Abstract
In an age of professionalization and specialization, the practice of clinical ethics is facing an identity crisis. Are clinical ethicists moral experts, ethics experts, or merely quasi-lawyers giving legal advice? Are they extensions of the hospital, always working to advance the hospital’s interests? Or is there another option? Since 1998, when the American Society for Bioethics and Humanities (ASBH) first issued its Core Competencies for Healthcare Ethics Consultation, there has been debate about the role of standardization and proceduralism in clinical ethics consultation. Now, as ASBH continues to move forward with its credentialing program, proceduralism in clinical ethics must be critically examined. In this paper, I argue that the proceduralist approach to clinical ethics consultation, as espoused by the ASBH’s call for credentialing, creates a demeaning experience for all parties involved and precludes goods internal to the practice of clinical ethics consultation from being actualized. As a practice embedded in medicine and in institutions such as the hospital, clinical ethics consultation must define and examine its own goods in order to bring about more than a sterile, law-like solution to difficult moral quandaries, as these sterile solutions leave patients, families, and providers unsatisfied, abandoned, and disappointed. Thus, in an effort to push back against this proceduralism in clinical ethics consultation, I will offer a preliminary exploration of what these goods might be.
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Notes
This distinction between right action and good action reflects a rift in bioethics between talking about good and evil (metaphysics) and talking about right and wrong (epistemology) that began with Kant and Hume. Jameton, in claiming that moral distress arises when one is constrained from doing what is right, falls into the procedural trap of discussing only what is right and wrong and can be instantiated in rules and procedures. By highlighting moral distress as a symptom of the failings of proceduralism in clinical ethics consultation, I am advocating for a return to a robust understanding of a metaphysical moral framework within which goods and evils can be discussed, particularly the goods of clinical ethics consultation. While I will not enter into the larger debate here, see MacIntyre (1984) for more on the return to a thick metaphysical moral ordering.
While some may argue that this reflective sense is just another “interpersonal skill” as defined by the ASBH Core Competencies, I argue that creating moral space is not necessarily aimed at bringing about a certain outcome but rather is good in and of itself—a good internal to the practice of clinical ethics consultation. Interpersonal skills such as the ability to listen well and to educate involved parties are ultimately aimed at bringing about a principled ethical resolution, while creating moral space allows patients, providers, and clinical ethicists to dwell in uncertainty, anger, joy, or sorrow when certain outcomes—or goals—cannot be achieved. In this way, clinical ethics consultation can still bring about good in these difficult situations.
These four traits of compassion, humility, prudence, and courage are part of a larger list outlined in the ASBH Core Competencies of important “attributes, attitudes, and behaviors of ethics consultants” (2011, p. 32). ASBH specifically notes that this section was previously called “character traits,” but the use of the word “character” was controversial, as character is harder to define and harder to quantitatively assess than procedures or knowledge points. However, I argue that character formation is an important good internal to the practice of clinical ethics consultation, as clinical ethicists must lead with their character instead of with procedural assessment or quality improvement tools to create a meaningful experience for all parties involved. While this is not an exhaustive list of the character traits that clinical ethicists can or should deploy, these traits offer an important starting point. Furthermore, while I will not discuss traits—or more specifically virtues—unique to clinical ethics consultation itself, this is an important topic that merits further inquiry.
It is important to note that the good of the patient is distinct from the goods internal to the practice of clinical ethics consultation. One of the goods internal to the practice of clinical ethics consultation is helping the patient to realize and actualize her own good, yet the patient’s good is not necessarily a good internal to the practice of clinical ethics consultation itself. For example, a clinical ethicist may help a patient to realize that a certain treatment is good for her. While a good of that patient is receiving the treatment, a good of clinical ethics consultation is helping that patient come to the realization about the treatment.
Checklists and procedures (in the generic use of the term) are not necessarily bad in and of themselves and may have certain benefits, such as improving consultation consistency or sparking rich conversation about what the consultation process should entail. However, given the nature of a checklist, something will inevitably be left out, and it is often the emotional and relational work of bringing about goods that is abandoned, as these are harder to quantify. While ethics consultants can certainly do more than what is prompted on a checklist or in a procedure, the highly bureaucratized setting of the hospital will slowly erode and eventually erase these more nuanced interpersonal skills that are vital to bringing goods internal to the practice of clinical ethics consultation into being.
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Friedrich, A.B. The Pitfalls of Proceduralism: An Exploration of the Goods Internal to the Practice of Clinical Ethics Consultation. HEC Forum 30, 389–403 (2018). https://doi.org/10.1007/s10730-018-9359-2
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DOI: https://doi.org/10.1007/s10730-018-9359-2