As everybody knows, advances in medicine and medical technology have brought enormous benefits to, and created vexing choices for, us all – choices that can, and occasionally do, test the very limits of thinking itself. As everyone also knows, we live in the age of consultants, i.e., of professional experts who are ready, willing, and able to give us advice on any and every conceivable question. One such consultant is the medical ethics consultant, or the medical ethicist who consults.Medical ethics (...) consultants involve themselves in just about every aspect of health care decision making. They help legislators and judges determine law, hospitals formulate policies, medical schools develop curricula, etc. In addition to educating physicians, nurses, and lawyers, amongst others, including medical, nursing, and law students, they participate in clinical decision making at the bedside. (shrink)

This paper explores the relevance of the debate about ethical expertise for the practice of clinical ethics. We present definitions, explain three theories of ethical expertise, and identify arguments that have been brought up to either support the concept of ethical expertise or call it into question. Finally, we discuss four theses: the debate is relevant for the practice of clinical ethics in that it (1) improves and specifies clinical ethicists' perception of their expertise; (2) contributes to improving the perception (...) of moral competence of non-ethicists; (3) gives insight into complementary styles of argumentation of ethicists and non-ethicists; and (4) contributes to the awareness of the problem of profession-building of (clinical) ethicists. (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)

This paper discusses the importance of Richard M. Zaners work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is (...) bound up with the normative commitments of medicine as a therapeutic enterprise. (shrink)

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they offer (...) against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates. Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one’s role as a moral agent and reflection on one’s progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project. (shrink)

Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints—and for what reasons—should be considered when evaluating the quality of a service. In this (...) paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research. (shrink)

Public bioethics bodies are used internationally as institutions with the declared aims of facilitating societal debate and providing policy advice in certain areas of scientific inquiry raising questions of values and legitimate science. In the United States, bioethical experts in these institutions use the language of consensus building to justify and define the outcome of the enterprise. However, the implications of public bioethics at science-policy boundaries are underexamined. Political interest in such bodies continues while their influence on societal consensus, public (...) debate, and science policy remains ambiguous. This article presents a theoretical discussion of public bioethics bodies as boundary organizations and examines them in terms of relationship to the moral and cognitive authority of science and other forms of expertise, mechanisms for public participation in controversial science policy, and the deployment of consensus models. The theoretical discussion is examined in the case of the U.S. Human Embryo Research Panel. (shrink)

In a recent issue of the Journal of Medicine and Philosophy, several scholars wrote on the topic of ethics expertise in clinical ethics consultation. The articles in this issue exemplified what we consider to be two troubling trends in the quest to articulate a unique expertise for clinical ethicists. The first trend, exemplified in the work of Lisa Rasmussen, is an attempt to define a role for clinical ethicists that denies they have ethics expertise. Rasmussen cites the dependence of ethical (...) expertise on irresolvable meta-ethical debates as the reason for this move. We argue against this deflationary strategy because it ends up smuggling in meta-ethical assumptions it claims to avoid. Specifically, we critique Rasmussen’s distinction between the ethical and normative features of clinical ethics cases. The second trend, exemplified in the work of Dien Ho, also attempts to avoid meta-ethics. However, unlike Rasmussen, Ho tries to articulate a notion of ethics expertise that does not rely upon meta-ethics. Specifically, we critique Ho’s attempts to explain how clinical ethicists can resolve moral disputes using what he calls the “Default Principle” and “arguments by parity.” We show that these strategies do not work unless those with the moral disagreement already share certain meta-ethical assumptions. Ultimately, we argue that the two trends of attempting to avoid meta-ethics by denying that clinical ethicists have ethics expertise, and attempting to articulate how ethics expertise can be used to resolve disputes without meta-ethics both fail because they do not, in fact, avoid doing meta-ethics. We conclude that these trends detract from what clinical ethics consultation was founded to do and ought to still be doing—provide moral guidance, which requires ethics expertise, and engagement with meta-ethics. To speak of ethicists without ethics expertise leaves their role in the clinic dangerously unclear and unjustified. (shrink)

There seem to be two clearly-defined camps in the debate over the problem of moral expertise. On the one hand are the “Professionals”, who reject the possibility entirely, usually because of the intractable diversity of ethical beliefs. On the other hand are the “Ethicists”, who criticise the Professionals for merely stipulating science as the most appropriate paradigm for discussions of expertise. While the subject matter and methodology of good ethical thinking is certainly different from that of good clinical thinking, they (...) argue, this is no reason for rejecting the possibility of a distinctive kind of expertise in ethics, usually based on the idea of good justification. I want to argue that both are incorrect, partly because of the reasons given by one group against the other, but more importantly because both neglect what is most distinctive about ethics: that it is personal in a very specific way, without collapsing into relativism. (shrink)

“Ethics” is used as a label for a new kind of expertise in the field of science and technology. At the same time, it is not clear what ethical expertise consists in and what its political status in modern democracies can be. Starting from the “participatory turn” in recent social research and policy, we will argue that bioethical reasoning has to include public views of and attitudes towards biomedicine. We will sketch the outlines of a bioethical conception of “public understanding (...) of ethics,” addressing three different issues: (a) the methodological relevance of moral questions and problems raised by lay persons in everyday life regarding biomedicine and technology, (b) the normative relevance of such lay moralities for the justification of ethical decisions, and (c) the necessity of public deliberation in this context. Finally, we draw conclusions in view of the concepts and methods such a conception of “public understanding of ethics” should employ. (shrink)

As AI is linked to more and more aspects of our lives, the need for algorithms that can take decisions that are not only accurate but also fair becomes apparent. It can be seen both in discussions of future trends such as autonomous vehicles or the issue of superintelligence, as well as actual implementations of machine learning used to decide whether a person should be admitted in certain university or will be able to return a credit. In this paper, we (...) will use Dreyfus’ account on ethical expertise to show that, to give an AI some ability to make ethical judgements, a pure symbolic, conceptual approach is not enough. We also need the ability to make sense of the surroundings to reframe and define situations in a dynamic way, using multiple perspectives in a pre-reflective way. (shrink)

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)

Douglas Diekema has argued that it is not the best interest standard, but the harm principle that serves as the moral basis for ethicists, clinicians, and the courts to trigger state intervention to limit parental authority in the clinic. Diekema claims the harm principle is especially effective in justifying state intervention in cases of religiously motivated medical neglect in pediatrics involving Jehovah’s Witnesses and Christian Scientists. I argue that Diekema has not articulated a harm principle that is capable of justifying (...) state intervention in these cases. Where disagreements over appropriate care are tethered to metaphysical disagreements, it is moral-metaphysical standards, rather than merely moral standards, that are needed to provide substantive guidance. I provide a discussion of Diekema’s harm principle to the broader end of highlighting an inconsistency between the theory and practice of secular bioethics when overriding religiously based medical decisions. In a secular state, ethicists, clinicians, and the courts are purportedly neutral with respect to moral-metaphysical positions, especially regarding those claims considered to be religious. However, the practice of overriding religiously based parental requests requires doffing the mantle of neutrality. In the search for a meaningful standard by which to override religiously based parental requests in pediatrics, bioethicists cannot avoid some minimal metaphysical commitments. To resolve this inconsistency, bioethicists must either begin permitting religiously based requests, even at the cost of children’s lives, or admit that at least some moral-metaphysical disputes can be rationally adjudicated. (shrink)

Background: There is growing interest in credentialing hospital ethicists. Consult volume is being incorporated into credentialing criteria, although few data supporting this approach are available...

For some time, clinical ethics committees (CECs) have been a prominent feature of hospitals in North America. Such committees are less common in the United Kingdom and Europe. Focusing on the UK, this paper evaluates why CECs have taken so long to evolve and assesses the roles that they should play in health care policy and clinical decision making. Substantive and procedural moral issues in medicine are differentiated, the former concerning ethicolegal principles and their paradigmatic application to clinical practice and (...) the latter dealing with how such application should be negotiated in the face of disagreement and/or uncertainty. It will be argued that the role of CECs is both substantive and procedural. Provided that they do not overstep their appropriate moral and professional boundaries, CECs will be shown to have an important and positive function in improving hospital care within the UK and elsewhere. (shrink)