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September 2018

We need more arguments in clinical ethics

By | Ethics, Uncategorized | No Comments

This blog post was originally published on the Journal of Medical Ethics Blog

Ethics is a philosophical discipline. The bedrock of philosophical scholarship is the construction of arguments – a set of reasons that justify a particular position. Philosophers spend years cultivating critical reasoning skills and applying them to many and varied problems. While philosophy has universal application, it is often erroneously perceived as an ‘ivory tower’ discipline, more concerned with abstract ideas and concepts than with ‘real world’ problems. Academic ethicists supposedly spend their time writing papers and pontificating on big issues like euthanasia, the importance of autonomy, and human rights. Those of us who work in the ‘real’ world of healthcare, know that it is rarely as the academic papers make it seem.

Clinical ethics should be different. Clinicians of all stripes think through ethical problems and make ethical decisions every day. Clinical ethics services (CES) are increasingly available as a resource to assist with difficult ethical decisions. There are a multitude of models for the delivery of CES. The goal they have in common is to provide decision-making support and/or advice to healthcare practitioners, and/or patients and families, grappling with difficult ethical situations. But what is it that CES actually do to provide this support? The truth is that no one is sure, or at least no one agrees completely. The nature of clinical ethics expertise remains up for debate. Some say that CES really function as a conflict resolution and mediation service. Some say their major contribution is in debriefing and managing moral distress. The more cynical among us may cast CES as a defensive mechanism for hospitals – being convened so that there is evidence of due process for legally controversial decisions.

All of the above are true. Some CES are only convened ad hoc, often in the context of legal controversy. Some CES function no differently to a mediation service. These services, in my view, are not actually providing clinical ethics consultation. Skills in conflict resolution and facilitation of discussion are important for clinical ethicists, but are not sufficient. It may be necessary for a hospital to go through due process, but merely convening a committee and discussing the issue is not sufficient – the discussion must be of a particular deliberative nature. Clinicians, and institutions, refer cases to CES when they need help making an ethically difficult decision. Making good ethical decisions involves critically appraising the arguments for and against possible courses of action. Assumptions need to be identified and challenged. Moral intuitions need to be explored and questioned. The rationale for the chosen course of action needs to be cogent and be made explicit. Clinical ethics expertise is in helping clinicians build a comprehensively considered, well-reasoned justification for their decision. In short – it’s all about the arguments.

Lest this sound too cold and analytical, I wish to stress that nothing can be critically appraised, or argued for or against in a robust manner, without considering the human complexity and rich narratives that inform people’s values and life views. In healthcare, difficult ethical decisions often arise in the context of interpersonal conflict, high emotions, and moral distress. Skills in conflict resolution, mediation, facilitation of discussion, and narrative exploration are necessary for a clinical ethics team. These skills enable them to engage meaningfully with all of the people involved in decision-making and gather the information required to do the philosophical work of developing a robust argument for how to proceed. What matters to people, what their emotional responses are to a situation, and how a particular event makes sense in their lives, are key components that must be made coherent with the medical facts of the case and incorporated into the rationale for a decision.

Philosophical work – that of critical reasoning and argumentation – is not well understood by many clinicians. We are trained in the scientific method and are adept at critically appraising scientific papers to inform clinical practice. We are much less familiar with philosophical methods of reasoning and with critically appraising philosophical papers. The ethical complexity of healthcare is increasing and the ethics literature is expanding. It is important for all clinicians to keep abreast of the ethics literature that is relevant to their practice, and even more so for those involved in clinical ethics consultation work.

In a paper I co-author with Peter Ellerton, we present a critical appraisal worksheet designed to assist clinicians to actively read ethics papers and critically appraise the arguments presented. We have used this worksheet in our own ethics journal club and found it to be a useful shared framework. Additionally, education that focuses on the critical appraisal of arguments hones this cognitive skill more generally. Clinicians are then more able to apply these critical reasoning skills in real time in clinical ethics consultation work, and in day to day ethical decision making. Ethics in the emotive, conflicted, ‘real world’ of healthcare, is still all about the arguments.