On Hospital Ethicists

At the beginning of August, Dan Sokol wrote a piece for the BBC news site in which he touched on the place of hospital-employed ethicists.  Apparently, this is a reasonably common position in the States.  I used to be of the opinion that hospital ethicists would be a good idea – when I was a student, it was one of the possible careers I saw for myself.  I even wrote to my local hospital trust to ask if they could sponsor my studies; in doing so, I had one eye on the possibility that the Chief Executive might slap his forehead, exclaim “An ethicist!  That’s exactly what we need!”, and offer me a job into the bargain.

 

Of course, that didn’t happen – I got neither the job nor the cash.  In retrospect, though, I wonder whether my enthusiasm might have been misguided anyway.  I’m not sure that hospital ethicists are such a good idea.  There’s a number of reasons for this.

 

The first is pragmatic.  I assume that the rationale behind having an ethicist on hand would be to give some sort of moral guidance in respect of problems that people in hospitals – professionals or patients – may face.  Yet it is also the case that what medical staff do is already regulated by the law, professional guidelines, government policies and so on.  And it seems to me that these would limit the use that an ethicist could be, because they would restrict the kind of advice that could be given.  Imagine, for example, that you had a dilemma to do with terminating a pregnancy, and that I was your local ethicist.  Often, inasmuch as I was acting in a professional capacity, it’d be hard to see how I could do much beyond point to the legal position in respect of what you were considering.  I might think that the law is wrong and that it’d be OK to break it – but I couldn’t realistically tell you this, any more than your accountant could advise you on the best ways to avoid tax.  The same would apply in respect of providing advice to patients.  Of course, I could take off my professional hat for a moment – but then I’d have stepped outside my professional role.  qua hospital ethicist, my movement would be limited.

 

Moreover, I’d be a little wary of the possibility of being drawn into disputes between parties.  While being assured by a competent lawyer or a competent surgeon may provide practitioners with a defence should something go wrong, I think that ethicists should be wary of being used in a similar way.  For sure, one would hope that an ethicist is the kind of person who would examine and analyse the problems in respect of this or that course of action coolly and disinterestedly – but “My ethicist told me that I was morally in the clear” is not a phrase I ever want to hear: it implies a delegation of responsibility for one’s actions that strikes me as antithetical to the very idea of being a moral agent.

 

A third problem has to do with treading on the toes of the chaplaincy.  Sticking with the abortion example: there are many people whose opinions on such procedures are at least informed by membership of a particular confession, and they might feel that some kind of religious guidance would be appropriate in the circumstances.  As it happens, I make no bones about my atheism and my antagonism towards appeals to religion when it comes to solving moral dilemmas.  But I would still be worried if I thought that I was seen as a secular version of the priest.  Again, this has to do with worries about acting as another person’s conscience – but there’s more to it than that.  It also has to do with the fact that ethics is not, and does not profess, a doctrine.  It is not the case that ethicists agree en bloc that an action is right or wrong – we don’t even agree en bloc about what is the correct way to think about a problem, or even whether certain things are problematic at all.  We could give a list of considerations, and describe the arguments – but that’d leave the dilemma unresolved.

 

In a wider context, though, my main problem with the idea of an on-call ethicist is that I don’t think that, as a profession, ethicists are all that good at solving particular problems, or that we should ruminate on particular cases.  It is not the ethicist’s job to approve or object to particular courses of action: that would be activism.  Although activism may be informed by a particular set of ethical claims, and ethicists may be activists, activism is not the same as ethics.

 

It is worth bearing in mind here the nature of moral dilemmas and their solutions.  Situations in which one has to choose between the right and the wrong thing are not the stuff of interesting ethics: if they ever arise, it’s plain what one ought to do, and there’s no problem.  The interesting and difficult questions get asked when either all the possible courses of action have a claim to be right, or when no course of action seems to recommend itself as being particularly tolerable.  At the heart of a moral problem one finds questions concerning how to distinguish between two or more apparently equally good or bad options.

 

One response to this point is to think that most of these options are only prima facie good or bad – that close examination will reveal that there actually is one morally sanctioned or mandated option in a given situation.  That’s not really a plausible response, though.  Deciding which to do out of a number of options presupposes a criterion by which we can assess each – a criterion that holds in the abstract and which can then used to measure each dispassionately.  But there is no such criterion readily available.  We live in a world in which there is disagreement about the right thing to do – for example, some people think that all abortion is wrong, some people think that infanticide might sometimes be permissible, and no position between these poles is unoccupied.  On top of that, even if everyone agrees that some action is right or wrong, they might disagree as to why.  Worse yet, it’s also the case that there is disagreement about how we should approach the solution to moral problems in the first place.  After two and a half thousand years of trying, we haven’t even got an agreed strategy or account of what would be a relevant consideration when deciding whether something is right or wrong.  We’d like to think that there’s a clear way – but there ain’t.  Not yet.

 

What, then, does this imply for the role of the ethicist?  For some, the absence of a clear account of rightness and wrongness means that ethics is, and can only be, concerned with attempts to marshal what people do think, perhaps in the hope of finding a compromise that could shape our norms.  This won’t do: for one thing, it presupposes that there’s a norm telling us that consensus is a something for which we ought to strive.  This norm could not, presumably, be based on an appeal to consensus, on pain of begging the question.  But if we can have one “self-sufficient” norm, why not any number of them?  For another, the mere fact that people do think thus-and-so is not enough to show that they’re correct to think thus-and-so.

 

This is a point that stands even in the absence of a clear positive account of rightness.  For ethics – as I see it – is concerned at least as much with arguments about rightness as with any notional facts; and we don’t need to appeal to the conclusion in order to assess an argument.  In any discipline, a true claim must be tenable; correspondingly, any untenable position must be (as good as) false.  Analysis of an argument, then, stands a chance of showing us whether a claim ought to be ditched.  If an argument cannot be shown to be untenable, then the conclusion that it generates will live to fight another day.  The same applies to moral argument: we can set about showing that an opponent’s position – and any possible opponent’s position – must be untenable for some reason, and showing why reasonable people must see the world our way. 

 

On this account, the solution to particular moral problems is of less importance than the analysis of the way we might solve them.  This means that an ethicist will be concerned with two things: first, the analysis of the application of certain reasons for acting; second, the analysis of those reasons themselves.  We can attempt to say whether an attempted justification – ours or another’s – for a course of action is successful given a certain starting-point, and we can attempt to say something about the choice of starting-point as well.  Admitting that a person reasons well from a plausible starting point will make it more likely that we will accept his proposal as if it were factually true.  Indeed, we perhaps ought to: we might have to swallow the intuitively unacceptable conclusion of a good argument on pain of irrationality – either that, or find the flaw.

 

This process lends itself to protracted debate.  More often than not, a half-decent analysis of any ethical problem will throw up more problems than it solves: we can’t really say whether procedure x is permissible, obligatory or whatever until we know more about the presuppositions of any claims that might be made.  And it’s for precisely this reason that an ethicist, if he does his job well qua ethicist, would be precisely the wrong person to employ in a hospital setting.  People seeking advice – be they medics or patients – would be left understandably frustrated by the sorts of preliminary analyses of arguments and principles that an ethicist ought to venture.  Neither has the time nor the inclination for what the consultation would offer.  (With this sort of consideration in mind, when I meet a new set of students, one of the first things I tell them is that I don’t want to tell them the right thing to do in a situation.  They might even be more confused than they were.  But it’ll be a rich and well-informed kind of confusion.)

 

Ethicists are well-armed to ask difficult questions about the gap between what policies are and what policies should be.  But we belong in the seminar room or the library, not the hospital.

 

Or have I missed something?  Are there any hospital ethicists out there reading this who could put me right?

 

 

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