Doing Well or Doing Good in Ethics Consultation

Clinical ethics consultation is the practice of using ethical principles and theories to engage in complex interventions with stakeholders (patients, families, healthcare providers) to address moral issues. Ethicists must master ethical principles and apply them to complex healthcare dilemmas, employing critical thinking and practical knowledge to address nuances in healthcare. Essential to a clinical ethics consultant's development is the need for professional identity formation. Central this discussion of professional identity formation is what defines a professional and what qualifies a person to serve in that professional capacity. Are these qualifications skills-based, or are there characteristics that a clinical ethicist must have to be in the profession? Must someone have a professional or educational background that begins the professional identity formation process before entering the field of clinical ethics? Furthermore, can someone be taught these qualifications through structured learning activities with the goal of socializing them to a professional community? This essay will explore the reasons why professional identity formation has eluded the clinical ethics consultation field and how educational and training programs in clinical ethics have a duty to help learners develop a professional identity as a clinical ethicist. These programs must not only impart theoretical knowledge and practical skills but also foster the interpersonal abilities essential for ethics consultation. By embedding reflective practices, values clarification, and mentorship opportunities, such programs can guide learners through the complexities of professional identity formation, ensuring they are equipped to navigate the moral and relational challenges of the field.

This commentary reflects on twelve stories of participants in clinical ethics consultations from the perspective of family members, some of whom are ethics consultants, and healthcare professionals. Together they reveal expectations of ethics consultations and suggest descriptions of the service. Some common themes emerge, including the role of the clinical ethics consultant in navigating complex situations, assuring all stake-holder voices are heard, attending to moral distress, addressing issues that seem beyond medical practice, and being accessible. They are almost uniformly positive about the experience, with criticism primarily about lack of access to the service.

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on second hand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.

We believe that clinical ethics consultants (CECs) should offer advice, options, and recommendations to attending physicians and their teams. In their article in this issue of The Journal of Clinical Ethics, however, Kornfeld and Prager give CECs a somewhat different role. The CEC they describe may at times be more aptly understood as a medical interventionist who appropriates the roles of the attending physician and the medical team than as a traditional CEC. In these remarks, we distinguish the role of the CEC from that of the physician, in contrast to some of these authors' recommendations, which confuse the two roles.

Clinical ethics consultation (CEC), as an activity that may be provided by clinical ethics committees and consultants, is nowadays a well-established practice in North America. Although it has been increasingly implemented in Europe and elsewhere, no agreement can be found among scholars and practitioners on the appropriate role or approach the consultant should play when ethically problematic cases involving conflicts and uncertainties come up. In particular, there is no consensus on the acceptability of consultants making recommendations, offering moral advice upon request, and expressing personal opinions. We translate these issues into the question of whether the consultant should be neutral when performing an ethics consultation. We argue that the notion of neutrality 1) functions as a hermeneutical key to review the history of CEC as a whole; 2) may be enlightened by a precise assessment of the nature and goals of CEC; 3) refers to the normative dimension of CEC. Here, we distinguish four different meanings of neutrality: a neutral stance toward the parties involved in clinical decision making, toward the arguments offered to frame the discussion, toward the values and norms involved in the case, and toward the outcome of decision making, that is to say the final decision and action that will be implemented. Lastly, we suggest a non-authoritarian way to intend the term “recommendation” in the context of clinical ethics consultation.

Clinical ethics consultation has developed from local pioneer projects into a field of growing interest among both clinicians and ethicists. What is needed are more systematic studies on the ethical challenges faced in clinical practice and problem solving through ethics consultation from interdisciplinary perspectives. The Thematic Issue covers a range of topics and includes five recent studies from various European countries and the USA, focusing on issues such as the ethical difficulties of end of life decisions, experiences with newly developed or well established ethics consultation services, and the expectations of physicians in various clinical fields who are still unfamiliar with clinical ethics consultation. The papers included illustrate the interface between different socio-cultural contexts and their ways of dealing with clinical ethics consultation. They deepen the dialogue on clinical ethics consultation that has emerged at the European and International level.

A Comparison of General Medical and Clinical Ethics Consultations: What Can We Learn From Each Other?

Peer Review: The Best of the Blemished?

In this paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist's perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending on the demands of the specific case, and should avoid attempts to identify a 'true' methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism's emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism's relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation.

Certification ISO 9001 in clinical ethics consultation for improving quality and safety in healthcare.

The question of moral expertise remains largely academic until it serves as a foundation for a morally charged act or practice. Clinical ethics consultation is a complex and potentially impactful practice typifying the translation of theoretical ethics to clinical ethics, from the textbook to the bedside. To this extent, clinical ethics consultation requires a very concrete, applicable form of moral expertise. This service is no different from consulting services provided by other disciplines in health care, which have long ago instituted professional practice standards and methods for evaluating quality of care. In addition to the skills identified by the ASBH, we contend that clinical ethics consultants would benefit from a personalist approach to professionalism, that encourages the development of character traits intrinsic to a profession. In clinical ethics, we argue that this could be achieved, as other professions have discovered, through apprenticeship and professional accreditation. We show that this suggestion is consistent with statements from the ASBH as well as the UK Clinical Ethics Network.

The day-to-day work of clinical ethics consultants and healthcare ethics committees can easily become overly routine. Too much routine, however, comes with a risk that morally important practices will be reduced to mere bureaucratic formalities, while practitioners become desensitized to ethically significant distinctions between cases. Clinical ethics consultation and organizational ethics must be set within the broader social and cultural context of the healthcare environment. This practice requires looking beyond mere legal compliance and the routinely false assumption that there are unambiguous ethical norms that easily govern clinical ethics and hospital policy formation. Together the essays in this issue of HEC Forum challenge readers to rethink taken-for-granted assumptions regarding patient care, physician obligation, clinical ethics consultation, and organizational ethics.

Irrespective of whether the practice of clinical ethics consultation (CEC) is generally accepted or not, the nature of moral expertise behind it continues to be a contestable concept. In this essay, instead of arguing for whether clinical ethics consultants possess such expertise or not, I envision a third way of understanding the nature of moral expertise in ethics consultation: as the locus of an inherent paradox. I argue that moral expertise in clinical ethics consultation is built on an inner ideological struggle between pluralism and expertise—inclusion and exclusion—and that this inbuilt tension forms the core of the paradox. However, I claim that this paradox does not have to lead into a paralyzing contradiction, but instead, it could be embraced positively as a guarantee of keeping the moral space open. Moreover, I argue that putting too strong emphasis on consensus as a professional ideal of CEC may, surprisingly, threaten the fostering of open social space for moral discussions. As the baseline of this argument I utilize Mouffe’s theory of agonistics. In the end of the chapter, I conclude that recognizing the division of values, and opening social space for struggle, can in itself be seen as both a goal and a justification for clinical ethics consultation.

The received wisdom is that peer review is a thankless task. Peer reviewers are overworked, unpaid, unacknowledged and generally unrewarded. Peer-review processes are not standardized, and each journal or grant review body has its way of deciding what should be approved for publication or funding, respectively. Peer review has also been a secretive process that was largely unstudied until the 1990s. The evidence on peer review in journals has improved in that time, although the central conclusion still holds: peer review is best for improving the quality of articles that editors decide to publish but it is not an objective decision-making process for selecting the best articles. A publication in a major journal is no guarantee of quality and will probably contain several errors, since peer review is poor at eradicating those errors or detecting research misconduct. Sensible journal editors have accepted this reality, and acknowledge the flaws in the system they supervise. Beyond this honest appraisal of peer review, journals can help by introducing open peer-reviewer processes whereby the identity of authors and peer reviewers are not hidden to each other. The research evidence suggests that open peer review does not affect the quality of decision-making at a journal but improves the quality of the conversation between the authors, reviewers and journals. The JRSM has an open peer-review process. The identity of peer reviewers, however, is still usually hidden from readers. Sometimes authors are kind enough to thank peer reviewers in their acknowledgements at the end of a paper. Some journals list peer reviewers without linking them to specific papers – a policy that the JRSM used to follow. A few other journals pay reviewers a small amount or offer them institutional or membership discounts, an existing JRSM benefit. Nonetheless, the reward that peer reviewers receive is paltry in relation to their effort and the contribution that a good peer reviewer can make to improve a paper. Many peer reviewers justify the effort as a necessary contribution to scientific discourse but also as a contribution to their personal development. Many are simply interested enough in the topic to lend their services. Scientific journals only thrive because of the passion of peer reviewers and the patience of readers. From 2010, the JRSM will be taking a bold step in improving the transparency of peer review. We will name peer reviewers on each peer-reviewed article that we publish. This journal does not have the resources to conduct a randomized trial before making this change as bigger journals are able to do. But the editorial team believes that it is the right decision in terms of openness. Any peer reviewers who do not wish to be named can simply decline to peer review the article they have been sent. We would welcome your views on this small but important development.

The social contract of peer review revisited and reinforced: An idea to reduce the strain for reviewers