.

On one hand, Bridget bought methamphetamine very frequently, and would continue to travel to buy it regardless of my own participation. On the other hand, by driving her I would make it significantly easier for her obtain it, and I was concerned about the coming months of data collection, if this precedent was established. Why do it one day and not another? I could still pass it all off as data collection, including ethnographic conversations during the car ride. Alternately, if I declined to drive today, would this risk alienating Bridget, making her act of purchasing drugs feel judged and stigmatised, despite all my efforts to avoid this? If this contributed to a breakdown in our relationship, could that in turn jeopardise her future participation in the research? Before leaving, I discussed some of these issues with Bridget, laying out for her exactly why I felt conflicted, and that this was a difficult challenge for me as a researcher. I ultimately decided that I would come with her, would avoid saying or doing anything to restrict her ability to buy methamphetamine, but that I would not drive us there that day. It felt different to actively assist in the process. Bridget was very understanding, and we talked it through more while we sat on the curb, waiting for the bus.

The dealer was a very good old friend of hers. We arrived at the pub, and she found them solemnly playing a slot machine. The friend was distressed about relationship problems and Bridget had to talk to her for a long time before they got around to exchanging money. After she bought the drugs, she went into the pub bathroom to inject, and I stood around trying to understand how the elaborate slot machines worked. On the way back to the bus stop we walked through the nearby shopping centre and Bridget was elevated, commenting on everything she saw in shop windows. Bridget said she had noticed that when talking to me she felt less guilt or shame about using, and that it felt good to talk so openly to someone who was not a drug user. By communicating openly with her about my thinking and reasoning, it seemed our ethnographic relationship had survived this episode.

This event challenged the value neutrality to which I had naively aspired. I reflected that I could not claim neutrality prior to then anyway, since I was actively assisting with recovery focused activities, such as going to doctors or counselling appointments. While in my presence Bridget used methamphetamine, shoplifted from supermarkets, became irate and screamed in the street, and dealt methamphetamine from her home. One day her new partner tried to convince me to buy some. For all of this, however, I could be more of an observer, whilst still embroiled in the scene. My behaviour was less directly instrumental. I was not personally concerned about the legality of any of these events, it was only an issue of how my relationship with Bridget should be structured, and my own confidence that my presence had not exposed her to any increased risks or harms. I could not stop her using methamphetamine even if I had tried, but there is a relationship between ease of access and frequency of use, and I could not justify putting myself on the ‘wrong’ side of that equation.

Kira’s Doctor

Kira was in her mid-thirties with four children and was introduced to methamphetamine by her former partner when she was 14. About 5 years ago, Kira’s family ‘blew up’ when her husband was prosecuted for child molestation and possessing child pornography. After their separation Kira’s methamphetamine use increased. Her three children were placed with relatives by child safety services. Kira also used cannabis daily and felt like this had a greater impact on her functioning than methamphetamine, which she described as her ‘cup of coffee’ that ‘just gets me moving and it just blocks all this shit that’s going on’.

One day I picked Kira up from her mother’s house to drive into the centre of Brisbane to visit a medical clinic she had previously attended. When asked what she needed to see the doctor for and she said:

Everything really. Having to go to [domestic violence counselling] and bring up trauma. Not sleeping. I don’t eat properly. My stomach’s always sore, like anxiety’s real bad.

She also wanted a new prescription for Lyrica which she was given for carpal tunnel syndrome. Before we left her mum handed her a single cigarette to put in her purse ‘for emergencies’.

Thirty minutes later we arrived at the medical centre which was hidden at the back of a single storey precinct with a pharmacy opposite and a couple of small offices. After sitting in the small grey waiting room for a few minutes, we were called in. The doctor nodded at me and did not ask who I was. Kira sat next to his desk, and I sat against the opposite wall taking notes on my phone. Kira said she was there for a few things. First was the carpal tunnel syndrome, and he said he would send off another referral to a nerve specialist. Then she brought up anti-depressants, saying she had taken them for a couple of weeks but then her prescription had gotten mixed up whilst she was moving. Then her voice started to waver and she sounded nervous.

Kira: I’ve got quite a bit of- past… past trauma that I’m dealing with at the moment.

Dr: Oh right…

Kira: Plus, what I’m, would you say-?

She looked over to me.

Kira: …Recovering? Recovering, kind of, trying to recover- drug- addict- user- at the moment… Um, so I still need to get back on something.

Dr: Lexapro.

Kira: Yeah or something.

Dr: Well you were on Lexapro last time.

The doctor’s voice was quiet and devoid of affect.

Kira: Yeah and I didn’t really even get a chance for that to kick in. Probably only had two weeks of it.

Dr: I’ll give you another script.

Kira: Okay, and for my anxiety, is there any chance of getting Valiums or anything like that.

Dr: No, no.

Kira: You’re not allowed to give-?

Dr: No.

Kira: Okay. But you can give me Lyrica for my hands?

Dr: Yeah. So you need Lyrica?

Kira: Yeah…

The doctor was looking at his computer, clicking slowly.

Kira: So what do you give people for anxiety and stuff? It’s so hard to get a 5mg Valium and you wonder why people go out there and pay for like an on-street prescription drug, you know?

Dr: Yeah, well it’s um, it’s-

Kira: And Lyrica is just like…

She looked over at me again, speaking to me now, shaking her head in exasperation, anxiety rising. The doctor started printing her prescriptions. The drone of the printer filled the room. When she spoke she was tearful again. She seemed to have given up on where she had hoped the conversation would go.

Kira: Oh I need a medical certificate too. I need a medical certificate for Centrelink [social security]. For exemption [from regular appointments] please.

Kira started talking to me again.

Kira: Do you understand that? Do you know what Lyrica does to people? How messed up Lyricas can- You should read up on it and then wonder why Valium is- why I can get one and I can’t get the other.

She started crying quietly.

Kira: I need an exemption from the 17 ^th please.

Dr: Of March?

Kira: Yeah.

He clicked in silence for a while.

Dr: 17 ^th is a Sunday.

Kira: Oh well the Monday then sorry.

Dr: So the 18 ^th . How long, three months, two months?

Kira: Three months.

Some more clicking. The printer whined again.

Dr: Here you go.

Kira: Cheers.

Dr: Thanks guys.

We got up and left. The appointment went for maybe 5 min. We walked over to the pharmacy, and she handed in the scripts, looking sour. We sat down to wait. Cheery music played. As we waited, she commented on how the doctor had written out a 3-month medical certificate without asking what it was for.

Kira: It’s a weird little system we have, isn’t it?

S.B.: How did you feel about that appointment?

Kira: Oh, you saw me, obviously [laughs]. Um [tearful], even when you come and ask for help you can’t get it, you know. Half the time they just flick through a book to see what they think you are, you know.

S.B.: Does that happen very often, when you ask for help?

Kira: Yep. Especially once you’re recorded as a drug user. This is why there’s so many illegal drugs on the streets because half the time you cannot get the help you need from your doctor. Seriously, I have a friend who has someone come and buy $20 of oxy off him every day, because it’s $1 a meg [milligram]. Last time I got the Lyrica they said not to tell anyone I had them.

She got the medications and we started walking back to the car. On the way she took the cigarette from her purse and lit it.

Kira: You know things are bad if you’re pulling out the emergency smoke!

This small interaction was heartbreaking to watch. In this medical appointment Kira received a specialist referral, renewed prescriptions, and a 3-month medical exemption certificate, but she did not get what she needed, which was to feel like someone cared. She struggled to present her issues, and perceived significant stigma towards her from a profoundly incurious doctor. She had looked at me, appealed to me to say something, to maybe help her get across what she needed. If I helped, maybe things would have gone differently. Maybe she would have at least felt more supported, like what she was saying made sense, that she was not alone in the room. I nodded and affirmed what she said when she looked to me, but I did not advocate for her. I did not convert what she was saying into the kind of acceptable, contextualised medical language that I, as a nurse, was sure this doctor would have preferred to hear. I did not explicitly vouch for her. By not doing that I was closer to seeing what a normal appointment was like for Kira. I saw how bare and cold and brief the interaction could be, and how truly alone someone with her kind of complex issues can be even within a comparatively functional and well-funded public health system. If I tried to make it better, I would not be able to show how bad it was.

Taking Jack to Hospital

Jack was in his early forties and had lived all his life in the outer suburbs of Brisbane. He met his wife at school, and they had four children before separating 6 years previously. In his twenties and thirties, he had struggled with binge drinking every weekend, while still working during the week. Jack had also struggled with gambling throughout his life. He started smoking methamphetamine around the time he separated from his wife. Jack had given up his job 2 years ago, and most of his family relationships had deteriorated partly due to gambling debts. He had started sleeping rough about 6 months before the start of the project.

One day Jack called me to ask about the recovery services at the hospital I worked at and how to access them. We had discussed this service previously when he was wondering what his options would be for recovery. I gave him this information, and then I offered to call the service to see if he could attend that day. I offered to do this for Jack partly because he had taken the initiative to call me during one of the brief windows in which he was sober and had a phone, and because I was familiar with the service and would know what to ask and how to ask it. The fact that he had followed up and tried to work out a plan for his recovery made me think maybe this could be a turning point for him. Additionally, however, there was the other tantalising incentive that lurks in the background of all fieldwork relationships: the need to obtain ‘hard to access’ data (Wilson and Hodgson, 2013). The process of accessing an in-patient recovery service would inevitably provide opportunities for rich and valuable analysis. Jack could be a hard man to find, and so the prospect of him seeking me out, and spending the day on recovery focused activities was a breakthrough for my data collection with him. At the time I was doing what seemed best for Jack but was also clearly good for the study. This makes beneficence more complex, as sometimes the beneficent act may support the research aims, and sometimes not.

The service said Jack could come in for an assessment, and I drove him there later that day. The service operated through the emergency department in which I had worked for some years; therefore, this was basically my place of work, and my colleagues he was talking to. This was not a choice, as this was the only option for him in the area. We sat together in the waiting room surrounded by other patients. A nurse from the drug and alcohol service came out to talk to him. After explaining some of the process they glanced to the side and were startled, having only just noticed it was me sitting there for the first time. Despite my years of work in the department, in plain clothes and sitting in the waiting room, I had literally become invisible to them.

I accompanied them both into an assessment room and Jack was asked an extensive list of questions about his drug use history and current use. Jack lied to them about his recency of use because he knew you had to have used very recently to get admitted to the service. I was not sure if this was true and did not try to find out for him. He had told me he planned to do this on the drive in, and it seemed strange that someone in such extremis would have to make his situation sound worse, to access treatment.

Jack was approved for admission, which I drove him to later that week. The standard length of stay for the service was about 1 week. I called the service three days later and was told that he had self-discharged after it was explained that there would be no long-term rehabilitation with accommodation available to him at the end of the withdrawal treatment. Talking to the admission nurse a week later, they told me that they normally do not admit people for methamphetamine withdrawal alone, unless there were complicating medical factors such as pregnancy or a heart condition. However, because I was there, I was taken to be ‘vouching for him’ and so they made the decision to admit. I was shocked to hear this and felt foolish for not realising how I would influence the situation, especially since their confidence in the pair of us was misplaced, and he self-discharged before completing the withdrawal program.

Discussion

These reflections present times when I enacted beneficence in constrained and difficult circumstances. The ethical challenges of fieldwork demonstrated to me the complex and relational nature of ethnographic or qualitative data, and the unfeasibility of collecting purely ‘observational’ data. Even if you manage to be a fly on the wall, flies tend to get noticed. My presence in participants’ lives involved me in the co-construction of their capacities, intentions, and behaviour (Bell, 2011; McCormick, 2010). The orientation of data collection and my own ethical obligations and were therefore constantly shifting in order to tessellate with the real-world context of these individuals. Whilst this approach conforms awkwardly with the prescriptive ethical frameworks of nursing and research, it does align with the basic tenet of relational ethics, which is that ethical actions are determined and enacted within the context of particular relationships, rather than in adherence to an abstract and predetermined set of rules (Pollard, 2015). I will now discuss the application of relational ethics to research practice, drawing also on the concept of microethics to understand the challenges that clinician researchers encounter in the field.

Relational Ethics

Relational ethics is founded on mutual trust and respect, engagement, embodied knowledge, and recognition of the interdependent environment (Kunyk and Austin, 2011; Pollard, 2015). These principles are more focused on the right process of determining ethical responses, rather than providing definite prescriptions for action. They are based on interpersonal processes, rather than on behavioural rules. The theoretical framework of relational ethics denies the feasibility or usefulness of moral reasoning as a disembodied process that can be conducted in a way that is abstracted from particular social and cultural contexts, arguing instead for ethics as something always emerging from embodied people in specific networks and environments (Given, 2008).

Relational ethics can also be particularly appropriate for ethnography, which is sometimes described as a ‘liminal’ discipline, performing a kind of translation between two moral cultures by analytically occupying the intermediary space between conflicting or divergent systems (Fleuehr-Lobban, 2000). Based on the reflections above, ethics for clinician researchers can be a similarly liminal activity, where decisions emerge from acts of translation between alternate moral frameworks. Relational ethics can also be viewed as an extension of an ethics of care, wherein moral decision making is guided by the degree of relationship and interdependence between individuals, and particular situational factors (Duff, 2015; Gilligan, 2008). This form of ethics based more in emotion and context can resist the conflation of norms and normativity which characterises many responses to drug use. Many critics have highlighted the narrow normative account of ideal health and behaviour drawn on across many developed nations in the governing of drug use, and the torturously narrow bandwidth of ethically valid options and pathways this leaves for people using drugs, at worst coming down to a binary choice between social expulsion and salvation through abstinence (Duff, 2004; Fraser and Moore, 2011; O’Malley and Valverde, 2004; Race, 2008). Without aspiring to make ethical choices through pure reason, an ethics of care remains sensitive to a wide range of human experience that usually colours most ethical reasoning, and also empowers people that use drugs to navigate richer and more nuanced ethical approaches to drugs, treatment, and their own wellbeing. As argued by Caine et al. (2020), relational ethics can represent an important development in this approach, beyond an explicit care and concern from researchers, towards a more equitable and mutual relationship where participants are still protected, but ethical actions are determined through trusting dialogue and co-construction of norms, values, and standards of behaviour

Such a process of co-construction can be seen in my discussion with Bridget about the act of driving her to meet her friend. Rather than me coming to a conclusion alone and in accordance with a set of rules Bridget was likely unaware of, we arrived at a plan together which we both felt comfortable with. It was a situation without a clear and correct way to navigate it, but by prioritising our authentic relationship, we could work through it together in a way that was most beneficent for her, hopefully without reinforcing stigma or facilitating harmful behaviour. In the example of attending the doctor with Kira, this could be seen as a failure of relational ethics, where I had not thought through sufficiently what might happen during the appointment and had not arrived at a plan of how to navigate it in collaboration with her. My discomfort in that setting, and her potential confusion, might have been reduced if I had put our equitable relationship first, instead of persisting in the fool’s errand of trying to neutrally observe a fraught medical appointment as one of only three people in a small room.

Relational ethics can also make more sense of the unique assistance I gave Jack in getting to hospital. It was not the purpose of the research project to advocate for this kind of service and help people to access it. Jack, however, was independently asking about and seeking this service out. He had moved our relationship in this direction and was taking advantage of the resource I could represent. I was trying to manage some degree of equitability between the participants’ experiences, and this could mean withholding all assistance regardless, or it could mean helping when it felt like it could make such a big difference that I was compelled to do so. In Jack’s case, that treatment episode could have been a significant turning point in his trajectory, as someone sleeping rough and increasingly desperate. In the context of our relationship, therefore, this was different to other participants that were perhaps more functional, housed, working, and talking about accessing services in a less active way. Jack got something none of the others got. I cannot claim this was perfectly reasoned at the time, but a relational ethics framework can bring forth the explicit and implicit justifications I was drawing on to navigate this situation ethically.

Relational ethics does not become simply relative and unreliable, subject to the whims of specific researchers at various times of the day. Relational ethics bend so they do not break, enabling them to grow in new directions; they can provide a strong guide, whilst also being iterative, revisionist, and emerging from the ground up. This approach does not give researchers more license for misconduct, by allowing ethical decision making to be endlessly reinterpreted. On the contrary it illuminates many areas of research misconduct that can hide inside of the basic and broad rules of healthcare and research. As Given (2008: 749) describes, ‘when research misconduct is conceptualized as fabrication, falsification, and plagiarism, the significance of ethical relationships in research … can be diminished’. Research participants can be vulnerable to a range of small and large ethical violations, transgressions, or injustices, which only become visible through a relational lens, when put into the context of a particular relationship and situation. Relational analysis of ethical situations can help to illuminate not just ethical challenges but also ‘ethically important moments’ occurring during research (Guillemin and Gillam, 2016: 262), moments which represent subtle shifts and negotiations around the bright lines drawn by ethical principles. Ethically important moments constitute the real experiential path people must navigate in clinical and research contexts; they are in fact where most ethics is done and where power is lost, found, and exerted (Nikku and Eriksson, 2006; Worthley, 1997).

The Microethical Environment

Researchers unavoidably hold significant power, especially in ethnographic relationships (Griffin, 1996; Karnieli-Miller et al., 2009; Sharpe, 2017). I was persistently concerned about falling into a mode of ‘sociological stalking’ (Sharpe, 2017: 242), feeling that it would be difficult to know when I was being an artful ethnographer, by gaining access to some of the infamous ‘hard to access’ data, and when I was engaging in some degree of exploitation. Distinguishing between these possibilities is necessarily a matter of ethical judgement for ethnographers (Hammersley and Atkinson, 2007), and is more often a relational negotiation enacted through seemingly minor actions and decisions.

The concept of microethics, first developed by Komesaroff (1995), views all clinical interactions as always entailing an ethical component, regardless of their proximity to major bioethical debates like abortion or euthanasia. Microethics does not present a new and different category of ethical problem that needs to be resolved; it contends instead that we should really be using an ethical lens to contemplate all clinical and research situations, and not restrict analysis to those comparatively few ethical decisions which tend to provide clear, binary, and eye-catching dilemmas. Komesaroff’s (1995: 75) description of microethics also sounds analogous to the practice of ethnography itself, claiming as he does that:

…its task is to chart the topography of the medical lifeworld, as it exists in its concreteness, its fluidity, and its temporal unpredictability.

Acknowledging the ‘microethical environment’ (Komesaroff, 1995: 68) renders visible the many small choices made by clinicians in how information is presented, what options are implicitly foreclosed, and to what degree patients are guided in their decision making (Truog et al., 2015). A principle such as beneficence can be adhered to or ignored not just in relation to issues of resource access, but by tone of voice or demeanour, by not inviting questions which are therefore not asked. More often it is these elements which add up to a clinical interaction, where the consequences may be more than the sum of its parts. This perspective can explain situations where patients may feel violated or exploited, whilst the clinician technically adhered to all the relevant ethical rules. These subtle violations or exertions of power are addressed by relational or ethics of care approaches. As highlighted by Gilligan (2008: 471), the uncritical application of general ethics rules ‘breeds moral blindness or indifference’ by encouraging the attitude that correct responses are easily determined and enacted.

Guillemin and Gillam (2016) argue that microethics can also be applied to research interactions, to understand the complex ebbs and flows of ethical actions during field work. The power dynamics inherent in research relationships lead to a similar microethical environment that requires the same relational negotiation. For the clinician researcher, therefore, this can provide a valuable continuity between how something like beneficence is enacted in both fields, by bringing it down to a more practical level and acknowledging its often piecemeal application. I suggest that microethics can provide a language for the kind of issues a relational approach is designed to navigate. It is microethical problems which require a relational perspective to not only address, but to identify in the first place.

The microethical issues that can emerge without directly contravening procedural ethics frameworks are multitudinous. In his harrowing exploration of mental health institutions, Taylor (1987) discusses his concerns over the effect of his presence in encouraging abusive staff members to ‘show off’. Moore (1993: 14) relates how forms of snowball sampling with people using illicit drugs may have been ‘ethically watertight’, but allow participants to develop an inaccurate picture of the researcher and the project, complicating the gaining of entry for ethnographic fieldwork. Maher (2002) describes how during her ethnographic research in New York, ethical obligation converged with civil disobedience in the act of handing out sterile needles and syringes, a crime at that time which nevertheless fulfilled the ideals of beneficence and non-maleficence. In his ethnography of methamphetamine use and cultural discourses, Gideonse (2013: 223) wrestles with the ‘ethical witnessing of suffering’, and the ethical implications of passivity while ‘receiving’ participants stories in a traditional anthropological way.

Ethnographies of drug use can take place across particularly acute power divides, and these can only be minimised by attending to the tapestry of microethical issues that continue to emerge within broader ethical frameworks. If they are not, then ethical injunctions such as autonomy or non-maleficence can be weaponised to coerce or dismiss the less powerful and oppressed. What are we doing by withholding help from people using drugs other than promoting their autonomy to help themselves, and avoiding the unintended harms that may come from intervention? Beneficence similarly can foster ambient paternalism (Brookfield et al., 2021) towards people suffering drug related harm, unless it is exercised from a place of deep relationship with the recipients, and a shared understanding of how to work through microethical dilemmas.

The microethics within the reflections above were played out in how I discussed driving with Bridget, how I chose to behave when she was using drugs, ways I may not have interacted with her daughter or chosen to explore how the day was affecting her, and how I responded when Bridget wondered aloud if wanted her to use drugs because it would be ‘good for the study’. With Kira, ethics was bound up in where I chose to sit in the doctor's room, who I chose to look at during their conversation, how I reflected on the scene with her afterwards, the clothing I wore that might make it clear I was there in an official capacity rather than a friend of hers. With Jack I chose to sit next to him in the waiting room, I chose not to explain my presence to some of the emergency department staff, I chose not to discuss his admission with the admitting nurse ahead of time, and I later chose not to discuss with Jack how big a role I had played in his admission. Each of these actions were beneficent in the relational setting within which I was embedded, but their explanation requires detail and context. Moreover, these situations are also not sufficiently navigated by the binary injunction to either ‘do good’ for the participant or ‘do good’ for the community. Each of these actions were carried out in a context of mutual trust and respect between myself and the participants, where I engaged honestly and openly with their experiences, and did not ignore the ways we were both dependent on the other for our various goals. By engaging in these relational ethical processes, I negotiated my best guess at ethical actions in each moment but was also able to reflexively examine my missteps and blunders once I had left the field. This can sometimes be the best-case scenario when a PhD student confidently sets out to ‘do good’.

Conclusion

The essential normative role of ethics committees and professional ethical frameworks cannot be discounted. Meanwhile for clinician researchers and especially for an ethnographer, the complexity of the microethical environment requires a more agile and relational approach. The inherent and intentional messiness of qualitative research cannot be straightened out with uniform adherence to broad principles. You cannot learn about the jungle by trying to prune it. To do so would be to damage research relationships, and also blow past the microethical challenges which researchers must navigate and reflexively incorporate into their findings. By acknowledging a relational form of negotiated ethical decision making that attends to the small and complex decisions made throughout research practice, clinician researchers can demonstrate a continuity between how they enact something like beneficence both in the context of clinical work and in the field.

What confidence I did have in the ethical decisions made during fieldwork was derived from the authenticity of my relationship with each of these people that were being so generous with their time, energy, and privacy. At the end of her final interview, Kira said she had appreciated our time together. As I went to turn off the audio recorder she said

…it’s good when you have somebody, and I know it’s for your study, but, that gives a shit, in a way, yeah, so thank you.

Beneficence is not always demonstrated through specific acts of help or guidance, but through the nature of genuine relationships. I would argue that this quote illustrates one of the surest footings the hapless clinician researcher can find, when traversing the field. Externally it may look like the principle of doing good is enacted inconsistently. However, if actions are derived from a beneficent relationship based on trust and respect, where you are fundamentally on the participant’s side (Becker, 1967), then everything else can follow.