Background: Clinical ethics support instruments aim to support healthcare professionals in dealing with moral challenges in clinical practice. CURA is a relatively new instrument tailored to the wishes and needs of healthcare professionals in palliative care, especially nurses. It aims to foster their moral resilience and moral competences. Aim: To investigate the effects of using CURA on healthcare professionals regarding their Moral Resilience and Moral Competences. Design: Single group pre-/post-test design with two questionnaires. Methods: Questionnaires used were the Rushton Moral (...) Resilience Scale measuring Moral Resilience and the Euro-MCD, measuring Moral Competences. Respondents mainly consisted of nurses and nurse assistants who used CURA in daily practice. Forty-seven respondents contributed to both pre- and post-test with 18 months between both tests. Analysis was done using descriptive statistics and Wilcoxon signed rank tests. This study followed the SQUIRE checklist. Ethical considerations: This study was approved by the Institutional Review Board of Amsterdam UMC. Informed consent was obtained from all respondents. Results: The total Moral Resilience score and the scores of two subscales of the RMRS, that is, Responses to Moral Adversity and Relational Integrity, increased significantly. All subscales of the Euro-MCD increased significantly at posttest. Using CURA more often did not lead to significant higher scores on most (sub) scales. Conclusion: This study indicates that CURA can be used to foster moral resilience and moral competences of healthcare professionals. CURA therefore is a promising instrument to support healthcare professionals in dealing with moral challenges in everyday practice. (shrink)

Clinical ethics consultants (CECs) are not moral authorities. Standardization of CECs’ professional role does not confer upon them moral authority. Certification of particular CECs does not confer upon them moral authority (nor does it reflect such authority). Or, so we will argue. This article offers a distinctly Orthodox Christian response to those who claim that CECs—or any other academically trained bioethicist—retain moral authority (i.e., an authority to know and recommend the right course of action). This article proceeds in three parts. (...) First, we discuss recent movements toward the certification of CECs in the United States, focusing primarily on proposals and programs put forth by the American Society for Humanities and Bioethics (ASBH). Second, we outline two secular reasons to be concerned about the relevant trends toward certification. For one thing, certification is currently being advanced via political dominance, rather than gaining authority by reliance on rigorous philosophical argument or reason. For another, the trends operate on the assumption that there exists a secular, content-full, canonical, morality. There is no such morality. Next, we argue that Orthodox Christians should resist the current trends toward certification of CECs. Specifically, we unpack ways in which the ASBH’s certification program (and those like it) conflict with Orthodox claims about moral authority and the moral life more generally. We conclude that Orthodox Christians should resist the current certification trends. (shrink)

I argue that moral skill is limited and precarious. It is limited because global moral skill—the capacity for morally excellent behaviour within an über action domain, such as the domain of living, or of all-things-considered decisions, or the same kind of capacity applied across a superset of more specific action domains—is not to be found in humans. It is precarious because relatively local moral skill, while possible, is prone to misfire. My arguments depend upon the diversity of practical structures confronting (...) human agents, the limitations of human skill learning and reason-sensitivity, and the failure of moral considerations to respect the social and institutional boundaries we develop to structure our practical lives. (shrink)

BackgroundThe theory and practice of ethics consultations (ECs) in health care are still characterized by many controversies, including, for example, the practice of giving recommendations. These controversies are complicated by an astonishing lack of evidence in the whole field. It is not clear how often a recommendation is issued in ethics consultations and when and why this step is taken. Especially in a facilitation model in which giving recommendations is optional, more data would be helpful to evaluate daily practice, ensure (...) that this practice is in line with the overarching goals of this approach and support the development of standards.MethodsWe analyzed all consultations requested from an EC service working under a facilitation approach at a maximum-care university hospital in Germany over a period of more than 10 years. Our aim was to better understand why—and under what circumstances—some consultation requests result in a recommendation, whereas others can be sufficiently addressed solely by facilitated meetings. We especially wanted to know when and why clients felt the need for clear advice from the EC service while in other cases they did not. We compared ethics consultations in terms of the differences between cases with and without recommendations issued by the ethics consultants using χ2 difference tests and Welch’s t-test.ResultsA total of 243 ECs were carried out between September 2008 and December 2019. In approximately half of the cases, a recommendation was given. All recommendations were issued upon the request of clients. When physicians asked for an EC, the consultation was significantly more likely to result in a recommendation than when the EC was requested by any other party. ECs in cases on wards with ethics rounds resulted in comparably fewer recommendations than those in wards without ethics rounds. When interpersonal conflicts were part of the problem or relatives were present in the meeting, clients less frequently asked for a recommendation.ConclusionFrom the client’s point of view, there does not seem to be only one “right” way to provide ethics consultations, but rather several. While facilitated meetings are obviously appreciated by clients, there also seem to be situations in which a recommendation is desired (especially by physicians). Further empirical and theoretical research is needed to validate our single-center results and re-evaluate the role of recommendations in ethics consultations. (shrink)

Volume 19, Issue 11, November 2019, Page 71-73.

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming (...) contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry. (shrink)

In biomedical ethics, there is widespread acceptance of moral realism, the view that moral claims express a proposition and that at least some of these propositions are true. Biomedical ethics is also in the business of attributing moral obligations, such as “S should do X.” The problem, as we argue, is that against the background of moral realism, most of these attributions are erroneous or inaccurate. The typical obligation attribution issued by a biomedical ethicist fails to truly capture the person's (...) actual obligations. We offer a novel argument for rife error in obligation attribution. The argument starts with the idea of an epistemic burden. Epistemic burdens are all of those epistemic obstacles one must surmount in order to achieve some aim. Epistemic burdens shape decision-making such that given two otherwise equal options, a person will choose the option that has the lesser of epistemic burdens. Epistemic burdens determine one's potential obligations and, conversely, their non-obligations. The problem for biomedical ethics is that ethicists have little to no access to others' epistemic burdens. Given this lack of access and the fact that epistemic burdens determine potential obligations, biomedical ethicists often can only attribute accurate obligations out of luck. This suggests that the practice of attributing obligations in biomedical ethics is rife with error. To resolve this widespread error, we argue that this practice should be abolished from the discourse of biomedical ethics. (shrink)

Volume 20, Issue 3, March 2020, Page 50-52.

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One of the most significant and persistent debates in secular clinical ethics is the question of ethics expertise, which asks whether ethicists can make justified moral recommendations in active patient cases. A critical point of contention in the ethics expertise debate is whether there is, in fact, a bioethical consensus upon which secular ethicists can ground their recommendations and whether there is, in principle, a way of justifying such a consensus in a morally pluralistic context. In a series of recent (...) articles in this journal, Janet Malek defends a positive view of ethics expertise, claiming that secular ethicists should comport their recommendations with bioethical consensus. In response, Nick Colgrove and Kelly Kate Evans deny the existence of a secular bioethical consensus; question why, even if it did exist, consensus should be considered a reliable way of resolving bioethical questions; and recommend a friendlier approach to clinical ethics based on the thought of H. Tristram Engelhardt Jr. In this article, I respond to Colgrove and Evans on all three points. In part one, I show there is a secular bioethical consensus but note it could be better consolidated and created through a more systematic and inclusive process. In part two, I argue that bioethical consensus is morally justified but note that this justification cannot be plausibly based upon claims that it only invokes moral principles available to or shared by all. In part three, I argue Engelhardt’s approach cannot be described as “friendlier” to clinical ethics because it is incompatible with many current healthcare laws and policies. (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)

Brummett and Salter propose a useful and timely taxonomy of clinical ethics expertise (2019). As the field becomes further “professionalized” this taxonomy is important, and the core of it is right. It needs some refinement around the edges, however. In their conclusion, Brummett and Salter rightly point out that there is a significant difference between the ethicist whose recommendations are procedure- and process-heavy, consensus-driven, and dialogical and the authoritarian ethicist whose recommendations flow from “private moral views” (Brummett and Salter, 2019). (...) This admission doesn’t go far enough. Brummett and Salter’s taxonomy fails to capture the notion that offering recommendations whose normative force is moral is different in kind from recommendations whose normative force is non-moral, such as those recommendations that are free of moral content or justified by convention. The difference is in kind, not scale. I argue further that clinical ethics expertise, if possible, consists at least in offering recommendations whose normative force is moral. These two claims imply that the taxonomy fails to cut clinical ethics expertise at the joints: the ethicist who offers justified non-moral normative recommendations is a different kind of ethicist from the one who offers justified moral normative recommendations, yet both are categorized as clinical ethics experts. I finish by offering a refinement of the taxonomy that more precisely categorizes clinical ethicists. (shrink)

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Volume 19, Issue 11, November 2019, Page 69-70.

Recent work calls for excluding clinical ethics consultants’ religious ethical commitments from formulating recommendations about particular cases and communicating those recommendations. I demonstrate that three arguments that call for excluding religious ethical commitments from this work logically imply that consultants may not use their secular ethical commitments in their work. The call to sever clinical ethics consultation from the ethical commitments of clinical ethics consultants has implications for the scope of work consultants may do and for the competencies required for (...) such work. (shrink)

The concept ethics defines health care ethics as a professional practice. Yet the meaning of “ethics” is often unclear in the theory and practice of clinical ethics. Clarity on this matter is crucial for understanding the nature of clinical ethics and for debates about the professional identity and proper role of ethicists, the sort of training and skills they should possess, and whether they have ethics expertise. This article examines two different ways the ethics of clinical ethics can be understood: (...) Real Ethics, which consists of objective moral norms grounded in moral truth; and Conventional Ethics, which consists of conventional norms grounded in bioethical consensus. Drawing on the bioethics literature and features of professional practice, it shows that Conventional Ethics is the dominant paradigm. Then it presents a critique of Conventional Ethics, arguing that it cannot avoid the challenge of moral pluralism, it fails to address vitally important moral questions, and it is incapable of providing an essential service to the people ethicists aim to help. It ends with suggestions about how the practice of clinical ethics might overcome these problems. (shrink)

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In the continuing debate about the role of the Clinical Ethics Consultant in performing clinical ethics consultations, it is often assumed that consultants should operate within ethical and legal standards. Recent scholarship has focused primarily on clarifying the consultant's role with respect to the ethical standards that serve as parameters of consulting. In the following, however, I wish to address the question of how the ethics consultant should weigh legal standards and, more broadly, how consultants might weigh authoritative directives, whether (...) legal, institutional, or professional, against other normative considerations. I argue that consultants should reject the view that authoritative directives carry exclusionary reason for actions and, further, ethicists should interpret directives as lacking any moral weight qua authoritative directive. I then identify both implications and limitations of this view with respect to the evolving role of the ethics consultant in an institutional setting, and in doing so propose the kinds of considerations the ethicist should weigh when presented with an authoritative directive. (shrink)

Clinical Ethics Consultation (CEC) has grown significantly in the last decade, and efforts are being made to professionalize the practice. The American Society for Bioethics and Humanities (ASBH) has been instrumental in this process, having published the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants and founded and endorsed the creation of the Healthcare Ethics Consultant Certified (HCEC) Certification Commission. The ASBH also published “core competencies” for healthcare ethics consultants and has delineated a clear identity and role of (...) such consultants distinct from that other healthcare professionals. In addition, more enter the field armed with advanced degrees (MA and PhD) or certification in clinical ethics consultation. While some have questioned the trend toward professionalization, the momentum is clearly in its favor. This paper explores three questions: Does the professionalization of healthcare ethics consultation expose those engaged in the field to the types of liability claims faced by professionals in other fields? What specific liabilities could affect a healthcare ethics consultant? And finally, what should healthcare ethics consultants do to protect themselves against liability claims? We conclude that while the risk of liability remains low, those engaged in the field should accept that risk just as part of their status as professionals and, like those in allied professions, seek appropriate protection in the form of liability insurance. (shrink)

Volume 19, Issue 11, November 2019, Page 91-94.