In this comment I discuss the role of an ethics case consultant in an institutional setting, in contrast to situations when an ethics consultant serves an individual client. In the former situation, I believe the case consultant should articulate ethical issues, options, and arguments, but not recommend a particular course of conduct. In the latter situation, the role of the ethics consultant can be defined and determined in negotiations with the client.

Autumn Fiester identifies an important element in clinical ethics consultation (CEC) that she labels, from the Greek, aporia, “state of perplexity,” evidenced in CEC as ethical ambiguity. Fiester argues that the inherent difficulties of cases so characterized render them inappropriate for voting and more amenable to mediation and the search for consensus. This commentary supports Fiester’s analysis and adds additional reasons for rejecting voting as a process for resolving disputes in CEC including: it distorts the analysis by empowering individual voters (...) preferences and biases rather than focusing on the interests and wishes of the patient and family; it offers an insufficiently sensitive model for resolving the awesome, nuanced, conflicted, and ethically complex issues surrounding life and death; it marginalizes minority opinions that may have moral validity. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

As groups around the country begin to craft standards for clinical ethics consultations, one focus of that work is the proper procedure for conducting ethics consults. From a recent empirical look into the workings of ethics consult services (ECSs), one worrisome finding is that some ECSs rely on a committee vote when making a recommendation. This article examines the practice of voting and its moral standing as a procedural strategy for arriving at a clinical ethics recommendation. I focus here on (...) the type of clinical ethics conflicts that are most likely to lead an ECS to vote, namely, conflicts involving ethical uncertainty—or, in the Greek, aporia. I argue that in cases of aporia, voting on an ethics conflict is not a morally justifiable procedure. Then on the same grounds that I use to show that voting is ethically problematic, I raise broader concerns about the common practice of making recommendations by other procedures. In contrast to the standard approach of adjudicating between moral claims, I argue that ECSs can best resolve aporetic conflict through the process of clinical ethics mediation. (shrink)

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and (...) professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted—a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

Is bioethics consultation a profession? Withfew exceptions, the arguments andcounterarguments about whether healthcareethics consultation is a profession haveignored the historical and cultural developmentof professions in the United States, the wayssocial changes have altered the work andboundaries of all professions, and theprofessionalization theories that explain howmodern societies institutionalize expertise inprofessions. This interdisciplinary analysisbegins to fill this gap by framing the debatewithin a larger theoretical context heretoforemissing from the bioethics literature. Specifically, the question of whether ethicsconsultation is a profession is examined fromthe (...) perspectives of trait theory, Wilensky''sfive-stage process of professionalization,Abbott''s interdependent system of professions,and Haug''s deprofessionalization thesis. Whilehealthcare ethics consultation does not meetthe criteria to claim professional status,neither could most professions pass these idealtheoretical standards. Instead of a yes or nodichotomous response to the question, it ismore helpful to envision a professionalizationcontinuum with sales clerks or carpenters atone end and medicine or law at the other. During the past decade healthcare ethicsconsultation has been moving along thiscontinuum toward greater professional status. (shrink)

In “Consensus, Clinical Decision Making, and Unsettled Cases,” David M. Adams and William J. Winslade make multiple references to both editions of the American Society of Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation in their discussion of two assumptions that are supposed to be at the heart of the facilitated consensus model’s inability to handle unsettled cases; that is, that:1. Consultants “should maintain a kind of moral impartiality or neutrality throughout the process,” “explicitly condemn[ing] anything resembling a (...) substantive ‘ethics’ recommendation,” and2. “What counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible.”Herein, I argue that neither of these assumptions is required by ASBH’s ethics facilitation approach. I then conclude by suggesting that, despite their fundamentally mistaken interpretation of the ASBH approach—perhaps even because of it—Adams and Winslade have made two important contributions to the ethics consultation literature. (shrink)

The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical ethics (...) consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)

The American Journal of Bioethics, Volume 12, Issue 8, Page 10-11, August 2012.