http://orcid.org/0000-0003-0511-574X
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Abstract
Our aim in this article is to bring some clarity to the clinical ethics expertise debate by critiquing and replacing the taxonomy offered by the Core Competencies report. The orienting question for our taxonomy is: Can clinical ethicists offer justified, normative recommendations for active patient cases? Views that answer “no” are characterized as a “negative” view of clinical ethics expertise and are further differentiated based on (a) why they think ethicists cannot give justified normative recommendations and (b) what they think ethicists can offer, if they cannot offer recommendations. Views that answer “yes” to the orienting question are characterized as a “positive” view of clinical ethics expertise. Positive views are distinguished according to four additional questions. First (P1), how are those recommendations generated? Second (P2), what is the nature of the recommendations? Third (P3), we ask, how are the recommendations justified? And finally (P4), how are the recommendations communicated?
Notes
1. Ana Iltis and Mark Sheehan can be read as taking this broad view of ethics expertise, which they define as knowing what ought to be done (Iltis and Sheehan Citation2016, 416). An additional critical point about our discussion is that we use the words ethical, normative, and moral interchangeably, which has precedent in the discourse over ethics expertise (Rasmussen Citation2005, 12, endnote 1). We also take a broad interpretation of ethics in this project. Any claim about what should or ought to be done is considered an ethical claim. Following John Haldane, we see the moral as ubiquitous: Every voluntary intentional action is morally significant because it expresses what the actor values (Haldane Citation2011). However, we think that further clarifying what is meant by ethics expertise is a question that deserves more attention, as the sort of claims one considers ethical will have a big impact on the position one takes on ethics expertise. For example, if ethical claims are restricted to classically contentious moral issues (e.g., abortion, euthanasia) then few would defend the claim that ethicists can make authoritative judgments on these questions. If, alternatively, one holds that any claim about what ought or should be done constitutes an ethical claim, then the question of ethics expertise immediately becomes less problematic.
2. Giles Scofield, a longtime critic of clinical ethics consultation, recently outlined the disagreement that continues over the nature of the clinical ethics consultant’s expertise despite decades of reflection by theorists in the field (Scofield Citation2018).
3. It should be noted that most clinical ethicists do more than just clinical ethics consultation. Indeed, most descriptions of the profession include three prongs of responsibilities: case consultation, policy development and review, and education. The debate about expertise within the field has been predominantly focused on expertise in ethics consultation and that is the prong we deal with here. However, there are certainly interesting connections between expertise in consultation and expertise in education or policy work (e.g., if you have a negative view of clinical ethics expertise, but believe ethicists ought to focus on education, what would be the content of your educational initiatives and how would you justify that content?), and this might be a productive topic for future work on clinical ethics expertise.
4. The authoritarian approach smacks of the paternalism bioethics was created to guard against, which includes making decisions that do not reflect patient values, making decisions for patients that reflect inappropriate biases of clinicians, and conceptualizing patient autonomy as patient assent (Emanuel and Emanuel Citation1992, 68; Quill and Brody Citation1996, 764).
5. An interesting related question is whether ethics consultants ought to ever think of themselves as advocates of particular positions or people (e.g., patients or other relatively disempowered parties, like nurses or trainees). See discussion of this question in Rasmussen (Citation2012) and Antommaria (Citation2012).
6. While most ethics programs in the United States do offer recommendations, their ability to do so is still debated in the academic literature. While offering recommendations is common practice in the U.S. model, in Europe, retrospective ethical analysis and an unwillingness to offer normative recommendations are the norm (Watson and Guidry-Grimes Citation2018, 24).
7. We have not presented an exhaustive list of arguments against ethics expertise here. For a more sustained treatment of arguments against ethics expertise, see Rasmussen and Caplan (Caplan Citation1989, 67–71; Rasmussen Citation2011b, 652–657).
8. Each step in the C.A.S.E.S. method includes several specific action items. For example, step 1, “Clarify the request,” involves characterizing the type of request, obtaining preliminary information from the requester, establishing expectations with the requester, and formulating the ethics question. However, these specific action items have not been included here due to space constraints.
9. The same constraints of principled mediation apply to the facilitation approach advanced by ASBH. Dubler and Liebman are, in fact, cited by the Core Competencies report (ASBH 2011, 6).
10. And this is precisely the ability that negative view theorists would deny ethicists: the ability to establish and justify the range of ethically acceptable options. Further discussion of how a positive-view ethicist might justify a particular range of options or a particular recommendation is offered in the next section.
11. For example, many clinical ethicists operating in a Catholic institution will justify consultation recommendations using moral guidance and standards offered by the Ethical and Religious Directives for Catholic Health Care Services (United States Conference of Catholic Bishops Citation2009) that “flow principally from the natural law, understood in the light of the revelation Christ has entrusted to his Church” (2009, 4). For space considerations, we do not discuss further the possible sources of religious justification for ethics consultation recommendations. For further reading, consider Hamel, Slosar, and Repenshek (Citation2013) and Bedford (Citation2011).
12. In his argument for ethics expertise, Stephen Wear also gives a list of now strongly entrenched normative claims for clinical ethics (Wear Citation2005, 252).
13. These three approaches may not be mutually exclusive. Ian Barbour has argued for a method of abductive reasoning when evaluating scientific and religious claims that combines all three views of truth (Barbour Citation1997, 110). Perhaps the method used for evaluating moral theories (something like the method advanced by Mark Timmons) can also be understood as combining the best parts of realist, justificationist, and conventional norms views (Timmons Citation2012).
14. We have chosen to focus on question of action theory here (as opposed to value and virtue theory) for considerations of space and also because these questions have been the dominant focus in bioethics.
15. One of the standard demonstrations of the effectiveness of midlevel moral theorizing for bioethics is the 1979 Belmont Report, wherein the commission was able to obtain consensus so long as it avoided discussion as to why its midlevel principles (beneficence, justice, respect for persons) were important, relevant, or justified (Toulmin Citation1987, 612). This methodology also managed to produce a stable consensus during the drafting of the Universal Declaration of Human Rights in 1947. As reported by Glendon, French social philosopher Jacques Maritain—a sitting committee member tasked with developing a framework for human rights—reported that “we agree about the rights but on condition no one asks us why” (Glendon Citation2001, 77). Although the midlevel approach has been successful in bioethics, there are alternatives (e.g., the high- and antitheory approaches described by Arras). We are not endorsing the midlevel approach here but only importing the way various approaches to moral theory for bioethics have been described in the literature.
16. For example, see Archard’s (Citation2011) moral objections to ethics expertise, described in the preceding.