Prompted by recent comments on the moral authority of dialogic consensus, we argue that consensus, specifically dialogic consensus, possesses a unique form of moral authority. Given our multicultural era and its plurality of values, we contend that traditional ethical frameworks or principles derived from them cannot be viewed substantively. Both philosophers and clinicians prioritize the need for a decision to be morally justifiable, and also for the decision to be action-guiding. We argue that, especially against the background of our pluralistic (...) society, it is only via unforced dialogue and properly founded argumentation, aiming for consensus, that we can ascribe rightness or wrongness in a normative fashion to dilemmatic situations. We argue that both the process of dialogue, properly constituted, and the consensual outcome itself have moral authority vested within them. Finally, we argue that the consensual decision made is able to withstand moral scrutiny and is action-guiding, without claiming absolute moral authority in other contexts. (shrink)

The historical emphasis of medical ethics, based on substantive frameworks and principles derived from them, is no longer seen as sufficiently sensitive to the moral pluralism characteristic of our current era. We argue that moral decision-making in clinical situations is more properly derived from a process of dialogic consensus. This process entails an inclusive, noncoercive, and self-reflective dialogue within the community affected. In order to justify this approach, we make two claims—the first epistemic, and the second normative. The epistemic claim (...) follows from Habermas’ “ways” of knowing. We argue that the dialogue emanating from this episteme focuses on the relevant facts about the patient, as well as on the values attached to these facts, thus allowing facts and their meanings to serve as the basis for reflective action appropriate to the circumstances. The normative claim follows from Habermas’ discourse theory of morality and communicative action. It determines that clinical decision-making should be approached from the perspective of the actual reality of people in their situation of illness, set in their socio-cultural background, and hence be grounded in the second-person perspective. Relocating ethical decision-making from a monological space into one characterized by dialogue is especially appropriate to the clinical encounter. (shrink)

The case study: a family requests that their grandmother, who does not speak English, is not informed of her terminal diagnosis focusses mostly on the issues of autonomy of patient and truth telling but fails to highlight the most ethically salient feature of the case; the clinician did not talk to the patient. The case study notes that the patient spoke a dialect of Cantonese and felt that translation services might not have been readily available. This is unacceptable practice given (...) the easy availability of professional telephone interpreters. In addition, it rendered the rest of the discussion academic as without a professional interpreter the clinician had no idea exactly what the family member who was interpreting was saying to their grandmother. This is an excellent case to discuss the ethics of the care of culturally and linguistically diverse people and the importance of interpreter use in patients with limited English proficiency. This case is also a good illustration of a limitation of Clinical Ethics Committees. A common norm is that there is no patient involvement in the deliberations of the committee. Without any patient involvement, it is very difficult to understand the patient’s position and impossible to engage in dialogue to find an agreed management plan. (shrink)