This written account of a clinical encounter - depicting fragments of a more extensive array of events - attempts to exemplify many facets and associated complexities of clinical ethics consultation. Within the general telling, I provide more detailed portrayals of several key events. In secion 1, I document briefly my initial interactions at the beginning of the consultation, focusing on the information gained - in the context of those interactions - as I read the medical chart of Mrs. Rose. Next (...) in section 2, I briefly describes my initial conversation with Mrs. Rose's three sons. Section 3 illustrates several questions raised in sections 1 and 2. Then section 4 presents my encounter with Paul, the youngest son, as he was carrying out his vigil at his mother's bedside in the hospital. Section 5 chronicles my interactions with several care providers involved in Mrs. Rose's situation, including two different meetings that occurred with Mrs. Rose's attending physician. I conclude in section 6 by telling about a conversation I had with Mrs. Rose's middle son, Russell, approximately one month after Mrs. Rose died. (shrink)

Despite increased attention to the question of how best to evaluate clinical ethics consultations and emphasis on external evaluation, there has been little sustained focus on how we, as clinicians, make sense of and learn from our own experiences in the midst of any one consultation. Questions of how we evaluate the request for, unfolding of, and conclusion of any specific ethics consultation are often overlooked, along with the underlying question of whether it is possible to give an accurate account (...) of clinical ethics consultants’ experience as experienced by ethics consultants. Before the challenge of submitting one’s accounts or case reports for review and evaluation from others, there is an underlying challenge of understanding and evaluating our own accounts. To highlight this crucial and deeply challenging dimension of actual clinical ethics practice, we present an account of a complex consultation, explicitly constructed to engage the reader in the unfolding experience of the consultant by emphasizing the multiple perspectives unfolding within the consultant’s experience. Written in script format, the three perspectives presented—prototypical clinically descriptive account; didactically reflective and self-evidentiary account often seen in journal presentations; highly self-critical reflective account emphasizing uncertainties inherent to clinical ethics practice—reflect different manners for responding to the ways actual clinical involvement in ethics consultation practice accentuates and refocuses the question of how to understand and evaluate our own work, as well as that of our colleagues. (shrink)

The primary goal of ethics consultation should be to provide effective assistance to patients and families in obtaining care that is duly responsive to their rights and their needs. The consultation reported by Mark Bliton fails in this regard because it never ascertains why the consultation was called; makes little attempt to ascertain the motives of those involved; avoids exploration of the ethical concerns of family, attending or staff; makes no connection with institutional policies or practices; uncritically adopts and serves (...) the medical treatment ethos; and substitutes fellowfeeling for compassionate action. (shrink)

Theoretical accounts of the nature and purposes of clinical ethics consultation are disappointingly superficial and diffuse. Attempts to illuminate the goals, the forms, the substance, and the criteria for the success of ethics consultations need to focus on detailed reports of cases and the contexts in which they occur. The uncommonly rich description of the consultation surrounding Mrs. Roses plight provides a splendid opportunity to explore such matters. The ethics consultant pursues a number of ventures providing and clarifying information, improving (...) communication, educating and counseling, and being a friend with variable degrees of success. What the ethics consultant can do and how well he can do it are in large part constrained by three features of the hospital context in which this consultation unfolds: pervasive, perhaps ineliminable, uncertainty; communication failures; and firmly entrenched power. A fundamental issue for an ethics consultant is whether structural and institutional constraints should be accepted or challenged. Should an ethics consultant be a peacemaker or a reformer? (shrink)

In an overview of the essays in this project, a number of clinical ethics issues receive emphasis. (1) One cluster concerns the ethical concerns presented within the relationship between the providers (doctor, nurse, etc.) and patient (and family), as distinct from those associated with being a clinical ethics consultant invited into a situation to assist. (2) Distinct from these are ethical issues intrinsic to the ways in which clinical encounters are variously written about (from chart notes to published articles). (3) (...) Finally, there is a set of issues connected with the major characteristics of clinical encounters, in view of which it is imperative to be specifically attentive to the fine details and complex interactions among patient, doctor, family, and others, within a specific social context. Keeping these matters in mind helps to clarify the differences between consulting (talking and listening) and writing about consultations, as well as among the various kinds of writing about clinical encounters. (shrink)

Baylis, Tomlinson, and Hoffmaster each raise a number of critiques in response to Bliton's manuscript. In response, we focus on three themes we believe run through each of their critiques. The first is the ambiguity between the role of ethics consultation within an institution and the role of the actual ethics consultant in a particular situation, as well as the resulting confusion when these roles are conflated. We explore this theme by revisiting the question of What's going on? in clinical (...) ethics consultations. Moving from those issues associated with the role of the ethics consultant to those associated with the role of inquiry within the practice of ethics consultation, we then take up the serious challenge that Bliton seems shackled by the assumptions and institutional dispositions embedded in the medical culture in which he is working. This reveals the second theme, namely that there is a risk of co-optation when acting in a role that derives its legitimacy from institutional sources. Finally, we focus on an even more problematic implication stemming from the first two, namely that the focus on institutional power as the crucial factor for determining ethical significance has the effect of distorting, and perhaps obscuring, other forms of relational, interpersonal, and moral meaning. (shrink)