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An Ethics Expertise for Clinical Ethics Consultation

Published online by Cambridge University Press:  01 January 2021

Lisa M. Rasmussen
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Extract

A major obstacle to broad support of clinical ethics consultation (CEC) is suspicion regarding the nature of the moral expertise it claims to offer. The suspicion seems to be confirmed when the field fails to make its moral expertise explicit. In this vacuum, critics suggest the following:

  1. (1) Clinical ethics consultation's legitimacy depends on its ability to offer an expertise in moral matters.

  2. (2) Expertise in moral matters is knowledge of a singular moral truth which applies to everyone.

  3. (3) The claim that a clinical ethics consultant can offer knowledge of a singular moral truth in virtue of her professional training is absurd, false, or gravely immoral.

    Therefore,

  4. (4) The field is illegitimate.

Type
Independent
Information
Journal of Law, Medicine & Ethics , Volume 39 , Issue 4 , Winter 2011 , pp. 649 - 661
Copyright
Copyright © American Society of Law, Medicine and Ethics 2011

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References

Of course, several authors have forwarded individual conceptions of expertise, some of which will be discussed in this paper. However, there is no field-wide consensus on a conception of moral expertise which could offer guidance in making decisions about professional standards.Google Scholar
Satel, Sally, for example, seems to endorse the premises explicitly: “The matter of ethical expertise—what it looks like, who can claim it—is a profound one. Bioethics' place in the academy, in the clinical realm, and in society turns on it. For most of us, the very idea of ‘right’ answers to complex moral and philosophical dilemmas such as euthanasia, embryonic stem cell cloning, or organ remuneration is absurd on its face. After all, deriving an “answer” depends upon which type of moral theory one favors.” Satel, S., “The Right (and Wrong) Answers,” The Book: An Online Review, The New Republic, 2010, available at <http://www.tnr.com/book/review/the-right-and-wrong-answers> (last visited September 9, 2011). Wesley Smith argues in a similar vein: “… training in bioethics adds little to resolving outcomes, since the field cannot provide ultimate verdicts on moral questions.” Smith, W., “The Question of Method in Ethics Consultation: Transforming a Career into a Profession?” American Journal of Bioethics 1, no. 4 (2001): 42–43, at 42. (last visited September 9, 2011). Wesley Smith argues in a similar vein: “… training in bioethics adds little to resolving outcomes, since the field cannot provide ultimate verdicts on moral questions.” Smith, W., “The Question of Method in Ethics Consultation: Transforming a Career into a Profession?” American Journal of Bioethics 1, no. 4 (2001): 42–43, at 42.' href=https://scholar.google.com/scholar?q=Satel,+Sally,+for+example,+seems+to+endorse+the+premises+explicitly:+“The+matter+of+ethical+expertise—what+it+looks+like,+who+can+claim+it—is+a+profound+one.+Bioethics'+place+in+the+academy,+in+the+clinical+realm,+and+in+society+turns+on+it.+For+most+of+us,+the+very+idea+of+‘right’+answers+to+complex+moral+and+philosophical+dilemmas+such+as+euthanasia,+embryonic+stem+cell+cloning,+or+organ+remuneration+is+absurd+on+its+face.+After+all,+deriving+an+“answer”+depends+upon+which+type+of+moral+theory+one+favors.”+Satel,+S.,+“The+Right+(and+Wrong)+Answers,”+The+Book:+An+Online+Review,+The+New+Republic,+2010,+available+at++(last+visited+September+9,+2011).+Wesley+Smith+argues+in+a+similar+vein:+“…+training+in+bioethics+adds+little+to+resolving+outcomes,+since+the+field+cannot+provide+ultimate+verdicts+on+moral+questions.”+Smith,+W.,+“The+Question+of+Method+in+Ethics+Consultation:+Transforming+a+Career+into+a+Profession?”+American+Journal+of+Bioethics+1,+no.+4+(2001):+42–43,+at+42.>Google Scholar
Because clinical ethics consultation includes a variety of skills and roles, none of which provide its sole raison d'être, the attempt might be made to avoid the critique altogether by focusing on skills other than moral expertise. For example, it is often observed that clinical ethics consultation regularly involves communication problems. This has been substantiated by at least one empirical study: Førde, Vandvik, conclude their study by observing that “[p]roblems related to information/communication may underlie a classical ethical problem. Identification of these ‘hidden’ problems may be important for the analysis, and hence, the solution to the ethical dilemma.” Forde, R. Vandvik, I. H., “Clinical Ethics, Information, and Communication: Review of 31 Cases from a Clinical Ethics Committee,” Journal of Medical Ethics 31, no. 2 (2005): 73–77, at 73. CECs may be most useful to the extent that they can resolve these kinds of problems, which may focus around an ethical question but involve no real ethical dilemma. However, this strategy to avoid the critique is problematic because “ethics” is usually understood to be a main function of the field's activity. It seems incumbent on clinical ethics consultants to articulate and defend a conception of the expertise they provide in ethical matters which does not fall prey to the objections of absurdity and grave wrongness.CrossRefGoogle Scholar
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Of course, many proposals have been made for a conception of moral expertise in clinical ethics consultation. However, pace the Core Competencies documents, which are tentative and advisory, the field has not formally adopted a conception of moral expertise on which to ground certification, accreditation, etc. See American Society for Bioethics and Humanities, Core Competencies for Healthcare Ethics Consultation, 2nd ed., 2011, and American Society for Bioethics and Humanities, Core Competencies for Healthcare Ethics Consultation, Glen-view, IL, 1998.Google Scholar
And which, incidentally, may be taught, assessed, certified, licensed, and in other ways standardized.Google Scholar
In a review of two books on clinical ethics consultation, Laurie Zoloth-Dorfman and Susan Rubin make a similar distinction between “moral expertise” and “ethics expertise:” “[The clinical ethics consultant's expertise] is an expertise not in morals, but in ethics. In other words, hers is a discipline that functions not by offering declarative normative judgments, but rather by raising critical questions and focusing conversation and deliberation.” Zoloth-Dorfman, L. Rubin, S., “Navigators and Captains: Expertise in Clinical Ethics Consultation,” Theoretical Medicine 18, no. 4 (1997): 421–432, at 430. However, as the focus of the article lies elsewhere, it does not further probe that distinction.CrossRefGoogle Scholar
“Ethical expertise” is another possible term, but because of the adjective's ambiguity, it can also mean “expertise delivered in an ethical way.” “Ethics expertise,” on the other hand, refers more explicitly to expertise in ethics.Google Scholar
This also includes knowledge of how moral arguments proceed, the objections to which they are vulnerable, the implications of adopting various premises, etc. However, as this is an unobjectionable form of moral expertise, I focus here on the “ethos” content of ethics expertise, and simply include analysis of arguments within the abilities of an ethics expert.Google Scholar
For example, that respecting the autonomy of individuals means not treating them contrary to their wishes, or that removing life support from a brain-dead patient is acceptable. I do not mean to imply that professional consensus means that the correct answer has been discovered or established. However, if patients and family members are uncertain about their choices, it may help to know what other people have thought about an issue. At the same time, consultants must be careful that the provision of such information not be used as a coercive tool.Google Scholar
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I assume that consultation must be legitimated on its own grounds (regardless of profitability) as a necessary condition for being practiced in hospitals, though I recognize that an institution may have a keen interest in the economic effects of the service. To that end, it is worth considering the evidence that consultation services can be seen as useful and as net cost-saving. Heilicser, B. Meltzer, D. Siegler, M., “The Effect of Clinical Medical Ethics Consultation on Healthcare Costs,” Journal of Clinical Ethics 11, no. 1 (2000): 31–38; Gilmer, T. Schneiderman, L. J. Teetzel, H. Blustein, J. Briggs, K. Cohn, F. Cranford, R. Dugan, D. Komatsu, G. Young, E., “The Costs of Nonbeneficial Treatment in the Intensive Care Setting,” Health Affairs 24, no. 4 (2005): 961–971. However, I have also cautioned against an overreliance on a cost-saving justification of clinical ethics consultation. Rasmussen, L. M., “Sinister Innovations: Beware the Cooptation of Clinical Ethics Consultation,” Journal of Value Inquiry 40, nos. 2–3 (2006): 235–242.Google Scholar
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In addition, the likely form of consultants' advice is that various options are possible. The appropriate measure of commonality among consultants might be that they (1) identify as inappropriate the same choices and (2) identify similar ranges of possibilities, as well as the kind of additional information that might help them to make a more decisive evaluation. It is also worth noting that the lack of consensus in this study at least fails to support any claims to moral or cultural hegemony among clinical ethics consultants.Google Scholar
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