Ethics Consultation-A Blind Spot of Philosophy in Bioethics?

Abstract

While making an important point for a strong role of philosophers and philosophical work in bioethics, Blumenthal-Barby and colleagues (2022) fail to mention one of the most pressing tasks in this field: a critique of ethics consultation (EC) in clinical settings. Since the early 1970s, a continuously growing number of health care institutions are complementing their teams with ethics consultants, who offer assistance whenever an uncertainty or a conflict arise about the ethically best course of action in clinical care (Tarzian and Force ASBH Core Competencies Update Task 2013). They work as single consultants or members of ethics committees and typically respond to requests of health professionals, patients or relatives in their institutions. Mainly the advances in intensive care and organ replacement therapies like mechanical ventilation have led to this development (Tapper 2013). With the availability of life-prolonging technology came the pressing question of justified criteria for their withdrawal. Physicians felt that their medical training did not provide all the instruments needed in such complex decision-making processes and it have been mostly philosophers like Albert Jonsen and John Fletcher, who in these early days of ethics consultation came to their aid (Tapper 2013). Since then, many medical and non-medical academics specialized in analyzing and weighing treatment options from an ethical point of view and, thus, contributed to the building of a new profession of ethics consultation. In 2018, 86.3% of all US general hospitals had an ethics consultation service (ECS) (Fox et al. 2022). Many other countries reported similar developments. What at first glance impresses as a success story, does reveal various inconsistencies at a closer examination. Not only is the actual utilization of ECSs still low. Fox and colleagues reported a median number of 3 case consultations per year for ECSs in the US (Fox et al. 2022). The data for other countries (if available) are similar. The whole practice is still characterized by an astonishing lack of evidence. We have little knowledge about by whom and how EC is offered and equally little about what are the ends and outcomes (Fox et al. 2022; Schildmann et al. 2019). Even more alarming are the deficiencies on the theoretical level. Regarding the normative framework of ethics consultation, the prevailing principlism in this context suffers from an oversimplification to an extent that its basic ideas are often barely recognizable. A principle like “autonomy,” for example, is not self-explanatory but there are important philosophical backgrounds that shape its meaning in ways that are relevant for the application in a concrete medical practice. Even if nobody expects an ethics consultant to have the entire history of this concept in mind, one should be able to deal with it to at least the extent that the most important meanings of the concept are present. On the other side of the spectrum of theories in clinical ethics, casuistry is a key tool. But since the early times, the methodology of casuistry has not been significantly improved. The approach of Jonsen and Toulmin (1988) has been quite dominant, although its short-comings are rather obvious. Their concept of casuistry depends e.g. on an existing agreement on paradigm cases. In cases of disagreement casuistry has a hard time. Likewise, it is still contested how the method of casuistry relates to the use of principles. Ethical particularists and an entire set of philosophical approaches have different opinions in this regard. This discussion is particularly relevant for EC since there is hardly any field which so directly is confronted with “cases.” A further development of this methodology is urgently needed. And it is likely that an improvement is possible. Huge parts of the history of ethics could contribute here while Jonsen/Toulmin only made use of a very limited tradition in early modern times (D€ uwell 2013).