Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

The moral expertise of clinical ethicists is not a question of mastering codelike theories and lawlike principles. Rather, ethicists are architects of moral space within the health care setting, as well as mediators in the conversations taking place within that space.

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)

Something is not working in ethics consultation: in certain situations, relationships within families and with careproviders and surrogates have become so emotionally charged and destabilized that attention is dominated by conflict and misunderstanding, foreshadowing a loss of dignity and hope. In a compelling, urgent article, informed by events in the Schiavo case, with examples from the literature on theory, practice, and outcomes, Caplan and Bergman address this situation: redirecting our attention to what they see as “a lack of effective mechanisms” (...) for dealing with a “painful class of disputes in which families disagree with one another, or with doctors, about the care of those who cannot communicate.”1 It is no small matter that many of these cases are situated in the immediate, intense environment of end-of-life decision making. -/- How might we understand these encounters, and their limits? What can we hope? Following the tack of Caplan and Bergman, I will extend the discussion of the complex relationships between patients, families, surrogates, and physicians, and “hope for consensual resolution,” offering a somewhat different account of what is lacking. While Caplan and Bergman foreground an apparent irreconcilability of appeals to competing biomedical principles as what is lacking, I will suggest that a “salient characteristic” among participants, what Caplan and Bergman identify as a common concern for the patient’s best interests, may be far less stable and more complex, and thereby less directive, than first imagined. When Caplan and Bergman sketch their expectations for mediation and for mediators, they are right in noting that abstract principles “articulated as dispositive by designated ‘experts’ fail to capture, and arguably respect, the unique and complex nature of each such individual decision-making process,” and that “patients and families are at the extreme end of a power imbalance.” It is less clear that their descriptions — or their hope for mediation — capture this enormous challenge. (shrink)