Abstract
One of the challenges of modern healthcare ethics practice is the navigation of boundaries. Practicing healthcare ethicists in the performance of their role must navigate meanings, choices, decisions and actions embedded in complex cultural and social relationships amongst diverse individuals. In light of the evolving state of modern healthcare ethics practice and the recent move toward professionalization via certification, understanding boundary navigation in healthcare ethics practice is critical. Because healthcare ethics is endowed with many boundaries which often delineate concerns about professional expertise and authority, epistemological reflection on the relationship between theory and practice points toward the social context as relevant to the conceptualization of boundaries. The skills of social scientists may prove helpful to provide data and insights into the conceptualization and navigation of clinical ethics qua profession. Empirical ethics research, which combines empirical description (usually social scientific) with normative-ethical analysis and reflection, is a way forward as we engage and reflect upon issues which have implications for practice standards and professionalization of the role. This requires cooperative engagement of the descriptive and normative disciplines to explore our understandings of boundaries in healthcare ethics practice. This will contribute to the ongoing reflection not only as we envision the professional role but to ensure that it is enacted in practice.
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Notes
It is acknowledged that there are a number of descriptors and references used to denote those who are in clinical ethics practice, including, but not limited to, ethics consultant, clinical ethicist, ethics practitioner, and related variations. In the Canadian context, the term Practicing healthcare ethicist (PHE) has been intentionally developed, in part to facilitate maintaining a broader focus. “A PHE has dedicated work responsibilities within a healthcare organization to provide a variety of ethics-related services which include one or more of the following: clinical and/or organizational ethics consultation; policy development and/or review; ethics education for staff; management of ethics programs (including clinical ethics committee); mentoring of staff/learners; and conducting research ethics consultations” (Simpson 2012, p. 149–150). Other descriptors will appear in relation to a specific reference or point of discussion as appropriate.
Examples include: The Core Competencies for Healthcare Ethics Consultation (2011) developed by the ASBH, and the accompanying Improving Clinical Competencies in Clinical Ethics Consultation: An Education Guide (2009) as well and the Canadian Bioethics Society Task Force on Working Conditions for Bioethicists 2008, in Chidwick et al. (2010) and the Canadian based draft of the Draft: Model Code of Ethics for Bioethics (MacDonald), Draft Code of Professional Responsibilities of Health care ethics Consultants Clinical Ethics Consultation Affairs Committee, (2011).
Arnold and Forrow (1993); Aulisio (1999); Austin (2007); Birnbacher (1999); Crigger (1995); De Vries and Conrad (1998); De Vries (2003); Engelhardt (2003); Farmer and Gastineau Campos (2007); Hoffmaster (1992, 2001); Nelson Lindemann (2000); Marshall 1992; Musschenga (1999); Pearlman et al. (1993); Van der scheer and Widdershoven (2004); Zussman (2000).
Scofield uses the descriptor “medical ethics consultant” throughout his paper to describe ethicists working in healthcare settings.
This includes conflicts amongst physicians and nurses, and physicians and administrators. Chambliss acknowledges that hospitals may have ethics consultation teams, which stand as proxies for the organization, but more often than not, ethics teams in his study saw these problems as “technical” and deferred to authority of physicians. His findings draw attention to how the “place” of the healthcare ethicists is defined and experienced in our diverse institutions and organizations in our current context.
Urban Walker (1998, 2007,) has forwarded an “expressive-collaborative” model of morality, which is best revealed in practice through the socially accepted patterns of assigning and deflecting responsibility. In her view these practices reveal, “shared understandings” of who we are, what we value, and to whom we are required to account for our actions. In this view morality is “collaborative.” Along with Lindemann et al. (2009) she has also forwarded a “naturalized bioethics” espousing that “self-reflexive, socially inquisitive, politically critical, and inclusive” ethics that is “empirically nourished but acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments (p. 5).
Emphasizing narrative as the pattern of moral thinking, she has asserted that it is “a way of seeing how morally relevant information is organized within particular episodes of deliberation… narratives in moral thinking come before, during, and after moral generalities” (p. 35).
Beauchamp (2003) describes the “appropriate sources of content” in applied ethics as distinctive from “internal” and “external” perspectives. Proponents of the “internal” perspective view applied bioethics as arising from the issues, practices, questions and dilemmas that arise from within each practice itself. Proponents of the “external” perspective view applied bioethics as arising from the application of issues, precepts, and standards that have a place in another moral realm (such as deontological or utilitarian systems) or an account of “common morality” to issues, practices, questions, and dilemmas that arise in the practices under consideration. This difference in content also reflects a difference about the kinds of moral judgments that will count as “authoritative” (see Tronto, p. 409).
Parallel cooperation means that descriptive scientists and ethicists do their work simultaneously, but without influencing each other. Serial cooperation implies that one of the two disciplines carries out its work first and then the other reacts to it. In continuous cooperation, the two disciplines work together throughout the entire research process (p. 452).
Please see the special issue of HEC Forum (2012) 24 “Getting Engaged: Exploring Professionalization in Canada” for a discussion of these important issues.
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Typically, when invited to a consult, we are asked to fill one or more particular roles including that of bioethicist, feminist, peer, expert consultant or moral observer…. As such, one of the issues we struggle with is how to set clear expectations for our participation in the consultation process and how to resolve tensions between roles without violating our own moral commitments or ending up at the margins, as a token or as an outsider. (p. 143).
Canadian bioethicists Susan Sherwin and Francoise Baylis (2003) reflecting upon their own healthcare ethics consultation experiences. Public Affairs Quarterly 17 (2) April 141–158.
Social scientists who remain observant outsiders and ask unsettling questions undoubtedly prove great benefit. Yet surely bioethicists should not hesitate to take social science perspectives and tools into greater account. In their role as advocates for certain visions of the good, bioethicists need what empirical researchers can offer: a variety of powerful means for getting from here to there. (p. 46).
Bioethicist and social scientist Mildred Z. Solomon (2005) reflecting on her work as a social scientist in bioethics. Hastings Center Report 4 July–August 40–47.
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Brown, N.C., McGee, S.J. Conceptualizing Boundaries for the Professionalization of Healthcare Ethics Practice: A Call for Empirical Research. HEC Forum 26, 325–341 (2014). https://doi.org/10.1007/s10730-014-9240-x
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DOI: https://doi.org/10.1007/s10730-014-9240-x