Craig M. Nelson

Being an architect of moral space within the health care setting as well as a mediator of the conversations that take place within that space calls for bold ideas and new thoughts. Modern medicine within the American health care setting has been criticized as separating matter from consciousness as well as fact from meaning and value.$\sp1$ Moral space and modern medicine have also historically fallen victim to a similar bifurcation. Moral conversation has traditionally been overlooked as an integral part of the medical enterprise. ;The architecture of a morally sensitive bioethics in this paper will unfold occasioned by awakened self-reflection..... by becoming aware and developing such awareness by pointing to the need for a new level of ethical consciousness: a new medical mythoeuroconsciousness. The movement of this extended essay will begin with a criticism of the dualism of modern medicine while calling for a new model of wholeness and connectedness to take its place. Process thought will be examined for its understanding of unity, convergence, interrelationship, and organismic understanding of reality. It will be argued that process needs assistance that will emphasize "quality of relating," a kind of ecological twist. This ecological-process becomes the theoretical basis for restructuring the modern concept of medicine and its ethics; but it still remains a theoretical model in need of a methodological tool for becoming practical. The architects of moral space look to the wisdom of neo-casuistry for its methodology because of its contextual flexibility and its dependence upon an organismic understanding of experience. This process ecological-casuistical postmodern bioethics, in its being life centered and contextual, must include an embrace for human dignity and its demands. Process vision, ecological orientation, a casuistical methodology, and the honoring of human dignity and its demands form the architecture of analysis for examining ethical dilemmas. ftn$\sp1$David Bohm, "Postmodern Science and a Postmodern World," in The Reenchantment of Science, David Griffin, ed. , 60

In clinical ethics an enduring case takes on a life of its own and comes to closure over a long period of time. This essay describes the evolution of such a case over a 1–year period. The case involves a 90–year old male patient with multiple chronic medical conditions who lacked decision–making capacity, was a resident of a long–term care facility, and did not have known previously expressed wishes regarding medical treatment. The ethics consultation initially revolved around this question: What method or process must be employed so that medical treatment decisions could be ethically reviewed and could include a shared decision–making process for Mr. Smith? This case analysis describes the evolution of this case and argues that the good of the patient must remain paramount throughout an enduring case.