John Miles Little, b. 1932, is a surgeon, philosopher, and poet, whose scholarship has been central to the beginnings and growth of bioethics and the medical humanities in Australia. As the commentaries by scholars in this volume demonstrate, his scholarship continues to influence and stimulate thinking in these fields.

From his school days, Little was the beneficiary of the archetypical Classical or Liberal Arts model of education. He attended the Cranbrook School and then was a resident of St Paul’s College at the University of Sydney where he had enrolled in a Bachelor of Arts and developed a growing love of Litterae Humaniores. At age twenty he was invited to the newly built University House at the Australian National University by its first Master, his erstwhile lecturer in Classical Archaeology, Latin, and Classical Greek at the University of Sydney (A.S. Trendall). Here, Little was immersed in an extraordinary, exploratory intellectual environment, created by the daily dinner table and afternoon stroll discussions of some of Australia’s most remarkable scholars from across the humanities and the social, natural, and applied sciences. Thus, even as he transferred into the narrow confines of a medical degree, Little was nourished by an interdisciplinary environment and role models of sagacity, kindness, and vision.

Little graduated MB BS in 1959. He qualified as a surgeon ten years later and as an MD nearly a decade after that. He was engaged early in both teaching medical students and in highly technical aspects of research. His studies included (among many others) a mathematical analysis of the importance of the profunda femoris in maintaining the integrity of the ischaemic limb, a tissue culture programme to predict in vivo response to cancer chemotherapy, and a survey of the clinical spectrum of chronic pancreatitis. He published a book on the management of liver injuries in 1971 and another on amputations for vascular disease in 1975. He held visiting Lecturer and Professorships in the United Kingdom, Hong Kong, and elsewhere and became the foundation President of the World Association of Hepatic Pancreatic and Biliary Surgeons in 1987.

From the start, Little was fascinated by the human side of medicine. He was a medical student in the era of Boys in White (Becker et al. 1961) and became a doctor at a time when medical practice was defined and centred in medical authority and when that authority seemed underwritten and extended by the extraordinary technical advances being made in the postwar era. But his medical career also coincided with the questioning of that authority. Some of these questions came from new research methods—in particular the rise of “Chicago School” qualitative research—scholars such as Howard Becker, Anselm Strauss, Kathy Charmaz, and Erving Goffman, who turned their critical, analytic eyes on medicine and healthcare. Some questions came from the blistering critiques of “Nazi medicine” and the treatment of subjects in medical research; others from the social movements of the 1960s and 1970s, which increasingly and angrily rejected the ways in which medicine had been used to disempower women, people of colour, people with mental illness, and others made vulnerable by illness. And some questions arose from the flourishing of the history and philosophy of science, which queried the basis on which authoritative knowledge claims could be founded. (Like Archie Cochrane [1993], Little advocated the application of what he referred to as an “agricultural” method to improve medical evidence: the randomized controlled trial; suggesting this in a paper with a typically erudite and literary title—“Eupompus gave splendour to art by numbers”).

Little was an active contributor to these critiques of medicine (he wrote a paper in 1972 titled “God and the doctor we alike adore”) and to new approaches to learning and practicing it. The growth of these ideas can be seen in papers Little published in the 1970s. For example, one offered a Popperian analysis of clinical process. Another series of papers explored the intellectual challenges of improving surgical techniques for the amputations needed to manage vascular disease (“Amputation of the leg—a dull topic revisited,” 1973), took a critical eye to assessing those techniques (“I.P.O.P.—miracle, menace or gimmick?,” 1975b), and expressed doubts about the value of these techniques to patients (“Successful amputation—by whose standards?”, 1975a; “Vascular Amputees—a study in disappointment,” Lancet 1974, discussed in this volume).

Little was especially interested in applications of philosophy and the humanities, including literature, to medicine. These fields had acquired considerable momentum by 1979, the year in which both the first edition of Beauchamp and Childress’ foundational text The Principles of Biomedical Ethics and Samuel Shem’s (1979) novel exposing the harms and dehumanizations of medical practice, The House of God, were published. Indeed, in some ways, these two texts mirror Little’s forty year contribution to bioethics and the medical humanities—informed by both the traditions of analytic philosophy and by poetry and literature. Little’s love of words and of rich language, expressive of conceptualizations of both the esoteric and the everyday, was always central to his practice (another of the erudite titles of Little’s papers of the 1970s: “Mantology and medicine,” We leave it to the reader to guess its topicFootnote 1).

By the late 1980s Little had embarked on a series of projects in the philosophy of medicine, at which time he was joined by Christopher Jordens, a postdoctoral scholar trained in public health, philosophy, and linguistics. At the outset of a research collaboration that would continue for the next two decades, they produced detailed analyses of the communication process in the clinical encounter, using linguistic, semiotic, and hermeneutic techniques and explored the qualia of patient experiences, as in their 1998Social Science and Medicine paper “Liminality: A major category of the experience of cancer illness,” discussed in this volume. At the same time, Little drew together a large network of colleagues—fellow poet-clinicians such as Stan Goulston, rising clinician policy-influencers such as Stephen Leeder, medical education innovators such as John Hamilton, Medical Humanities leaders like Jill Gordon, and medico-legal scholars such as John McPhee, and engaged them in conversation through interdisciplinary “Core Group” meetings.

Miles Little’s Phronesis: Values and Humanistic Practice at VELiM

In 1995, Little established the Centre for Values, Ethics and the Law in Medicine (VELiM) at the University of Sydney and was its director until 2003, when Ian Kerridge took over the lead. From the outset, VELIM flourished—becoming the largest and most research-active bioethics centre in the Southern Hemisphere and one of the largest internationally. Postgraduate courses were established in bioethics, qualitative research, and the medical humanities. The Centre attracted extraordinary academics from a very diverse range of disciplines and from across the globe. The atmosphere at VELiM was uniquely constructive, lively, and intellectually daring, both rigorous and adventurous. Ethical principles of power sharing and inclusivity produced new University resources (like ethical authorship guidelines) and warm collegial processes. Many of the scholars nurtured there have become leaders in their fields, establishing research programmes and Centres of their own.

It was extraordinary, and unique, as such places of flourishing are.

Importantly, once freed from the administrative tedium and political tension of securing and growing the Centre, Little became its soul and academic heart. “Conversation,” initially a forum for established academics and thinkers, became more diverse, inclusive, and exploratory. Conversation was also the medium through which the Centre intellectual flourishing occurred—and it is notable that “flourishing” was, not accidentally, a concept that, like phronesis, Little was drawn to as a scholar while experiencing its actualization. Perhaps the quality of this era is best exemplified in the title of Little’s 2004 monograph, “Community, security, and human flourishing,” because at VELiM, a true community of scholars, students, and researchers sought (and continue to this day) to explore ideas, test out the limits of their thinking, and discuss different methodologies, resources, theories, concepts, disciplines, and perspectives at the Centre—each one coming away challenged and enriched, intellectually and personally.

And at the same time Little’s own thinking, research, and writing grew from the community and the discursive practices that he had established at the Centre. His work continued to reach across disciplines and into myriad different fields of enquiry—survivorship, illness experience, agency, existential distress, mortality, virtues, silence, identity, value-based care, decision-making and consent, corruption, peer review, ontology, methodology, epistemology and evidence, medical foundationalism, exceptionalism, terror, trust, discourse and communal norms, hope and despair, aging and dementia—his vision and creative energy were expansive and infectious.

Introducing the Symposium

This symposium seeks to do two things. The first is to introduce and to re-acquaint academics, researchers, and students in bioethics with the work of Miles Little. It is our view that his work is salient not just to the issues bioethics concerns itself with but also, and perhaps more importantly, to the way that bioethics can be done. The second goal is to identify and honour Miles Little’s contributions to bioethics and the medical humanities. To achieve this, we have republished five of Little’s papers (selected by Little himself, who was asked to nominate his “favourites”) along with new commentaries on each of these papers. The idea behind this structure was not simply to provide contemporary reflections on contributions but to replicate, in some small way, the kind of dialogue that Little established at VELiM and that he and we continue to value so highly; to open up new conversations. The observations of Little’s work offered up in these commentaries are not, therefore, uncritical or sycophantic but reflect new ideas and new thought fomented by Little’s original offerings.

The first paper is “Vascular amputees—a study in disappointment” (1974), co-authored with Dora Petritsi-Jones and Charles Kerr. In this paper, Little and his co-authors explore the disparity between the views of vascular amputation patients and those of the medical staff who perform them. Based on interviews with post-amputation patients, Little and co-authors argue that practitioners must be more honest and realistic with their patients about the effects of amputation, which can be lasting and fundamentally disruptive. In their responses to this paper, Christopher Jordens (2022) and Michael Loughlin (2022) pick up on important themes that emerged from this work. Jordens examines Little’s choice to pursue qualitative research through his work, instead of two other paradigms available, including evidence-based medicine and quality-of life research, highlighting the way in which qualitative research methods engage with the power relations of socially marginalized individuals (especially as research subjects), which Little’s legacy helps to explain. Taking a different tack, Loughlin (2022) discusses the significance of Little’s paper for the development of the disability rights movement, as well as the movements for values-based medicine and person-centred care.

The second paper presented here is “Liminality: A major category of the experience of cancer illness” (1998), co-authored with Christopher Jordens, Kim Paul, Kathleen Montgomery, and Bertil Philipson. This paper analyses the experience of patients who have had colon cancer and elucidates three themes: the impact of the diagnosis on personal identity, feelings of alienation, and a sense of boundedness in time. Together, Little and co-authors describe this as “liminality.” In their commentary, symposium editors Claire Hooker and Ian Kerridge (2022) reflect upon the concept of liminality as a social phenomenon and explain how we see it arising in late modernity in various forms due to our increasingly unsettled global world. Jackie Leach Scully (2022) discusses the import of the concept of “liminality” for cancer survivorship and increasingly for other disease or treatment types as well. The range of health concerns to which liminality is applied challenges the concept, even as it helps to enlighten patient experiences.

The third paper is “Discourse communities and the discourse of experience” (2003), co-authored with Christopher Jordens and Emma-Jane Sayers. In this paper, Little and co-authors discuss the benefits and risks presented by discourse communities, which are created by groups of people who share common ideologies and ways of speaking about things. In medicine, the existence of many discourse communities created by patients, practitioners, and policymakers can make it difficult to communicate across groups. In his commentary on this piece, Paul Macneill (2022) focuses on drawing out parts of the theory of discourse community to illustrate the overlap of ethics with aesthetics in dialogue. Christopher Mayes (2022) takes a more experiential approach, using Little and co-authors’ discussion as a springboard for reflection upon his own interviews with Little about establishing a bioethics centre, and his own experience of that centre as a discourse community.

The fourth paper is “Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation” (2007), co-authored with Christopher Jordens, Catherine McGrath, Kathleen Montgomery, Ian Kerridge, and Stacy M. Carter. This paper describes interviews conducted with patients undergoing autologous stem cell transplantation for cancer treatment and their carers, to understand their attitudes toward alternative medical advice and to discover instances of contested understanding of transplant-relevant information. In his commentary, Paul Komesaroff (2022) argues that contested understandings in the clinic are not necessarily undesirable. As “an unruly collection” of practices, medicine must engage in productive dialogues across divides, rather than be represented in a single discourse. In the second commentary, Siun Gallagher (2022) focuses on how the norms of qualitative inquiry affect the representation of emotional features of interview data. Highlighting an alternative split, of empirics and emotion, Gallagher writes that emotional data ought to be included in reports, and that this is important to narrative technique and reflexive practice.

The final paper in this symposium is the most recent, “An archeology of corruption in medicine” (2018), co-authored with Wendy Lipworth and Ian Kerridge, and provides a conceptual exploration of corruption as it appears in social institutions and especially medicine. Little and co-authors argue that corruptibility is a necessary feature of institutions which will be exploited by people who have anti-social tendencies. Elliott (2022) takes this piece as the starting point for a discussion of how capitalist market-driven medical systems can corrupt the character of doctors. Continuing the analysis of corruption along capitalist lines, symposium editor Kate MacKay (2022) explores whether corruptibility is a necessary feature of social entities, arguing that while not a necessary feature, it may frequently arise where individualistic values are unchecked. Montgomery (2022) highlights similarities between Little and co-authors’ discussion of medicine with the persistence of scientific misconduct in research and publishing and incorporates research about the importance of trust and trustworthiness at individual and institutional levels to people’s well-being and sense of security.

Making (Provisional) Sense of the Work of Miles Little

What is immediately apparent from Little’s approach to each of the issues explored in these five papers is that his work does not adhere to or apply a single normative theory or framework. His approach, in contrast, is a more axiological or meta-ethical one—opening up exploration of issues or ideas and providing guidance for the examination of the lifeworld rather than seeking to provide an “answer” through philosophical analysis. This “incredulity towards meta-narratives” marks out Little’s work as undeniably post-modern (Lyotard 1994). But this label, as is so often the case, understates and misunderstands Little’s philosophical approach or process of intellectual inquiry.

What more then, can be said about his work and its place in the history of bioethics? Here we offer some tentative suggestions as to how Little’s methodology may be understood. These comments extend those offered at more length in the introduction to the collection of Little’s papers that was published in 2003 to mark Little’s retirement from the role of Director and reflect on the wealth of co-authored papers Little has published since that date (Jordens et al. 2003).

First, Little’s work is grounded in lived experience, history, place, context, and culture. In this regard, like Foucault and Nussbaum, Little’s work combines theoretical richness and empirical data—using an approach he termed “dialectical empiricism”—providing immediately accessible but also deeply humane and theoretically informed insights into the moral domain and into our search for the “good life” (human flourishing).

Second, as with many Continental philosophers and critical bioethicists, Little’s work is informed not simply by the clinic or by moral philosophy but also by sociology, the humanities, and political philosophy—by critiques of medical dominance, by descriptions of symbolic power and governmentality, by conceptions of surveillance and the panopticon (Foucault 1973), and by accounts of social roles, illness, and the social construction of disease. Consequently, Little’s approach to understanding corrupt people or organizations, or the experience of someone who has had a leg amputated or been diagnosed with cancer, is to start by examining how history, power, language, community norms, human relationships, ideas about evidence, political action, and contested values shape, define, and delimit each of them. Little’s concern is not to pathologize or medicalize these things but to understand them better—to see what gives them meaning. In this regard, his work is concerned not simply with ethics but also its intersection with ontology and epistemology.

Finally, Little’s writing, like that of Habermas, Levinas, Benhabib, Deleuze, Lyotard, Apel, and Rehg, is characterized by its attention to language, communication, discourse, and narrative—which for Little express social, political, and moral qualities—giving us meaning, purpose, belonging, identity, and security. Indeed, for Little, unless we actively listen, unless we understand how narratives and discourse are shaped, informed, constructed, empowered, and constrained, we cannot even begin to understand an issue, perspective, argument, or experience. As he noted in a 1998 paper examining the ethics of evidence and reasoning in medicine and epidemiology, “Assignments of meaning in epidemiology”:

The various stakeholders often do not know each other’s concerns and their geneaology. Logical argument and sustained reasoning will only work if they have a sound base from which to start. We are only likely to discover what our own perceptions are, let alone the perceptions of the other stakeholders, if we systematically generate and review the narratives within which we are consciously or unconsciously working. (1142)

At a time when the world appears divided and torn apart—its divisions, inequities, injustices, experiences, and histories exposed and accentuated by COVID-19, this notion, that bioethics, healthcare, research, policy, and politics require reflection, respect, understanding, and listening, seems more important than ever. We hope that these five small papers and the commentaries that accompany them provide an introduction to the enduring legacy of Miles Little’s work and open up new conversations around how we should live.