Fall 2003, Vol. 10, Issue 3
By David Ozar, PhD
Professor and Director for the Center for Ethics
Department of Philosophy
Loyola University, Chicago
Most hospitals and health systems now have either an ethics committee or trained ethicists on staff to provide ethics consulting assistance. In most institutions, such assistance is available to caregivers, patients, families and anyone else involved in an ethically complex decision. Most ethics consultation programs are less than 10 or 15 years old, but health care ethics scholars and professional societies like the American Society for Bioethics and Humanities have begun to study ethics consultation carefully. This essay is the fruit of such study.
What is the value of an ethics consultation? Why would someone ask for this kind of assistance and what do those who offer ethics consultations aim to provide?
James Rest, 1 a psychologist of ethical development, has identified four components of ethical decision-making and implementation and to these I will add two more. The six factors are: ethical sensitivity; ethical reasoning and judgment; ethical motivation; practical implementation; shared rather than isolated ethical wisdom; and fitting ethical decisions into our lives.
The first component of every ethical decision is being aware of what is ethically at stake. Rest calls this ethical "sensitivity." It is the ability to understand all that is ethically significant about a situation so it can be assessed from the perspective of various values, ethical principles, rights, virtues and duties. It also entails appreciating the perspectives of the stakeholders.
Sometimes we overlook something that is ethically significant because we have a pattern of blindness to that kind of thing. For example, we might discount certain kinds of reactions or feelings as not important, or we might discount all of the experiences or feelings of a certain kind of person. But whether such deficits are situational or a more stable part of our makeup, if we want to make a good ethical decision, we need to rectify them. An ethics consultation can help with this, revealing a gap in our awareness of what is ethically at stake - either some ethical data that we are overlooking or the perspective of someone whose point of view we are not adequately attending to. Correcting a deficit of ethical sensitivity is one possible value of an ethics consultation.
Suppose, for example, a patient or a family requests life-extending treatments with serious side effects and little likelihood of benefit because they fear a lonely and painful death and see it as the only alternative. If they cannot hear caregivers' offers of good palliative care and assurances that they will not abandon them, an ethics consultation might get this message across.
A second thing that goes into good ethical decision-making is good judgment about ethical matters. A person whose sensitivity is well attuned to a situation will often have a lot of ethical data to process; good ethical decisionmaking depends on having the necessary skills for processing that data and using it to reach a sound judgment.
Most adults have some skill at processing ethical data, but very few have thought much about how ethical judgments are reached, much less about the thought patterns by which different kinds of ethical judgments are formed (e.g. the differences between judgments based on character and virtue, those based on maximizing values and minimizing harms, those based on principles or duties or rights, and so on). Few are truly skillful in determining when an ethical judgment is defective because it doesn't process the ethical data coherently. An ethics consultation can assist a decisionmaker in drawing a sound conclusion from the ethical data. Ethics consultants are also often able to offer helpful concepts and distinctions, such as those developed in the scholarly literature of health care ethics that can clarify the elements of a puzzling situation and render a difficult situation easier to comprehend. In addition, they are often able to clarify ethical judgments by being knowledgeable about the standards of professional ethics that are relevant to the situation.
Suppose a physician caring for a neurologically damaged patient feels confident that life-extending care is best for the patient, but has not asked what intervention the patient would choose if he or she could do so. An ethics consultation could help the physician attend to this important ethical principle for patients incapable of decision-making.
A third element of good ethical decisions is motivation to do what one ought to do. Even when a person is sensitive to what is ethically at stake in a situation and judges well about what ought to be done, the person may not be motivated to act accordingly. The elements of motivation - a person's habits and patterns of living according to certain values, principles and ideals - typically develop and grow only over time. So it would be inappropriate to expect an ethics consultation to magically rectify a deficit of motivation if that is the problem. But straightforward description of appropriate motivation and straightforward discussion of people's actual motivations can be very helpful. Occasionally it prompts significant change in decision-makers' motivations and, in any case, it can at least assist the others involved in "calling a (motivational) spade a spade."
The fourth component of a good ethical decision is knowing how to implement it in a practical way and being emotionally able to do so rather than being hindered by feelings of fear or hopelessness. On the practical side - especially in complex institutional and professional settings like contemporary health care - people sometimes discover they do not know how to do what they ought to do. They may lack the needed expertise and do not know how to get assistance, or perhaps they do not know how to work the institution's systems. On the emotional side, they may have to confront powerful fears or a sense of hopelessness in order to carry out the action they have judged appropriate. Ethics consultations often contribute by educating the person on how to make it happen or helping the person handle his or her fears or sense of hopelessness. In many situations, for example, patients, family members or caregivers are quite thoughtful in determining what they ought to do, but are overwhelmed that their choice is a choice between tragedies. An ethics consultation can help them deal with the hopelessness of such terrible choices and the fear that often attends being responsible for choosing the least bad outcome for someone else.
Throughout this essay, the decisionmaker has been spoken of as if the decision-maker is always an individual. However, very frequently, the "decisionmaker" is a group of people acting as a unit. For example, if a patient is incapable of decision-making, several family members may need to come to a consensus about treatment, even if one of them is formally and legally the official spokes-person. The nursing staff or the residents caring for a particular patient or the entire interdisciplinary team may, in a given situation, function as a unit in deciding the ethically right intervention for the situation.
It is sometimes assumed that ethics consultations are there to serve ethics, to make sure people act ethically, as a sort of ethics police force. This view of ethics consultations is deeply mistaken. Ethics consultations are done for the sake of decisionmakers, to help them in their desire to make the best ethical decisions they can, not for some more abstract purpose.
This means that when deciding whether to seek an ethics consultation, those wanting assistance should stop to figure out who the decision-maker is in the situation. Is this my personal decision? Is it my ethical questions with which I need help? Or is this a collective decision? Obviously, making this clear to those providing the ethics consultation will also help them in serving the decision-maker or group effectively.
This takes us to a fifth component of good ethics consultations. Judging difficult ethical matters can be a very lonely business (whether the decision-maker is an individual or a group) because we humans make our ethical decisions, in an important sense, before all the world. While no one else can be responsible for our actions, it is consoling (in the root sense of the word: solari, "to soothe," con-, "together") to know that other thoughtful people are sharing in what may be a particularly difficult process or ethical judgment. This means that an ethics consultant - whether a committee or an individual - cannot walk out of a consultation thinking that everything that happened rested solely on the shoulders of the decision-maker. Unless the decision-maker chooses to ignore what has been shared in the consultation, the judgment about what ought to be done must be viewed as a shared judgment between decision-maker and consultant. This sharing of responsibility, this gift of consolation, is often a very great gift for a decision-maker.
Sixth, good ethical choices should make sense to the one making the decision. Furthermore, the decision-maker should be able to explain it so it makes sense to others. When the story is told of what was ethically at stake in the situation, of the judgments this led to, of the motivation to carry out the decisions, the efforts taken to implement the decision and overcome hindrances, and of the actor's recognition of being the responsible party for what was done - that story needs to make logical, cognitive sense and affective, emotional sense.
Why would someone ask for an ethics consultation?
Since we know that these six characteristics of good ethical decision-making are sometimes very hard to achieve, if there are people who can help us achieve them even a little better than we could on our own, that is a good thing. Many of us have friends or family members to whom we can turn to for assistance with ethical decisions in personal matters. What health care ethics committees and individual ethics consultants can do is provide similar assistance for difficult ethics decisions that need to be made within the institutional setting. That is the value of ethics consultation.
Footnotes
1 Rest JR. The major components of morality. In Kurtines W, Gewirtz J (eds). Morality, Moral Behavior, and Moral Development. New York: Wiley, 1984.
Suggested reading
Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med 2000;133:59-69.
Freedman B. Francoicse B (ed). The Roles and Responsibilities of the Ethics Consultant: A Retrospective Analysis of Cases. Hagerstown, MD: University Publishing Group, 2000.
Ozar DT. Professions and professional ethics. In Reich W (ed). Encyclopedia of Bioethics, revised edition. New York: Macmillan, 1995.
Rest JR. Background: theory and research. In Rest JR, Narvaez D (eds). Moral Development in the Professions. Hillsdale, NJ: Lawrence Erlbaum, 1994:1-26.
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
