I recall being a PhD candidate in philosophy in the 1970’s, I often pondered the subject matter of my graduate courses in ethics. I would ask myself, what does any of this have to do with ethics? What are we doing?
As our courses went from Kant to Mill to G.E. Moore to the Emotivists and others, I couldn’t help but have a sense of unreality about the content of what I was learning.
How can we use reason to find a basis for knowing right action? What are the ways we can define right action based on a normative moral theory?
What is the meaning of good? Right? And obligation? Can these terms be defined within a theoretical, substantive moral framework or are they just expressions of feelings and emotions without any cognitive content? If they are more than the latter, what do they mean?
To be sure those were interesting questions but only if you were an ivory tower philosopher. Philosophers were thinking and arguing over which moral theory was more persuasive and cogent, but clearly they weren’t doing anything in terms of actions or strategies that might have an impact on any aspect of the practical world. Ethics was entirely a theoretical, academic pursuit. Which raised the question, just what were we philosophers fit to do besides argue with each other and prepare ourselves for a future in academia?
It was about this time that the practical ethical dilemmas in medicine began to make regular headlines in the news. From organ transplantation to rationing dialysis machines to life supports in the ICU to test tube babies, many moral dilemmas were arising that required practical ethical attention in public policy and law. But first some kind of ethical approach or understanding was required. It’s true that there was already a small cadre of theologians and a few philosophers on the scene. But the new fields of medical ethics and bioethics were just emerging and it seemed obvious to many that the new practical problems in medicine should be taken up more broadly by academic philosophers. After all, they studied philosophical ethics and they were assumed to be ethicists. But given the types of problems and questions that occupied philosophers up to that point, what were philosophers to do? ‘Doing’ means getting your hands dirty in the messy, real world of practical affairs.
So what has become of philosophers who made that journey from then to now, specifically in the terms of doing ethics?
As a philosopher who does clinical ethics consultations my “doing” begins and ends with the problems reported to me by physicians and nursing in the process of caring for patients. But those problems, which we call ethical, are radically unlike the ethical problems that have been of interest to philosophers. It is crucial to realize that the requests for ethics consultations stem from the “felt” concerns of clinical practitioners and often patients and family members. Those concerns reflect a larger concern about a conflict between the main participants in a patient case about how to define goals of care or, in more ethical language, the “good” for the patient. When the ethics consultant becomes involved there is the expectation that he or she will do something to ameliorate the clinical, problematic situation.
It’s worth noting that such problematic situations presented in the abstract are often much of the content of clinical ethics education. And much can be learned by students looking at cases hypothetically and making suppositions along the way about various ways of justifying certain outcomes based on an application of the principles of medical ethics. It is possible to apply various theories and make various analyses to this case to justify certain outcomes. Philosophers are adept in making such somewhat speculative cases about cases from afar, that is, of theoretical interest only. But it is crucial to point out that a theoretical discussion and treatment of clinical cases apart from the actual clinical setting in which the case occurs is not really doing clinical ethics. So back to the question, what is the ethicist to do?
The ethics consultant called to help in the actual case would start by actually talking and interacting with the key participants. A fuller and richer account of the medical perspective from the physicians is usually an important first step to take, for without a clear understanding of the medical facts of “this” particular case the ethical problem cannot be understood or resolved. For example, a case that turned on the patient refusing what would likely be short-term dialysis, which would likely allow the patient to return to prior baseline afterward, is a very different ethical situation than the patient refusing permanent dialysis which would entail significant burdens. A careful examination of the medical chart would further clarify the medical facts as well as provide a broader understanding of the patient’s prior medical condition and overall relevant contextual factors. Next would be actual communication with the patient if possible—this might entail a lengthy discussion about her life leading up to hospitalization; what her life was like over the years and in more recent years; what were her concerns now and moving forward; what her relationship with her family was like and so on; and specifically, does she understand the full implications of refusing life-sustaining treatment, that is, that she will die? The ethics consultant would likely have some sense or assessment of the patient’s capacity to make a decision about refusing life-sustaining treatment. The information and impressions gleaned to that point would be taken into account and used to frame a meeting with the family. It is possible that the meeting would be framed as a task to let the family know the patient has full capacity to make her own healthcare decisions; conversely, if the patient lacks capacity the family or certain members of the family would be informed that they are the patient’s surrogate and decision about care of the patient must be made. In the end, the ethics consultant would develop a recommendation that fits the precise details of the case and would strive to get all the main participants to agree. This is the process of facilitation consistent with well-established ethical and legal principles.
It is somewhat ironic that many of us who work in the field of bioethics and clinical ethics began as philosophy students studying abstract problems with little or no bearing on practical affairs are now involved in actually doing ethics in very practical settings where we strive to reduce conflicts and improve the quality of patient care. How did we get from then to now? What are we doing? I ask this question somewhat facetiously but there is a very serious component to it as well. Something has dramatically changed in how we think of ethics and it has made a significant difference to patient care in the hospital clinical setting. But the change has been even more significant to the professional persona or skills sets of ethicists like myself.
The doing of ethics is no longer just thinking and arguing abstractly—ethics must also include interacting, communicating, and learning the facts about particular cases and making a positive difference. The analytical skills that were the centerpiece of ethics when I started as a graduate student in philosophy are still necessary. But clearly they are no longer sufficient to do ethics. This raises the question: how has the turn toward more practical ethics affected or should affect philosophical ethics? This is a question I will take up in another blog.
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.