Abstract
The preceding chapter concluded with the suggestion that the greatest threats to the integrity of practising healthcare ethicists may not be the temptations associated with extrinsic conflicts of interest (such as the inducements that come in the form of contracts with pharmaceutical companies or even the promises of secure salaries), but instead come in the form of intractable, perhaps inescapable, challenges associated with the nature of the role (at least as it is often structured). Although some practising healthcare ethicists may see themselves as champions of underdogs in the clinical encounter (for example, for patients who are vulnerably situated owing to a tragic combinations of variables such as illness, socio-economic status, or addiction), it must be acknowledged that even a PHE who holds that view will have difficulty defending a conception of the role that limits her sphere of responsibility to the interests of a single patient or patient population. If healthcare ethicists are, however, not agents of particular parties but are accountable to a wider community (like Stark’s judges, critics, and journalists) they will need to find, or produce for themselves, a conception of the role that informs their deliberations and allows them to contribute productively to the challenges presented by complex cases. PHEs, unlike judges, may not—and generally ought not—have the authority to render binding decisions, but framing questions, participating in (or leading) mediation sessions, and offering advice are also tasks that should not be taken lightly. Some of the threats to judgement that may be associated with the practice of healthcare ethics consultation and support are, therefore, the subject of this chapter. Whether they can be appropriately managed, and what an apt management strategy might consist in, are important topics to which I will return after a much needed exploration of the imprecise but, increasingly widespread, charge that healthcare ethics is a partisan endeavour.
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Notes
- 1.
A collection of essays called Beyond Bioethics: Toward a New Biopolitics has recently been released and it joins other volumes whose titles may not expressly reference the political character of the field but that are nonetheless occupied with similar or related concerns. A few such offerings are: Tom Koch’s, Thieves of Virtue, Lisa Eckenweiler and Felicia Cohn’s, The Ethics of Bioethics, and Barry Hoffmaster’s, Bioethics in Social Context.
- 2.
Carl Elliott. White Coat, Black Hats: Adventures on the Dark Side of Medicine, 150–151.
- 3.
It is understood that these charges have both descriptive and normative dimensions. My interest is not in uncovering strategies for measuring the degree of influence that ethicists exert in healthcare settings or even in surveying their ideological orientations. It is, rather, in answering more philosophical questions. These are: Is the PHE’s work necessarily political? and, if so, Should that be a cause for concern?
- 4.
Although Tom Koch and Giles Scofield, among others, use the phrase “medical ethicist” to describe those I am calling practising healthcare ethicists, the usage is not a widespread or unproblematic one. Many in the field view the modifier “medical’ as unnecessarily limiting (as it seems to exclude issues that arise in public health and global health ethics, for example) and is reflective of a tendency to place priority on the practice of medicine or the work of physicians. In contrast, the PHE designation can make space for conversations about the social determinants of health and recognize the importance of listening to the diverse stakeholders who ought to be engage in ethical deliberation.
- 5.
Thieves of Virtue: When Bioethics Stole Medicine, 18.
- 6.
Ibid., 5.
- 7.
There is truth to the claim that health systems attend closely to the costs associated with care provision. Provincial Ministries of Health impose funding formulas that specify the rates that can be charged for procedures such as hip and knee replacements and dictate the number of days that hospitals will paid to keep patients in their beds. Similarly, institutional of Offices of Research Operations struggle with challenge of generating high quality research with limited public funds. Bio-repositories offer opportunities to generate revenues to support costly knowledge-generating activities. What is not self-evident, however, is veracity of the contention that PHEs generally will regard these financial considerations as more important than the competing interests of patients and research participants.
- 8.
See especially Carl Elliott’s “Throwing a bone to the watchdog.” Hastings Center Report (2001), 9–12.
- 9.
During the Council’s tenure a flood of articles were published by prominent bioethicists critiquing its composition as well as its specific recommendations. See, for example, “The Endarkenment” by R. Alta Charo in Eckenwiler & Felicia Cohn (eds.), The Ethics of Bioethics: Mapping the Moral Landscape. Johns Hopkins University Press (2007). Contrary to Koch’s contention, most members of the field were far from supportive of what might have been described as the Council’s neo-conservative agenda.
- 10.
Mark B. Brown, Three Ways to Politicize Bioethics, The American Journal of Bioethics 9 no. 2, (2009): 44.
- 11.
Ibid.
- 12.
Principlism, most often identified with the work of Tom L. Beauchamp and James F. Childress, is one of most recognizable frameworks for ethical decision-making. The principles in which it is grounded are autonomy, beneficence, non-maleficence, and justice. Beauchamp and Childress have clarified that they see do not see these principles as occupying all of the space that is available for moral reasoning. Instead they suggest that they should “function as an analytic framework that expresses the general values underlying rules in the common morality” or serve as “guidelines for professional ethics.” See: Beauchamp, Tom L. and James F. Childress, Principles of Biomedical Ethics, Fifth ed., 12. Unfortunately, the language of rules, and the crude application of principles to cases, can support precisely the sort of engineering approach to ethics that many of its critics deride. My view is that while it can support such an approach, it is not inevitable that it do so. Indeed, I maintain that principlism, properly understood, ought to prompt healthcare providers to interpret and apply contested concepts in their best moral light.
- 13.
Koch, 111. Earlier, I made reference to the very interesting question of whether PHEs should take legal standards to be binding in all cases. Whether laws constitute porous or impermeable boundaries in a case may depend on a number of variables (such as whether the law is habitually disobeyed, and what the penalties for disobedience are likely to be) which will not be addressed here. These are questions which could very fruitfully be addressed via the establishment of practice standards should PHEs succeed in becoming a regulated healthcare profession.
- 14.
Ibid.
- 15.
I leave aside the question of whether a practising healthcare ethicist should ever recommend a course of action which conflicts with the law or with policies set by the colleges of the regulated health professions, or of the institution that employs the PHE and those seeking her counsel. This question is an important one which has interesting parallels in jurisprudential debate. As PHEs explore professionalization, they may benefit from engagement with a broader literature which is careful to distinguish law from morality, and which looks at the question of obedience to so-called wicked law.
- 16.
See especially: Margaret Urban Walker’s “Keeping Moral Space Open: New Images of Ethics Consulting” in the Hastings Center Report 23.2 (1993), 35.
- 17.
Joan Tronto, “Who is Authorized to Do Ethics? Inherently Political Dimensions of Applied Ethics,” Ethical Theory and Moral Practice, 14.4 (2011), 414.
- 18.
Ibid., 414.
- 19.
Tronto, 416.
- 20.
Tronto, 416.
- 21.
Ibid.
- 22.
Tronto, 413.
- 23.
Indeed, Tronto cited Caplan’s experiences in order to provide clear illustrations of some ways that practising healthcare ethicists can, and ought, to use their role-based authority to reduce power differentials in very hierarchical settings such as bedside teaching rounds. She is not so naïve as to imagine that the PHE will always prevail, but she appears to be optimistic enough to countenance an institutional ethics practice that permits the consultant to engage strategically in the art of compromise without becoming hopelessly compromised.
- 24.
Susan Sherwin. Whither Bioethics? How Feminism Can Help Reorient Bioethics, International Journal of Feminist Approaches to Bioethics 1.1 (2008), 23–24.
- 25.
Ibid., 12.
- 26.
Ibid., 14.
- 27.
Ibid., 15.
- 28.
Ibid., 13.
- 29.
Horst W. J. Rittel and Melvin M. Webber. “Dilemmas in a General Theory of Planning,” Policy Sciences 4.2 (1973), 160.
- 30.
Ibid.
- 31.
See, for example, Adrienne M. Young. “Solving the Wicked Problem of Hospital Malnutrition,” in Nutrition and Dietetics 72 (2015), 200–204, or Carol A Heimer. “‘Wicked’ Ethics: Compliance Work and the Practice of Ethics in HIV research,” Social Science & Medicine 98 (2013), 371–378.
- 32.
Ibid.
- 33.
Ibid., 156.
- 34.
For a superb treatment of the evolution of the professions in the United States, as well as an analysis of the debate surrounding the professional status of healthcare ethics consultants see Deborah S. Cummins, “Professional Status of Bioethics Consultation.” Theoretical Medicine 23 (2002), 19–43.
- 35.
Ibid.
- 36.
Susan Sherwin, “Foundations, Frameworks, Lenses: The Role of Theory in Bioethics,” Bioethics 13.3–4 (1999) 198–205.
- 37.
Ibid, 200.
- 38.
H. Tristram Engelhardt, Jr. “Consensus Formation: The Creation of an Ideology.” Cambridge Quarterly of Healthcare Ethics (2002) 11, 8.
- 39.
Physicians are still high status members of healthcare teams, but other professionals are becoming insistent about receiving recognition for the value of the contributions that they bring to the table. At least in academic teaching hospitals it is common for non-physician team members to hold advanced degrees and many are quick to reference the fact that hierarchical communication structures have negative effects on safety, quality, efficiency, morale, and the patient experience.
- 40.
Ibid.
- 41.
On occasion, these kinds of cases can generate uncertainty, but hard cases are generally ones involving minors, decisionally-incapacitated persons, or individuals thought to be particularly vulnerable to coercion. For adult members of the faith the right to refuse certain treatments is well-established and uncontroversial.
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Heesters, A.M. (2022). Scrutinizing the Standing of Principles: On the Politics of Bioethics. In: How Legal Theory Can Save the Life of Healthcare Ethics. The International Library of Bioethics, vol 101. Springer, Cham. https://doi.org/10.1007/978-3-031-14035-8_3
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