Academic journal article The Hastings Center Report

Keeping Moral Space Open: New Images of Ethics Consulting

Academic journal article The Hastings Center Report

Keeping Moral Space Open: New Images of Ethics Consulting

Article excerpt

The moral expertise of clincal ethicists is not a question of mastering codelike theories and lawlike principles. Rather, ethicists are architects of moral space within the health care setting, as well as mediators in the conversations taking place within that space.

Thinking about "moral expertise" and the idea of ethics "consulting," I asked some physician friends about their experiences working with ethicists in the large urban medical centers in which they teach and practice. One replied that he had found ethicists helpful; they encouraged him to consider issues of autonomy and paternalism, for example, to which he might not otherwise have attended in those terms. After a thoughtful pause, he offered another evaluation. With all the personal and institutional pressures of medical practice in such environments, he suggested, it was important to have a place to go for that kind of thinking; having done it allowed him to feel more confident or more responsible about the decisions taken.

While not mutually exclusive, these two responses are importantly different. The first response corresponds closely to a prevalent picture of ethics consultation as a kind of expert input. Specifically, moral theories or concepts, either global (utilitarianism, rights, vulnerability) or local (patient autonomy, strict advocacy, quality of life), constitute the domain of the ethicist, that for which and about which the ethicist is charged to speak as one specialist among others. The second response captures something less easily pegged. It is about a kind of interaction that invites and enables something to happen, something that renders authority more self-conscious and responsibility clearer. It is also about the role of maintaining a certain kind of reflective space (literal and figurative) within an institution, within its culture and its daily life, for just these sorts of occasions. I want to explore the second answer here, for it could represent not just another feature of ethics consultation but a significantly different view of it.

Literature of the last fifteen years on moral expertise and ethics consulting shows a shift in emphasis from issues of content to those of process--from what the ethicist knows, to what the ethicist does or enables. This shift parallels two others, one practical and one philosophical. The establishment of institutional ethics committees accelerated rapidly in the 1980s, spurring questions about whom should serve on them, what they should be doing, and how it should be done.[1] Philosophical ethics in the academy has also been a scene of change in the last two decades; the project of constructing and refining moral theories (in a quite limited and particular sense) has been ever more criticized, while moral philosophers of diverse stripes attend more closely to the languages and practices of actual moral communities and to the constructive process of renewing common moral life. I want to link these parallel shifts in practical medical ethics and general philosophical ethics from thinking of ethics as a "what" to thinking of ethics as a "how." I do this to consider the difference this makes in conceiving the nature of ethics consultation and the role of ethicists.

Familiar Suspicions about a Familiar Idea

A certain familiar conception of ethics is that it is the attempt to articulate and justify the right or best moral theory. This conception is familiar because it has been the prevailing definition of academic philosophical ethics for most of the twentieth century. It is also thoroughly embedded (although not uncontested) in medical ethics. On this view a moral theory is not merely any comprehensive, reasoned, and reflective account of morality, of the ways and means, point and value, of a moral form of life. (A classic example of such an account is Aristotle's Nichomachean Ethics.) On this dominant modern view of proper moral theory is instead a highly specific kind of account of where moral judgments come from: a compact code of very general (lawlike) principles or procedures which, when applied to cases appropriately described, yield impersonally justified judgments about what any moral agent in such a case should do. …

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