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Keeping moral space open: new images of ethics consulting.

The moral expertise of clincal ethicists is not a question of mastering codelike theories and lawlike principles. Rather, ethicists are architects of moral space within the health care setting, as well as mediators in the conversations taking place within that space.

Thinking about "moral expertise" and the idea of ethics "consulting," I asked some physician friends about their experiences working with ethicists in the large urban medical centers in which they teach and practice. One replied that he had found ethicists helpful; they encouraged him to consider issues of autonomy and paternalism, for example, to which he might not otherwise have attended in those terms. After a thoughtful pause, he offered another evaluation. With all the personal and institutional pressures of medical practice in such environments, he suggested, it was important to have a place to go for that kind of thinking; having done it allowed him to feel more confident or more responsible about the decisions taken.

While not mutually exclusive, these two responses are importantly different. The first response corresponds closely to a prevalent picture of ethics consultation as a kind of expert input. Specifically, moral theories or concepts, either global (utilitarianism, rights, vulnerability) or local (patient autonomy, strict advocacy, quality of life), constitute the domain of the ethicist, that for which and about which the ethicist is charged to speak as one specialist among others. The second response captures something less easily pegged. It is about a kind of interaction that invites and enables something to happen, something that renders authority more self-conscious and responsibility clearer. It is also about the role of maintaining a certain kind of reflective space (literal and figurative) within an institution, within its culture and its daily life, for just these sorts of occasions. I want to explore the second answer here, for it could represent not just another feature of ethics consultation but a significantly different view of it.

Literature of the last fifteen years on moral expertise and ethics consulting shows a shift in emphasis from issues of content to those of process--from what the ethicist knows, to what the ethicist does or enables. This shift parallels two others, one practical and one philosophical. The establishment of institutional ethics committees accelerated rapidly in the 1980s, spurring questions about whom should serve on them, what they should be doing, and how it should be done.[1] Philosophical ethics in the academy has also been a scene of change in the last two decades; the project of constructing and refining moral theories (in a quite limited and particular sense) has been ever more criticized, while moral philosophers of diverse stripes attend more closely to the languages and practices of actual moral communities and to the constructive process of renewing common moral life. I want to link these parallel shifts in practical medical ethics and general philosophical ethics from thinking of ethics as a "what" to thinking of ethics as a "how." I do this to consider the difference this makes in conceiving the nature of ethics consultation and the role of ethicists.

Familiar Suspicions about a Familiar Idea

A certain familiar conception of ethics is that it is the attempt to articulate and justify the right or best moral theory. This conception is familiar because it has been the prevailing definition of academic philosophical ethics for most of the twentieth century. It is also thoroughly embedded (although not uncontested) in medical ethics. On this view a moral theory is not merely any comprehensive, reasoned, and reflective account of morality, of the ways and means, point and value, of a moral form of life. (A classic example of such an account is Aristotle's Nichomachean Ethics.) On this dominant modern view of proper moral theory is instead a highly specific kind of account of where moral judgments come from: a compact code of very general (lawlike) principles or procedures which, when applied to cases appropriately described, yield impersonally justified judgments about what any moral agent in such a case should do. Invocations of theory and principles in practical medical ethics have tended to reproduce this conception. "Theories" are impersonally action-guiding formulations, like versions of utilitarianism or Rawls's theory of justice; principles are lawlike directives of high generality, like those giving autonomy, sanctity of life, or beneficence absolute or relative priority.

This conception of ethics directly constructs a particular and familiar picture of moral expertise. If the core of moral understanding from which particular judgments flow is theory in this sense--a compact impersonal system of action-guiding directives--then it seems clear what moral expertise is. It is being specially learned about the epistemic foundations, internal structures, relative merits, and types and limits of application of the most currently promising theories. This special, subtle, and refined knowledge qualifies one as an expert in ethics (as opposed to nephrology or hospital administration); this expertise in turn qualifies one as a technically equipped specialist in moral input or intervention. The consulting ethicist represents and is expected to supply expert moral opinion as an additional component of the process of evaluating or making decisions.

As familiar as this picture is, so are a battery of suspicions about it, either about its conception of ethical competence, or about the relevance to the clinical setting of the abstract kind of moral-theoretic knowledge it features. Could full moral competence really consist entirely in intellectual mastery of codelike theories and lawlike principles? What of skills of attention and appreciation, of the practiced perceptions and responses that issue from morally valuable character traits, of the wisdom of rich and broad life experience, of the role of feelings in guiding or tempering one's views? Philosophers within and outside medical ethics have questioned the equation of expertise in state-of-the-art theory deployment with superior or specially reliable moral insight.[2]

Furthermore, can philosophers' abstract constructions of morality be brought into contact, sensitively and usefully, with problems in the clinic? What of the typical complexity of clinical decisions, and of the inevitably ad hoc nature of real-time decisionmaking? Philosophers' lawlike principles seem remote from the typically vague maxims nonphilosophers (and philosophers when they're not philosophizing) actually use in moral deliberation.[3] Aren't abstract principles often given (sometimes new) meaning under the impact of concrete cases, rather than cases being simply "decided" by the "application" of principles? And who or what decides what is a "case"--a moral problem--in the first place, as well as what sort of case--subject to what principle or principles--it is?

These objections are as familiar to medical ethics as the paradigm of expertise to which they object. Arthur Caplan's frequently cited critiques of this model of ethics and experts have given it a handy name: the "engineering model." Caplan and others in the medical ethics literature have homed in on how misleading, if not harmful, this engineering or application model of clinical ethics is.[4] Yet it is the natural companion of a certain very specific view of what you know when you know, specially or expertly, about ethics; you know codelike theories and how to apply them.

Sometimes attacks on the application idea are understood as salvos against having theories in ethics at all, and some ethicists respond to the perceived attack on theory with a kind of incredulity. "If ethical theories are useless," asks Ruth Macklin, "is it not likely that all attempts at rational analysis and systematic resolutions of moral problems are doomed?" In the same volume of essays Robert Veatch warns that without the "systematic approach" to problems that ethical theory provides, the alternatives are "an intuition, gut feeling, appeals to authority, or just blatant inconsistency."[5]

The term 'systematic' is an important marker in these arguments. 'Systematic' solutions can mean 'rationally ordered' or 'considered' as opposed to 'whimsical,' 'inexplicable,' or 'unjustified' ones; or systematic solutions can mean solutions generated by a system 'by the rules,' 'by the book,' or 'according to the theory.' To criticize the engineering model is to raise suspicions, not about logical, intelligent, informed moral judgment for which consistent and persuasive reasons can be given, but about judgment that is supposedly yielded by deducing conclusions from codelike moral theories. If there are other kinds of moral theories, or better, methods of moral deliberation that do not travel through top-down application of codelike theories, then to reject the engineering model is not to abandon rationality or consistency. It might just involve abandoning the neat but suspicious view of essential moral knowledge as captured in moral "systems," those codelike theories whose mastery makes someone an "ethical expert" on the engineering view.

Suspicions about codelike theories or their application within medical ethics mirror diverse critiques of specifically modern codelike theories within philosophical ethics generally. Is morality obviously best represented by something like utilitarian, or Kantian, or contractarian--i.e., codelike--theories? In the last few decades a remarkably diverse collection of moral philosophers--Aristotelians and Wittgensteinians, casuists and communitarians, pragmatists and feminists, Hegelians, postmodernists, and assorted others--have thought not.[6] Certain themes have been widely (though not universally) repeated across the "antitheory" critiques, despite profound differences and outright antagonisms among them.

One recurrent theme is the social situation of morality: moral understandings are always embedded in and make sense of a particular social setting and its characteristic relationships, problems, and practices. This warns us off trying to abstract some pure all-purpose core of moral intelligence from the historically specific assumptions and circumstances that give moral conceptions their point and meaning. Another theme is the importance of specific ways and means of bringing morality to bear upon the particular occasion. General moral maxims or principles can often be connected to particular instances only by a thick tissue of perceptions and interpretations; these are fed by diverse skills and rooted in varied habits of thought and feeling. Moral competence is thus not reducible to a codelike decision instrument (much less an algorithmic one) any more than carpentry is reducible to a saw. A third theme (more controversial, but easily implied by the other two) is that moral deliberation and decision are often (and in novel or hard cases are always) constructive. Communities, relationships, and moral ideas themselves are often not left where they were, but are renewed and revised as the process of interpersonal negotiation and interpretation in moral terms goes on. Moral concepts, principles, values, and argument forms may be starting points and reference points for moral deliberation, but that process is progressive and once traversed may not leave everything as it was at the outset.[7]

One idea has reappeared so often in views that stress the social, the particular, and the constructive dimensions of morality that it has become a sort of buzzword in the checkered terrain of recent moral philosophy. It's the idea that deductively modeled theory-and-application in ethics should give way to a narrative understanding of moral problems and moral deliberation. I'll use this central idea of narrative as a way to shift perspectives: from thinking about morality as a theory applied to cases, to thinking about morality as a medium of progressive acknowledgment and adjustment among people in (or in search of) a common and habitable moral world. This will lead us back to the ethics consultant, who will have undergone a parallel metamorphosis, from engineer to architect and from technical expert to mediator.

Another Idea: Narratives and Negotiation

Emphasis on narrative as the pattern of moral thinking is, first, a way of seeing how morally relevant information is organized within particular episodes of deliberation. The idea is that a story, or better, history is the basic form of representation for moral problems; we need to know who the parties are, how they understand themselves and each other, what terms of relationship have brought them to this morally problematic point, and perhaps what social or institutional frames shape or circumscribe their options. Emphasis on narrative also captures the way moral resolution itself takes the form of a passage conditioned but not completely determined by where things started, and indefinitely open to continuation. Different resolutions will be more or less acceptable depending on how they sustain or alter the integrity of the parties, the terms of their relationships, and even the meaning of moral or institutional values that are at stake. A narrative approach reminds us that "moral problems" are points in continuing histories of attempted mutual adjustments and understandings among people.

A narrative picture of moral understanding doesn't spurn general rules or broad ideals, but it doesn't treat them as major premises in moral deductions. It treats them as markers of the moral relevance of certain features of stories ("But isn't that lying?"); as guidelines to the typical moral weight of certain acts or outcomes ("Surely we ought to avoid lying"); as necessary shared points of departure ("We've got a problem here with undermining the patient's trust in the physician's candor"); and (with any luck) as continuing shareable points of reference ("Might the patient not still see that as misleading?") and reinterpretation ("Withholding isn't necessarily deception, though") that lead to a morally intelligible resolution.

So narratives in moral thinking come before, during, and after moral generalities (whether of theory, principle, or basic moral concept). They permit and invite full exploration of what often seems neglected or devalued on the engineering model: specific histories of individual commitment, of relationship and responsibility, of institutional practices and evolving moral traditions. The need to "apply" principles at the level of abstraction typical of codelike moral theories creates pressure to shear off complicating, possibly "irrelevant" details to magnify "repeatable," even "universalizable" features general enough to map cases onto available theoretical categories. Emphasis on narrative construction pulls in the opposite direction--from premature or coercive streamlining of cases toward enrichment of context and detail.

Specific values and commitments (personal, religious, professional, or cultural) may matter crucially to individuals' maintaining integrity and coherent moral self-understanding over time.[8] Determining our responsibilities in the concrete usually involves a grasp of the history of trust, expectation, and agreement that gives particular relationships distinct moral consequences. To know what general values or norms mean in situations now requires appreciating how these have previously been applied and withheld, circumscribed, and reinterpreted within individual, social, or institutional histories. So adequate moral consideration needs to follow these stories of identity, relationship, and value to see how they can go on, and whether it is better or worse that they do so. Principles and theoretical concepts mark broad areas of value or define generic priorities. But only the content of those specific histories can define what in an actual case is owed--by whom, to whom, and why--and what different moral resolutions of cases will mean (and will cost) for involved parties. The determinations we make on their basis may alter our grasp of principles and concepts with implications for future moral reasoning as well.

Consider the case study of Carlos and Consuela, recently debated in these pages.[9] Carlos, a young man who is HIV-positive, is to be discharged from the hospital to complete his convalescence from a gunshot wound under the care of his twenty-two-year-old sister, Consuela. Medicaid will not pay for nursing because a caregiver is available in the home. Consuela is willing but is ignorant of Carlos's HIV status; Carlos refuses to inform her, fearing that she--and worse, his father--will learn of his homosexual orientation. Two commentators arrive at different conclusions about how to reconcile respect for confidentiality with a duty to warn.

One models the case in a way that approximates the application or engineering model; the issue is whether a duty to warn could outweigh a duty to keep the patient's status in confidence. Considering the degree of risk and possible alternatives and harms (couched in terms of the physician's telling or not telling Consuela, and inferring how Consuela might behave if told or not told), this commentator concludes that three general conditions that would justify elevating the duty to warn are not met. Therefore, the physician is morally obligated to respect confidentiality. Unless Carlos can be persuaded to reconsider telling his sister, the physician's duty to warn will be reasonably fulfilled by providing Consuela with serious training and the equipment for universal precautions.

The second discussion embodies more fully a narrative approach. This commentator foregrounds the relationship between Carlos and Consuela, as well as the history, both personal and social, that places Consuela in the caregiver role. Consuela has cared for Carlos and another sibling since their mother's death ten years before; the health care system deems her (a woman in the home) an available caregiver, thus relieving itself of the expense of providing professional care. But, asks the commentator, would a private nurse or other healthcare worker not be told of Carlos's HIV status? Is access to Consuela's caregiving taken for granted by that system, by the physician, by Carlos? Is Consuela not seen as a responsible party who chooses to give care? If so, must she not be respectfully allowed to consider possible risk and assume her responsibilities with clear understanding of what she must do both for Carlos and to protect herself? Is Carlos mindful of what he asks of Consuela, and should he not be willing to assume some responsibilities and risk some trust if he expects her to do so? This ethicist agrees that the physician should not breach confidentiality, but also concludes that unless Carlos will deal forthrightly with his sister, the physician should not risk exploiting Consuela's good will under conditions of ignorance. If Carlos will not tell her, he must do without her nursing care.

Although both ethicists (inevitably) draw on stories of the origins and possible outcomes of the problem, the second features Carlos and Consuela as moral actors whose history and future of moral responsibilities are intertwined in specific ways, and who need to respond to each other as such, within a larger web of family relations and societal pressures. The physician is, appropriately, dealing with a problem of medical management and the norms of professional ethics. But Carlos and Consuela are at a juncture of prior and continuing moral stories that tell who they are, what they expect of and owe to one another, and what forms of trust and what commitments they are willing to undertake.

Moral generalities on the narrative view are ingredients rather than axioms. They are ingredient to stories that reveal how problems have come to be the problems they are, that imagine what ways of going on are possible, and that explore what different ways of going on will mean in moral terms both for the people involved and for the values at stake. In the case of Carlos and Consuela, the general duties to warn and keep confidence are immediately apparent from the physician's point of view. But Carlos's and Consuela's stories, in social perspective, draw other general concerns of self and mutual respect, filial obligation, exploitation, gratitude, and trust into the picture. The second ethicist's rendering not only enriches the "circumstantial" detail of the case, it induces a more complete view of the moral values at stake, and this in turn defines more sharply what the different parties must acknowledge and take responsibility for.

The fuller narrative construction also highlights the situation's dynamic potential. The deductive relation of validity (invoked by the model of applying principles to cases) either holds or it doesn't, and when it holds, does so under the impact of all further additions of information. In narratives, however, what comes later means what it does in part because of what preceded it, while what came earlier may also come to look very different depending on what happens later. Narratives are built or constructed, and remain open to elaboration, continuation, and revision; they make more or less sense, and may be more or less stable as they unfold. In Carlos's and Consuela's situation, there are (at least) three moral actors who have powers and unfolding opportunities to influence each other and to determine how well the resolution they effect responds to the values at stake.

Narratives and Mutual Accountability

The narrative picture of moral deliberation I've outlined implies that the resolution of a moral problem is often less like the solution to a puzzle or answer to a question than like the outcome of a negotiation. But this does not mean that anything settled on is right, nor that a resolution is right only if everyone can settle on it. A narrative view can be just as committed to holding that certain kinds of things are really better or worse for people, or certain requirements are really deeply obligating, as any other. In the case of Carlos and Consuela, I argued that the fuller narrative account was more adequate because it uncovered real values and obligations that had to be reckoned within a morally justifiable resolution.

The narrative approach addresses the question of how values and obligations can guide particular people facing complex problems to solutions that are morally justifiable. There are usually multiple parties and multiple values to be acknowledged and (ideally) reconciled in cases that require any serious deliberation at all. (Cases that provoke discussions in clinical ethics are invariably of this kind.) There is no reason to assume these sorts of moral problems have unique right solutions, rather than ones that are more or less responsive to the values at stake. And there is every reason to think that competing claims posed by agents' integrity, their valued commitments, and the moral ideals they and their communities recognize may not be smoothly reconcilable in many instances. Elaboration through narratives opens moral deliberation to fuller consideration of these claims and so to better, more responsive solutions. But whether uniquely compelling and universally satisfying resolutions are possible--and especially where they are not--fuller consideration serves the larger end of keeping us morally accountable to each other, renewing common moral life itself.

Moral deliberation and its enabling stories have to make sense to and stand up within some moral community. We deliberate so that we may act justifiably, in a way we can convincingly account for in moral terms. This requires that we share (enough of) a common moral medium (moral languages, moral paradigms, deliberative strategies) and familiarity with the social terrain of interactions, roles, and relationships to which it belongs. Prior moral understandings do not have to be unanimous; imperfect understandings, conflict, and incomprehension provide opportunities for critical and constructive moral thinking. They can propel close rethinking and the search for mediating ideas or reconciling procedures. They challenge complacency, superficiality, parochialism, and groupthink. Even when disagreement is intractable, rendering it articulate may be a moral passage, pressing deliberators to acknowledge what commitments they are taking responsibility for and which understandings they refuse, foreclose, or silence.

Moral narratives are (ideally) authored and judged by those whose moral stories they are: those by whom, to whom, and about whom these moral accounts are given. Mutual moral understanding presupposes and seeks a continuing common life negotiated through moral terms, and so intelligible to its parties in those terms. By accounting to each other through a moral medium, parties to a common life (or the hope of one) recognize each other as agents of value, capable of considered choices, responsive to value, and so responsible for themselves and to others for the moral sense and impact of what they do. They invoke their shared moral resources not only to achieve solutions, but to achieve solutions that at the same time protect, refine, and extend those very moral resources themselves--ones that keep the moral medium alive and available, that keep the moral community itself going. Morality, philosopher Stanley Cavell reminds us, "provides one possibility of settling conflict, a way of encompassing conflict which allows the continuance of personal relationships."[10] Fully personal relationships are ones in which we provide for continuing mutual acknowledgment of our status as agents of value. Disagreements may be settled and communities regimented in other ways, some of them involving fists and weapons, propaganda and censorship, forced medication or detention. "Morality is a valuable way," Cavell remarks, "because the others are so often inaccessible or brutal."

The larger aim of continuing moral relationship and mutual moral intelligibility moves us to look at not only what we are doing in moral deliberation--solving problems, setting policies, invoking moral norms and notions--but at how we are doing it. It prompts self-consciousness about the moral means we conserve, renew, or invent, and our responsibility for keeping our individual and communal moral lives vital and coherent by means of them. It also shifts attention to the important question of who "we" are. If moral accounts must make sense to those by whom, to whom, and about whom they are given, the integrity of these accounts is compromised when some parties to a moral situation are not heard or represented. If chances are missed for different perspectives that open critical opportunities, moral community is doubly ill served; alternate narratives go unexplored, and some members are in practice disqualified as agents of value. If some positions in a deliberation in fact carry greater authority, it is important to acknowledge this, so the legitimate grounds of that authority are commonly understood.

In these ways the narrative conception of moral thinking shifts attention to the process of interpretation, negotiation, construction, and resolution required by any complex deliberation, as well as to the roles of deliberators. If this sketch of the structure of moral deliberation is even roughly right, knowing specially about ethics and moral thinking can no longer be seen simply as knowing about ethical theories, principles, or concepts and some standard patterns of argumentation in which they are put to work. It is not only knowing what the theories, concepts or arguments are, but knowing what they are for, and understanding under what conditions they can be made to serve.

Ethics Consulting Rethought

Recent literature on ethics consulting shows a shift. Discussions from the mid-1970s through the mid-1980s were largely preoccupied with what the ethicist knows, and figured the consultant as a logical superintendent who sharpens concepts, upholds standards of rigorous argument, and polices fallacious thinking. These were the moral engineers, needed to service the engines of ethics (the theoretical hardware) through purely conceptual maintenance routines.[11]

Since the mid-1980s concerns about what the ethicist does have moved to the fore.[12] Matters at issue include: different institutional functions of ethicists; the differing kinds of responsibility, authority, and accountability that should accompany them; how the ethicist fits with the criss-cross of relationships among health care providers, patients, families, and caretakers; and how moral deliberation within health care institutions connects to larger social arenas of moral consensus and conflict.[13] Terrence Ackerman models the ethicist's role as that of the facilitator in an inherently social process of moral inquiry by which one identifies norms and problem-solving plans of action that evoke "shared and stable social commitments."[14] The ethicist is one within a community; the ethicist's privilege in hypothesizing plans of action is warranted to the extent of the ethicist's currency in the dialogue of the larger moral community. In a similar vein, recent discussions of institutional ethics committees emphasize "their ability to facilitate the process" of moral decision through "pluralistic exchange of values," and to move ethical discernment "from the realm of private judgment to the arena of discourse and communal review."[15]

These recent views capture the interactive, constructive, and open-ended character of moral inquiry and decisionmaking in clinical and other settings. What views of the ethicist's capability, authority, and responsibility fit this picture? If the ethicist is not a technical expert who strategically "inputs" ethics, but rather a participant who "facilitates" a social process of moral negotiation and mutual accountability, how might we remodel the ethicist's role? Indeed, is there a well-defined and justifiable role left specifically for ethicists under this change in perspectives?

Arthur Caplan questions whether "society should create a social role that accords power and authority to moral experts,"[16] however moral expertise is understood. But when we consider the site at which most organized ethical consultation occurs, there are strong reasons to think an institutionally specified and authorized role of ethicist is necessary. That site is the acute care setting of medical center/teaching hospital, a "quintessentially communal world" where "bureaucratic procedures essential to mass production of services" prevail. In such settings, "hierarchically structured health care teams ... administer their responsibilities collaboratively," and "patients are fortunate if they can assert any autonomy at all."[17]

Some early essays about ethicists as "strangers" or "outsiders" to professional and institutional cultures of medicine recognized the crucial representative role of the ethicist. For Larry Churchill, "what makes the ethicist truly a stranger is his advocacy for normative inquiry." In William Ruddick's words, "The short-term goal is to make moral discussion professionally acceptable, even routine, among medical students and clincians ... [to] encourage current and future clinicians to think of moral questions about therapeutic decision as a matter of public analysis, rather than a matter of intuition or private conscience protected by professional authority."[18] The role of the ethicist marks the institution's recognition of the ever-present moral dimension of its works and ways. The presence of the ethicist shows the institution's acceptance, in fact sponsorship, of a visible and authorized process of communal moral negotiation as part of its life. The ethicist's role is an emblem of that institutional commitment. But the ethicist is not a repository of the institution's ethics, nor is she or he its conscience. The ethicist's special responsibility is to keep open, accessible, and active (and if necessary to create and design with others) those moral-reflective spaces in institutional life where a sound and shared process of deliberation and negotiation can go on.

It is precisely in busy, bureaucratized, and balkanized acute care settings where the maintenance of these spaces will be most urgent. In multiple and fleeting contacts, the moral force of ongoing relationship is easily depleted or never builds at all; the collaborative nature of treatment can render individual responsibility confused or skewed; the parade of patients and press of cases fragment and blur whatever institutional moral memory there may be; an asymmetrical web of communications makes it difficult to get a clear view of who has been heard from and what has been heard. Given a setting "steeped in routine and hierarchy,"[19] institutionalization of the ethics consulting role is probably the only way reliabily and authoritatively to mark and open moral-reflective spaces. These will be actual spaces--places and times--where there are regular discussions, consultations, conferences, lectures, meetings, rounds, and so on, that animate and propel the moral life of that institution and link it to the larger communities of moral discourse in which it nests and to which it must account.

To be effective in creating these spaces and in enabling shared moral deliberation to proceed within them requires a different authority than the authority to decide cases, deliver ethical verdicts, or set policies. Continuing concerns about whether ethicists (or institutional ethics committees, on which ethicists now often serve) should be decisionmakers, rather than educators and facilitators, are appropriate. Ethics consulting, whether by individual or committee, should serve the ends of clarifying the responsibility and accountability of patients, proxies, and professionals, not preempting, erasing, or diluting it.

The ethicist is neither a virtuoso of moral theory nor a moral virtuoso, but is one among other participants in a process. All will be concerned with making responsible decisions. All will be recruited to the distinctly human and humanizing task of keeping moral community and traditions alive and meaningful--each being at once, in Kant's moving and durable phrase, a "legislator," both member and sovereign, in a moral "kingdom of ends." Yet different participants will have distinctive interests in the process. Ethicists will want to discover the potency and limitations of our moral resources as they stand, measured by all the complexity and intensity of clinical practice. Patients will hope not only for medically sound therapy, but for enhanced dignity, comfort, and peace of mind. Medical professionals will want, among other things, "to remain therapists, despite professional and institutional pressures to become functionaries."[20] The ethicist does, however, have the special responsibility as ethicist to foster and nurture a collective and collaborative moral process. What aptitudes and attitudes does this role require?

The orchestration of moral collaboration will be complex. Parties will share morally problematic situations but may have different senses of what is relevant and understandably different personal stakes. The ethicist has special responsibility to enliven a process in which these common moral concerns stay in focus while differences are recognized and, ideally, mediated. The old staples of conceptual and analytical skills, honed specifically for medical and clinical contexts, remain important tools. They are necessary to keep track of where the discussion has (and has not) been going. But knowing where the discussion might or could go, and how the process is shaped not only by ideas but concretely by actors and environments, requires other sorts of preparation as well.

One sort of preparation is very wide (and critical) conversance with the actual terms, usually diverse and not tightly systematized, of moral assessment in the society the institution takes as its community--conversance with what Howard Brody calls "the broadest and most inclusive conversations in the area of medical ethics over a reasonable period of time." Ackerman calls it being current in the "reflective social dialog," embodied in "a myriad of academic journals, books, newsletters, government publications, and public discussions."[21] Whatever one calls it, it is very different from familiarity with those breath-takingly streamlined artifacts of philosophical texts and textbooks designated moral "theories" in the characteristically modern sense.

This wide conversance calls for an understanding, informed historically and sociologically (as well as conceptually), of the community's moral resources and the current state of discussions within institutions and outside them. Long-term ethicists within institutions may encourage the institutional moral memory of hard cases. They may also be well placed to track "housekeeping" problems--ongoing practices and assumptions, norms and authority relations that are so familiar they are hardly remarked, but may nonetheless be moral sore spots.[22] At the same time the moral culture of institutions must respond to larger academic, legal, and social currents in moral discussion, and the ethicist must be sensitive to significant differences among these contexts. Wibren Van der Berg, in a recent analysis of the "slippery slope argument" so common in applied ethics, warns, for example, that "too often, ethicists simply assume that a sound argument in the context of morality is also sound in the context of law, and vice versa."[23] He reminds us that applied ethicists themselves need discrimination and agility in keeping straight the moral, conventional, legal, and political dimensions of problems, policies, and practices.

Another part of the institutional ethicist's critical equipment must be alertness to differences between the conceptual weight of certain moral considerations and the social authority that may or may not be behind them. If an ethicist has a special responsibility for the moral-reflective space, this includes sensitivity to configurations of authority and dynamics of relationship that can either help structure that space or deform it. Interest in and practice with professional norms, typical role-structured perspectives, and particular institutional folkways is vital. This is not only because ethicists won't be respected if they don't know "the nuances and complexities of moral life as it is lived in a hospital,"[24] although they probably won't if they don't. It is also because without this kind of nuanced understanding the ethicist may not be effective in encouraging critical, reflective, and collaborative moral thinking. This includes moral thinking in which the unselfconscious exercise of power or expression of role-bound interests is replaced by conscious acknowledgement of legitimate authority and justified interests, and accepting the responsibilities these entail.[25] Differences "ideally" will be mediated, reconciled, or blended in fruitful compromise; but even in cases where they cannot be, clarification of roles, values, and responsibilities is an achievement and a resource for future deliberation. This is exactly one of the things the moral space must provide for.

Ideal ethicists, then, would be equipped with broad cultural and philosophical understanding of morality as a living social medium. They would cultivate perceptions and skills that help them to help others move deliberations along in ways that both arrive at resolutions and produce mutual recognition and clarified responsibility along the way. One important qualification for this role is appreciating its very complexity, its ideal requirement of very broad intellectual and social culture combined with keen interpersonal perceptiveness.

These attitudes and aptitudes are not easily mapped back on to exiting disciplinary models in higher education. Graduate education in academic ethics in American universities today aims at a far narrower form of intellectual preparation than that discussed here. (This philosophical training in elegant theory-construction "tested" largely against hypothetical cases and ingenious counterexamples was, after all, the root of the engineering model.) As momentum builds for certifying or credentialing practical medical ethicists it is well to consider how limited and limiting are current disciplinary definitions. It seems clear that training for ethics consultants would need to be both interdisciplinary (by present definitions) and interwoven with intern- or apprenticeships that rehearse ethicists in the ways of the clinical world. It is also true that the idea of "the" ethics consultant (reflecting the idea of some one person as a repository of expert or privileged moral knowledge) is questionable. Flexible networks of inside and outside ethicists, linking the moral space of particular institutions to other sites of "the reflective social dialog"--in universities, policy centers, government, patient activist organizations, and other places--need to be explored.

From Engineers and Experts to Architects and Mediators

It's not surprising that when the idea of ethics consulting caught on, academic ethicians were recruited to define and execute the task, and not surprising that many of them would tend to envision it in the prevailing mode of mid-twentieth-century ethics as quasi-scientific theory building and testing. It's also unsurprising that a promise of expert input would help to insert them into settings thoroughly organized in terms of professional specializations and prestige hierarchies. But while ethicists gained access, the center of the original model does not seem to be holding, either in philosophical or in applied medical ethics. The picture of morality as construction and negotiation offers some new images.

Try thinking of a consulting ethicist from one angle as like an architect, someone who designs a structure to fulfill a function at a given site. Architects must have certain kinds of genuinely technical expertise--in basic engineering principles, for example. But they must also draw on social and psychological fact and on aesthetic sensibility, both programmatic and vernacular, to relate structure to function in workable and satisfying ways. A consulting ethicist needs conceptual tools and training, but also a sense of where moral space needs to be created or sustained, and of how to structure that space for an integrated and inclusive process of moral negotiation within the constraints of a particular institution.

Now try thinking of the consulting ethicist acting within the moral space as a kind of mediator. A mediator actively participates in a situation (usually one of actual or potential conflict of viewpoint and interest) with a primary commitment to a fruitful process of resolution. The mediator isn't "value-free," because the mediator is deeply interested in good resolution. A good resolution is the kind that might come from stakes being clearly assessed, parties becoming clear of their own and others' legitimate positions, compromises being achieved that will stand up satisfactorily to later review because of the care with which they were constructed. The process itself becomes a constituent in the good of the product.

These two images might be further explored in reviewing the concept and the practice of ethics consulting.

Acknowledgments

Much thanks to the editors of the Report for initial encouragement and invaluable editorial judgment. Thanks also to Drs. Caroline Kalina and James Whalen, who provided the conversation for the opening anecdote. I am grateful to Fordham University for a Faculty Fellowship in spring, 1992, during which this essay was written.

References

[1.] Joan McIver Gibson and Thomasine Kimbrough Kushner cite a 1985 survey by the American Hospital Association's National Society for Patient Representatives showing that as many as 60 percent of hospitals nationwide may have established IECs, a figure double that for 1983. See "Will the 'Conscience of an Institution' Become Society's Servant?" Hastings Center Report 16, no. 3 (1986): 9-11.

[2.] See Gilbert Ryle, "On Forgetting the Difference between Right and Wrong," Essays in Moral Philosophy, ed. A. I. Melden (Seattle: University of Washington Press, 1958); Robert W. Burch, "Are There Moral Experts?" Monist 58 (1974): 646-58; Bela Szabados, "On 'Moral Expertise,'" Canadian Journal of Philosophy 8 (1978): 117-29; Francoise Baylis, "Persons with Moral Expertise and Moral Experts: Wherein Lies the Difference?" in Clinical Ethics: Theory and Practice, ed. Barry Hoffmaster, Benjamin Freedman, and Gwen Fraser (Clifton, N.J.: Humana Press, 1989) pp. 89-99.

[3.] See Daniel Dennett, "The Moral First Aid Manual," The Tanner Lectures on Human Values, vol. 8, ed. Sterling M. McMurrin (Salt Lake City: University of Utah Press, 1988).

[4.] See Arthur L. Caplan, "Mechanics on Duty: The Limitations of a Technical Definition of Moral Expertise for Work in Applied Ethics," supplementary volume 8, Canadian Journal of Philosophy (1982): 1-18.

[5.] Ruth Macklin, "Ethical Theory and Applied Ethics: A Reply to the Skeptics," in Clinical Ethics: Theory and Practice, pp. 102-24; Robert M. Veatch, "Clinical Ethics, Applied Ethics, and Theory," in Clinical Ethics: Theory and Practice, pp. 7-25, at 8-9.

[6.] One handy collection that represents some of these critiques is Stanley G. Clarke and Evan Simpson, Anti-Theory in Ethics and Moral Conservatism (Albany: State University of New York Press, 1989).

[7.] Abraham Edel, "Ethical Theory and Moral Practice: On the Terms of Their Relation," in New Directions in Ethics, ed. Joseph P. DeMarco and Richard M. Fox (New York: Routledge and Kegan Paul, 1984), pp. 317-35, provides a good discussion of all these factors.

[8.] On the bearing of the individual's moral histories, see Margaret Urban Walker, "Moral Particularity," Metaphilosophy 18 (1987): 171-85.

[9.] "Please Don't Tell!" case study, with commentary by Leonard Fleck and Marcia Angell, Hastings Center Report 21, no. 6 (1991): 39-40.

[10.] Stanley Cavell, The Claim of Reason, part 3 (Oxford: Oxford University Press, 1979), p. 269.

[11.] Two early and interesting exceptions to this are Larry R. Churchill, "The Ethicist in Professional Education," Hastings Center Report 8, no. 6 (1978): 13-15; and William Ruddick, "Can Doctors and Philosophers Work Together?" Hastings Center Report 11, no. 2 (1981): 12-17, which explore the roles of ethicists as "strangers" or "outsiders" to professional medical culture and to the institutional cultures of their consulting locales. I return to these important insights below.

[12.] See Bruce Jennings, "Applied Ethics and the Vocation of Social Science," New Directions in Ethics, pp. 205-17, especially 208-9, on this "second stage" of applied ethics.

[13.] In a recent Humana Press collection that focuses on the consulting role, fully seven out of ten papers deal primarily with these issues. See Hoffmaster et al., eds., Clinical Ethics: Theory and Practice.

[14.] Terrence Ackerman, "Moral Problems, Moral Inquiry, and Consultation in Clinical Ethics," in Clinical Ethics: Theory and Practice, pp. 141-60; especially 150-56.

[15.] Janet E. Fleetwood, Robert M. Arnold, and Richard J. Baron, "Giving Answers or Raising Questions? The Problematic Role of Institutional Ethics Committees," Journal of Medical Ethics 15 (1989): 137-42; Sisters of Mercy Health Corporation, Hospital Ethics Committees (November 1983), p. 8, quoted in Gibson and Kushner, "Will the 'Conscience of an Institution' Become Society's Servant?"

[16.] Arthur Caplan, "Moral Experts and Moral Expertise," in Clinical Ethics: Theory and Practice, pp. 59-87, at 85.

[17.] Robert Baker, "The Skeptical Critique of Clinical Ethics," in Clinical Ethics: Theory and Practice, pp. 27-57, at 44-45.

[18.] Churchill, "The Ethicist in Professional Education," p. 15; Ruddick, "Can Doctors and Philosophers Work Together?" p. 15.

[19.] William Ruddick and William Finn, "Objections to Hospital Philosophers," Journal of Medical Ethics 11, no. 1 (1985): 42-46, at 45.

[20.] Ruddick, "Can Doctors and Philosophers Work Together?" p. 17.

[21.] Howard Brody, "Applied Ethics: Don't Change the Subject," in Clinical Ethics: Theory and Practice, pp. 183-200, at 194; Ackerman, "Moral Problems, Moral Inquiry, and Consultation in Clinical Ethics," p. 156.

[22.] Virginia Warren, "Feminist Directions in Medical Ethics," Hypatia 4 (1989): 73-87, discusses how preoccupation with "crisis" cases in medical ethics persistently occludes "housekeeping" issues. In the same special issue on medical ethics and feminist critique, see also Susan Sherwin, "Feminist Medical Ethics: Two Different Approaches to Contextual Ethics," pp. 57-72, and Susan Wendell, "Toward a Feminist Theory of Disability," pp. 104-24.

[23.] Wibren Van der Berg, "The Slippery Slope Argument," Ethics 102 (1991): 42-65.

[24.] Caplan, "Moral Experts and Moral Expertise," p. 84.

[25.] See Fleetwood et al., "Giving Answers or Raising Questions?" pp. 139-40.
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