Abstract
We believe that clinical ethics consultation (CEC) has as its goal the delivery of healthcare in a manner consistent with the moral rules and the moral ideals. Towards this end, CEC pursues the instrumental ends of clarifying the limits of acceptable ethical disagreement and facilitating a choice among ethically acceptable alternatives. In pursuing these ends, healthcare ethics consultation (HEC) and CEC services confront three broad categories of questions; 1) questions of professional duty; 2) questions of law; and 3) questions of general morality. Professional duty questions concern what has been referred to as the “internal morality of medicine”, and include questions such as the medical legitimacy of the goal(s) being pursued, or the acceptability of the means being employed.
Questions of law concern themselves with what the law requires, permits or prohibits.
Questions of general morality include all those not falling within the scope of the above categories.
We submit that this has implications for the organization and structure of consultation services and HEC and for the methodology and processes employed in CEC. Thus:
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1.
Questions of professional duty should be addressed only by physician members (whom we would distinguish by employing the term “ethicians”) of the HEC or CEC service. The only role for non-ethicians under these circumstances would be in helping to resolve disagreements between/among professionals;
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2.
questions of law, in contrast, should be addressed only by the attorney member(s) of the HEC or CEC service;
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3.
questions of general morality may be addressed by the entire membership of the HEC or CEC service.
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References
Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Core competencies for health care ethics consultation: the report of the American Society for Bioethics and Humanities. Glenview, IL: ASBH, 1998.
Annas GJ. Legal aspects of ethics committees. In: Cranford RE, Doudera AE, eds. Institutional ethics committees and health care decision making. Ann Arbor, MI: Health Administration Press, 1984: 51–9.
Siegler M. Defining the goals of ethics consultations: a necessary step for improving quality.QRB Qual Rev Bull 1992; 18: 15–6.
Capron AM. Decision review: a problematic task. In: Cranford RE, Doudera AE, eds. Institutional ethics committees and health care decision making. Ann Arbor, MI: Health Administration Press, 1984: 174–85.
Spicker SF, Kushner T. The principle functions of HECs.HEC Forum 1989; 1: 57–62.
Fletcher J, Siegler M. What are the goals of ethics consultation? A consensus statement.J Clin Ethics 1996; 7: 122–6.
Fox E, Arnold RM. Evaluating outcomes in ethics consultation research.J Clin Ethics 1996; 7:127–38.
Andre J. Goals of ethics consultation: toward clarity, utility and fidelity.J Clin Ethics 1997; 8: 193–8.
Gert B: Morality: its nature and justification. New York, NY: Oxford University Press, 1998.
Pellegrino ED. Professionalism, profession and the virtues of the good physician.Mt Sinai J Med 2002; 69: 378–84.
Fuller LL. The morality of law. Revised edition. New Haven, CT: Yale University Press, 1969.
Schmidtz D. Choosing ends.Ethics 1994; 104: 226–51.
Pellegrino was referring to the ends of medicine, not the ends of CEC. His actual statement was: “What those other ends might be is problematic at best and raises questions as to whether medicine would lose its essential character”. See note 10, p. 384.
Ladd J. The internal morality of medicine: an essential dimension of the physician-patient relationship. In: Shelp, E, ed.The clinical encounter. Dordrecht: Kluwer Academic Publishers, 1983: 209–31.
Thus, the desiderata constituting theinternal morality of law include that there be rules, that they be promulgated, that they not be retroactive, that they be clear, that they not be contradictory, that they not require the ompossible, that they be constant over time, and that they observed in practice by those charged with their administration. See note 11.
Brody H, Miller FG. The internal morality of medicine explication and application to managed care.J Med Philos 1998; 23: 384–410.
Miller FG, Brody H. Professional integrity and physician-assisted death.Hastings Cent Rep 1995; 25: 8–17.
An important area of the internal morality of medicine not addressed explicitly by Brody and Miller (though, in fairness, they did address it implicitly) concerns the importance of the nexus between goal(s) being pursued and the means being employed—the “tightness,” in other words, of the means-end fit.
Black’s Law Dictionary 866 (abridged 6th edition), 1991.
Braddock CH 3rd, Tonelli MR. Too much ethics, not enough medicine: clarifying the role of clinical expertise for the clinical ethics consultant.J Clin Ethics 2001; 12: 24–30.
Merriam Webster’s Collegiate Dictionary 397, 398 (10th edition) defines “ethician,” n (1629) as an ethicist. “Ethicist,” ca (1890), is in turn defined as a specialist in ethics.
Ladd J. Expert testimony, 5 Vand. L. Rev. 1952: 414, 418.
Morreim EH. Professionalism and clinical autonomy in the practice of medicine.Mt Sinai J Med 2002; 69: 370–7.
Veatch RM. Why physicians cannot determine if care is futile.J Am Geriatr Soc 1994; 42: 871–4.
Gordon R. The independence of lawyers. Boston, MA: Boston University L. Rev., 1988.
Model Rules of Professional Conduct. Preamble (1983). In: Gillers S, Simon RD, eds. Regulation of lawyers: statutes and standards. Boston, MA: Little, Brown and Company, 1989.
Latham SR. Medical professionalism: a Parsonian view.Mt Sinai J Med 2002; 69: 363–9.
Moros DA, Rhodes R. Introduction, Issues in medical ethics 2000.Mt Sinai J Med 2002; 69: 354–5.
Deciding to forego life-sustaining treatment. A report on the ethical, medical, and legal issues in treatment decisions, 1983. Reprinted in: The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1983.
U.S. v. Carroll Towing Co., 159 F.2d 169, 1947.
Helling v. Carey, 83 Wash. 2d 514, 519 P.2d 981, 1974.
Guidelines on Mediation and the Unauthorized Practice of Law 1, available at http://www.courts.state.va.us/text/drs/upl/preface.html (accessed February 13, 2003).
Morrison AS. Is divorce mediation the practice of law? A matter of perspective. 75 California Law Review 1093, 1987.
Spielman B. Has faith in health care ethics consultants gone too far? Risks of an unregulated practice and a model act to contain them. 85 Marquette Law Review 161, 2001.
New York County Lawyers’ Association v. Dacey, 21 N.Y.2d 694, 287 N.Y.S.2d 422, 234 N.E.2d. 459.
Oregon State Bar V. Gilchrist, 272 Or. 552, 538 P.2d 913, 1975.
Florida Bar v Stupica, 300 So. 2d 683 (Fla. 1974).
For the purposes of illustration, we group the ethical issues raised by this case into questions of professional duty, questions of law and questions of general morality. In real time, of course, the questions would not be considered in this order, but in an order dictated by considerations of logic and efficiency.
Burton v. Brooklyn Doctors Hospital, 88 A.D.2d 217, 452 N.Y.S.2d 875 (App Div. 1982).
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Paola, F.A., Walker, R. Ethicians, ethicists and the goals of clinical ethics consultation. Int Emergency Med 1, 5–14 (2006). https://doi.org/10.1007/BF02934714
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DOI: https://doi.org/10.1007/BF02934714