Were the “Pioneer” Clinical Ethics Consultants “Outsiders”? For Them, Was “Critical Distance” That Critical?

Abstract

“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of the day if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field.

Keywords:

• education
• history
• medical humanities
• professional ethics

This article is referred to by:

Outsider/Insider

Exploring Clinical Ethics' Past to Imagine Its Possible Future(s)

An Alternative Account of Clinical Ethics: Leveraging the Strength of the Health Care Team

Does Professional Objectivity Require Clinical Ethicists to Be Neutral?

Where Have All the Theologians Gone and Should We Lament Their Passing?

Reflections of a ‘Pioneer’: A Somewhat Different Path

Goals Change Roles: How Does the Clinic Redefine Philosophical “Critical Distance”?

Getting the Story Straight: Clinical Ethics as a Distinctive Field

Demythologizing Bioethics: The American Monomyth in Clinical Ethics Consultations

Outside/Inside/Outside

A Road Oft Traveled: Stumbling Into Clinical Ethics

Philosophers' Invasion of Clinical Ethics: Historical and Personal Reflections

Ethics Consultation: Critical Distance/Clinical Competence

ACKNOWLEDGMENTS

The authors deeply appreciate the helpful assistance of E. Haavi Morreim, JD, PhD, George J. Agich, PhD, Mark P. Aulisio, PhD, and Mark Siegler, MD, in preparing a presentation on this topic, particularly in checking the historical points and comments, and in reviewing the article in process. Much of this material was presented at the 18th Annual Meeting of the American Society for Bioethics and Humanities in Houston, TX, on October 7, 2016. The authors gratefully acknowledge the many helpful comments from participants during and after the presentation.

The authors realize that during the early days of clinical ethics consultation, there probably were several more pioneers laboring in academic medical centers and hospitals during the period discussed. To them—unknown and perhaps unidentifiable now—we gratefully acknowledge a great debt for their contributions to the field.

Notes

1. “Pioneer” was used by Albert R. Jonsen, PhD, at a conference that he organized at the University of Washington, Seattle, on September 23–24, 1992, celebrating what he called the 30th anniversary of the “birth of bioethics” and those who forged its beginnings (Fox and Swazey 2008, 125–131).

2. There was no one predominant model for even “teaching” medical ethics and humanities topics in the early days. Some humanists taught in traditional classroom settings, and others taught on rounds with teams and in small group seminars and conferences or offered consultation services outright. And, as teachers' clinical understanding expanded and deepened, opportunities for participation in actual cases grew as well (Morreim 1986).

3. In Ethics Consultation, John La Puma, MD, and David Schiedermayer, MD—both of whom had trained with Siegler at the University of Chicago—remarked: “Physicians and nurses generally understand the importance of clinical detail, are comfortable in patient care settings, and speak the language of health care. However, philosophers, theologians, and lawyers understand the logical analysis and theory, and with sufficient and long clinical training can become very insightful consultants. These consultants can combine the power of their intellectual rigor with a humane approach to the individual patient” (La Puma and Schiedermayer 1994, 45–46).

4. One should observe that a clinical ethicist charting in the patient's medical record may have been controversial in some institutions early on. Counsel and risk managers and others may have been leery about noncredentialed individuals leaving notes in the permanent record. However, one should recall that often hospital chaplains, patient representatives and advocates, and even clinical librarians left notes and materials to show helpful interventions thought to improve care delivery. Moreover, even some clinicians—such as genetics counselors—in a few jurisdictions were not licensed health care providers, yet made notes in the medical record. Regardless, the notes did show that the consultants or committees had responded to requests and allowed for a record of any advisory suggestions or recommendations (Bruce et al. 2014).