{"id":19,"date":"2008-09-29T14:08:33","date_gmt":"2008-09-29T13:08:33","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=19"},"modified":"2008-09-29T14:09:39","modified_gmt":"2008-09-29T13:09:39","slug":"on-hospital-ethicists","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2008\/09\/29\/on-hospital-ethicists\/","title":{"rendered":"On Hospital Ethicists"},"content":{"rendered":"

At the beginning of August, Dan Sokol wrote a piece<\/a>\u00a0for the BBC news site in which he touched on the place of hospital-employed ethicists.\u00a0 Apparently, this is a reasonably common position in the States.\u00a0 I used to be of the opinion that hospital ethicists would be a good idea \u2013 when I was a student, it was one of the possible careers I saw for myself.\u00a0 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 \u201cAn ethicist!\u00a0 That\u2019s exactly what we need!\u201d, and offer me a job into the bargain.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Of course, that didn\u2019t happen \u2013 I got neither the job nor the cash.\u00a0 In retrospect, though, I wonder whether my enthusiasm might have been misguided anyway.\u00a0 I\u2019m not sure that hospital ethicists are such a good idea.\u00a0 There\u2019s a number of reasons for this.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

The first is pragmatic.\u00a0 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 \u2013 professionals or patients \u2013 may face.\u00a0 Yet it is also the case that what medical staff do is already regulated by the law, professional guidelines, government policies and so on.\u00a0 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.\u00a0 Imagine, for example, that you had a dilemma to do with terminating a pregnancy, and that I was your local ethicist.\u00a0 Often, inasmuch as I was acting in a professional capacity, it\u2019d be hard to see how I could do much beyond point to the legal position in respect of what you were considering.\u00a0 I might think that the law is wrong and that it\u2019d be OK to break it \u2013 but I couldn\u2019t realistically tell you this, any more than your accountant could advise you on the best ways to avoid tax.\u00a0 The same would apply in respect of providing advice to patients.\u00a0 Of course, I could take off my professional hat for a moment \u2013 but then I\u2019d have stepped outside my professional role.\u00a0 qua<\/em> hospital ethicist, my movement would be limited.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Moreover, I\u2019d be a little wary of the possibility of being drawn into disputes between parties.\u00a0 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.\u00a0 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 \u2013 but \u201cMy ethicist told me that I was morally in the clear\u201d is not a phrase I ever want to hear: it implies a delegation of responsibility for one\u2019s actions that strikes me as antithetical to the very idea of being a moral agent.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

A third problem has to do with treading on the toes of the chaplaincy.\u00a0 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.\u00a0 As it happens, I make no bones about my atheism and my antagonism towards appeals to religion when it comes to solving moral dilemmas.\u00a0 But I would still be worried if I thought that I was seen as a secular version of the priest.\u00a0 Again, this has to do with worries about acting as another person\u2019s conscience \u2013 but there\u2019s more to it than that.\u00a0 It also has to do with the fact that ethics is not, and does not profess, a doctrine.\u00a0 It is not the case that ethicists agree en bloc<\/em> that an action is right or wrong \u2013 we don\u2019t even agree en bloc<\/em> about what is the correct way to think about a problem, or even whether certain things are problematic at all.\u00a0 We could give a list of considerations, and describe the arguments \u2013 but that\u2019d leave the dilemma unresolved.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

In a wider context, though, my main problem with the idea of an on-call ethicist is that I don\u2019t think that, as a profession, ethicists are all that good at solving particular problems, or that we should ruminate on particular cases.\u00a0 It is not the ethicist\u2019s job to approve or object to particular courses of action: that would be activism.\u00a0 Although activism may be informed by a particular set of ethical claims, and ethicists may be activists, activism is not the same as ethics.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

It is worth bearing in mind here the nature of moral dilemmas and their solutions.\u00a0 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\u2019s plain what one ought to do, and there\u2019s no problem.\u00a0 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.\u00a0 At the heart of a moral problem one finds questions concerning how to distinguish between two or more apparently equally good or bad options.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

One response to this point is to think that most of these options are only prima facie<\/em> good or bad \u2013 that close examination will reveal that there actually is one morally sanctioned or mandated option in a given situation.\u00a0 That\u2019s not really a plausible response, though.\u00a0 Deciding which to do out of a number of options presupposes a criterion by which we can assess each \u2013 a criterion that holds in the abstract and which can then used to measure each dispassionately.\u00a0 But there is no such criterion readily available.\u00a0 We live in a world in which there is disagreement about the right thing to do \u2013 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.\u00a0 On top of that, even if everyone agrees that some action is right or wrong, they might disagree as to why.\u00a0 Worse yet,\u00a0it\u2019s also the case that there is disagreement about how we should approach the solution to moral problems in the first place.\u00a0 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.\u00a0 We’d like to think that there’s a clear way – but there ain’t.\u00a0 <\/span>Not yet.<\/span><\/p>\n

\u00a0<\/span><\/p>\n

What, then, does this imply for the role of the ethicist?\u00a0 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<\/em> think, perhaps in the hope of finding a compromise that could shape our norms.\u00a0 This won\u2019t do: for one thing, it presupposes that there\u2019s a norm telling us that consensus is a something for which we ought to strive.\u00a0 This norm could not, presumably, be based on an appeal to consensus, on pain of begging the question.\u00a0 But if we can have one \u201cself-sufficient\u201d norm, why not any number of them?\u00a0 For another, the mere fact that people do think thus-and-so is not enough to show that they\u2019re correct<\/em> to think thus-and-so.<\/span><\/p>\n

\u00a0<\/span><\/span><\/p>\n

This is a point that stands even in the absence of a clear positive account of rightness.\u00a0 For ethics \u2013 as I see it \u2013 is concerned at least as much with arguments <\/em>about rightness as with any notional facts<\/em>; and we don\u2019t need to appeal to the conclusion in order to assess an argument.\u00a0 In any discipline, a true claim must be tenable; correspondingly, any untenable position must be (as good as) false.\u00a0 Analysis of an argument, then, stands a chance of showing us whether a claim ought to be ditched.\u00a0 If an argument cannot be shown to be untenable, then the conclusion that it generates will live to fight another day.\u00a0 The same applies to moral argument: we can set about showing that an opponent\u2019s position \u2013 and any possible opponent\u2019s position \u2013 must be untenable for some reason, and showing why reasonable people must see the world our way.\u00a0 <\/span><\/p>\n

\u00a0<\/span><\/p>\n

On this account, the solution to particular moral problems is of less importance than the analysis of the way we might solve them.\u00a0 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.\u00a0 We can attempt to say whether an attempted justification \u2013 ours or another\u2019s \u2013 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.\u00a0 Admitting that a person reasons well from a plausible starting point will make it more likely that we will accept his proposal as if<\/em> it were factually true.\u00a0 Indeed, we perhaps ought<\/em> to: we might have to swallow the intuitively unacceptable conclusion of a good argument on pain of irrationality \u2013 either that, or find the flaw.<\/span><\/p>\n

\u00a0<\/span><\/span><\/p>\n

This process lends itself to protracted debate.\u00a0 More often than not, a half-decent analysis of any ethical problem will throw up more problems than it solves: we can\u2019t really say whether procedure x<\/em> is permissible, obligatory or whatever until we know more about the presuppositions of any claims that might be made.\u00a0 And it\u2019s for precisely this reason that an ethicist, if he does his job well qua<\/em> ethicist, would be precisely the wrong person to employ in a hospital setting.\u00a0 People seeking advice \u2013 be they medics or patients \u2013 would be left understandably frustrated by the sorts of preliminary analyses of arguments and principles that an ethicist ought to venture.\u00a0 Neither has the time nor the inclination for what the consultation would offer.\u00a0 (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\u2019t want to tell them the right thing to do in a situation.\u00a0 They might even be more confused than they were.\u00a0 But it\u2019ll be a rich and well-informed kind of confusion.)<\/span><\/p>\n

\u00a0<\/span><\/p>\n

Ethicists are well-armed to ask difficult questions about the gap between what policies are and what policies should be.\u00a0 But we belong in the seminar room or the library, not the hospital.<\/span><\/p>\n

\u00a0<\/p>\n

<\/div>\n

<\/p>\n

Or have I missed something?\u00a0 Are there any hospital ethicists out there reading this who could put me right?<\/span><\/p>\n

\u00a0<\/p>\n

<\/span><\/p>\n

\u00a0<\/span><\/p>\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

At the beginning of August, Dan Sokol wrote a piece\u00a0for the BBC news site in which he touched on the place of hospital-employed ethicists.\u00a0 Apparently, this is a reasonably common position in the States.\u00a0 I used to be of the opinion that hospital ethicists would be a good idea \u2013 when I was a student, […]<\/p>\n

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