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June 24, 2013 | Posted By Wayne Shelton, PhD

The moral basis for competent, clinical ethics consultation, I would like to argue, is largely derived from the moral premises of our normative understanding of what it means to be a “good doctor” as reflected in a self-conscious commitment of a good physician to treat patients as best as one can according to prevailing standards of professionalism and medical ethical principles. The good doctor stands in relationship to a patient, within a well-defined framework of moral rights and professional obligations. This linkage between the activity of clinical ethics consultation and our understanding of a good physician further defines the work of the ethics consultant squarely in framework of clinical, medical competencies.  

To further see this linkage, it is useful to consider how and when value conflicts arise in the physician-patient relationship. For the vast majority of physician-patient encounters, there is agreement and absence of conflict. But in the less frequent cases of moral conflict, there are competing visions of what should happen—regarding the goals of care and who has the moral authority to define those goals. In short, how are competing rights and obligations to be balanced between the patient and physician, but also the surrogate, the hospital and potentially many other interests, especially in the midst of the emotion and stress that illness and impending death can induce both to patients and their families? It is the latter contextual aspect of grounding value conflicts within a patient’s and family’s illness experience, and the necessary ability to function effectively in clinical encounters, that requires the competent ethics consultant to also possess the general qualities of a caregiver, and to understand the moral perspective of a good physician.

I am assuming the concept of the good physician entails, at least ideally, the full range of competencies, not only scientific and technical, but also those broader competencies essential to providing optimal care for patients. These broader competencies include the skills to perform an ethics consultation, including both knowledge to make sound judgments and the clinical skills to communicate effectively and build consensus. In today’s medical setting the complex, multidimensional nature of providing medical care precludes one person, viz. the physician in charge, to be able to do everything. This is why an attending physician who needs a consult for his patient in a medical specialty cannot realistically be expected to perform the medical consultation herself. The medical consultant performs the specialty consult for the purpose of providing information to the attending physician necessary in order to clarify and define certain goals within the physician-patient relationship. 

Clinical ethics consultation should be viewed as a type of expert clinical consultation along side other types of medical consultations that may be required in order to provide excellent medical care. And, it should be emphasized that the ethics consultant is not a medical moral expert in the sense that he or she can issue normative right answers to difficult clinical ethical problems.  Moral expertise in ethics consultation has to do with skills and knowledge within a well-established procedural process that attempts to balance ethical principles, rights and obligations that are usually in conflict, and have to be negotiated; as opposed to the ethics consultant issuing substantive moral judgments about right and wrong. There are times when the clinical ethics consultant must advocate for a particular position, but this arises in cases where certain procedural rules are not being followed, e.g. when a competent patient’s right to refuse treatment, or a surrogate’s right to make decisions for an incompetent loved one, become compromised.  

But my sense is that unlike other types of medical consultations, ethics consultation often reflects a need to repair some problematic aspect of the physician-patient relationship in terms of its inability to reach common agreement on basic facts and goals in a given case.  Like all consultants, ethics consultants must be able to gather the facts systematically as in any consultation and describe them in ethical terms, i.e. the language of rights, obligations, professional codes, etc., and be able to map out the range of options, consistent with well-established ethical guidelines and practices. Most importantly, a competent ethicist must be able to recognize options that are ethically unacceptable. The analysis of these options in ethical terms often reflects the importance of a formal academic background and training, and moreover points to how an ethicist with less formal ethics training may fail to dissect these ethical aspects with the same level of focus and precision. This difference in the quality of the ethical analysis could yield important practical differences in case outcomes.    

The ethical analysis and discussion in the consultation process should provide the framework in which outcomes, ideally, can be forged by reaching consensus among the medical team, patient and/or family. The process of reaching consensus requires effective communication and interpersonal skills. The ethicist must interact with people in the hospital setting who are stressed, often from the shock that a loved one is ill or dying. Regardless of whether the ideal consensus is reached, focused support, understanding and sometimes education must be provided to reach common ground and new direction. Often a key part of reducing stress involves a clarification of the ethical problems reframed in ordinary language. For example, a clarification of artificial feeding as being a type of medical treatment that may be refused if it does not serve to promote important patient goals, can help a family member remove the unnecessary guilt of wrongly thinking that she is directly killing her loved one by refusing a G-tube. 

In short, the fully competent ethicist should possess both a deep knowledge of clinical ethics and the essential clinical skills of all medical caregivers necessary to function and be effective in ethically problematic clinical situations.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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