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The hospital ethics committee: health care's moral conscience or white elephant?

Early in their formation, ethics committees enjoyed a considerable and reassuring consensus regarding their functions. It was generally agreed that these were three: case review or consultation, policy or guideline development, and education in the field of bioethics. It seemed to be assumed, moreover, that whatever else these committees might do by way of generalized policies or educational reflections on the problems of bioethics, first and perhaps foremost they would labor amid the messy and complicating details of individual cases. In fact, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research actually worried that the case review function would be over-utilized. Ironically, just the opposite has occurred: case review is what these committees are now least likely to do or to be known for doing. [1] It is this irony that motivates my suggestion that the time has come for a serious reconsideration of the hospital ethics committee.

The Decline in Case Review

The factors that have contributed to the shift away from case review as the committee's central task fall into at least three loosely defined categories: political, psychological, and cultural or intellectual.

As a political matter, case reviews by committees may be problematic because they tend, de facto, to infringe upon the authority (and prerogatives) of attending physicians. We might wonder, however, whether the authority of the attending physician is an ethical authority. That is, are there purely or mostly ethical reasons for the physician to be the final arbiter of treatment decisions in the management of individual cases? Or is this authority mostly a matter of the social statute of physicians in comparison to other health care professionals (or to the public at large)? It is not, in any case, self-evident that this authority is an ethical authority in need of preservation by an ethics committee.

Mark Siegler has argued:

Most troubling of all, [institutional ethics committees] may remove or at least attenuate the decision-making authority of the physician who is responsible--medically, morally, and legally--for the patient's care. Some physicians may abdicate their medical responsibility by delegating difficult clinical-ethical decisions, an intrinsic part of medical practice, to such committees. In contrast to individual physicians, committees lack specific medical knowledge, have not been trained in the ethic of caring, have little responsibility for decisions, and have not been sanctioned by the patient to make such decisions. Thus, to delegate decision making to the IEC may be unethical for physicians and hospitals. [2]

The argument here is, however, less than compelling. Surely the moral responsibility that Siegler assigns to the physician does not exist because of some explicit, special agreement between physician and patient, wherein the patient specifically gets the physician to assume this kind of responsibility. It is a responsibility that attends one's work and role as a health care professional. Since physicians are not the only health care professionals involved in patient care, they are not the only ones with a moral responsibility for that care. Thus, Siegler would have to provide a special warrant for assigning the physician the kind of authority he is concerned to preserve; without such warrant, the authority, like the responsibility, may legitimately be shared. Otherwise, the committee's possible infringement of the physician's authority is simply a matter of (health care) politics.

A second category of factors contributing to the decline of case reviews might be loosely termed psychological. Here we have all those tensions that attend sitting in judgment on morally problematic situations--tensions that can easily explain why many committees see their role as providing non-judgmental emotional support, in the style of group therapy. The case review is merely meant to reassure both those involved in the case and committee members themselves that ethical problems are indeed difficult to solve and that others will surely sympathize with whatever decision is reached. [3] I do not minimize the importance in ethical discourse of either the psychological components of the ethical problem itself or the psychological conditions affecting the discourse on the problem. There is, however, an important difference between a group that sees itself mainly in the emotionally supportive role of providing "someone to talk to" and a group that sees itself as a critical forum for discussing and resolving substantive issues of conduct. [4]

These psychological factors point to certain cultural or intellectual conditions that ultimately underlie the ethics committee's failure to live up to expectations regarding case reviews. Chief among these conditions is the profound difficulty with which our society conducts its ethical discussions and debates. Over the last ten years a growing body of philosophical research and reflections has addressed the problematic state of ethical discourse in this society. Perhaps the three best known and most hotly debated examples of this emerging critique of culture are Alasdair MacIntyre's After Virtue, Robert Bellah and colleagues' Habits of the Heart, and Allan Bloom's The Closing of the American Mind. Their common thread of criticism is not that contemporary Americans have become morally corrupt--or not any more so than other generations or citizens of other societies. Rather, the common impression one gets from these critiques is that Americans no longer have a single, common, comprehensive, and coherent way of addressing ethical issues or dilemmas. We are a people of common ethical terms--'the good,' 'what's morally right,' 'justice,' 'rights'--but of disparate ethical meanings or "universe of discourse."

One consequence of this fragmentation of American moral thought is that we are often misled into thinking that there is real communication and dialogue in our public discussions of ethical issues. For example, members of an ethics committee might imagine that they are engaged in real dialogue over the issue of autonomy in some case of patient care simply because the members have agreed to discuss the case as an autonomy problem. But what a Utilitarian or Kantian or Natural Rights Theorist or Roman Catholic or Orthodox Jew or Lutheran sees as the substance of true human autonomy could differ dramatically from other views: true autonomy could be anything from acting in a narrowly defined rational manner to getting whatever one wants.

This is an issue that has yet to be seriously addressed in the literature on hospital ethics committees. In the Handbook for Hospital Ethics Committees, Judith Ross and colleagues mention that "ethical systems" disagree about the nature of the good. They also mention that ethical differences can run along cultural, religious, institutional, and even professional lines. [5] But these differences are presented as if they should not greatly hinder the work of ethics committees. Part of the reason for this optimism may be that the Handbook sees a broad consensus on certain "principles" that committees can employ in performing their assigned functions. These are the bioethical principles made famous by Beauchamp and Childress in Principles of Bioethics: autonomy, beneficence/nonmaleficence, and justice. These principles are assumed to have enough agreed-to substance for ethics committees to perform their functions without getting embroiled in the kind of intellectual and cultural controversies addressed by MacIntyre, Bellah, and Bloom in their critiques. But has this assumption been borne out in the work of ethics committees? Are these principles the same consistently understood starting points for all those who labor in the field of bioethics?

While it is unlikely that an ethics committee would ever explicitly address the moral fragmentation of Western or American culture in the midst of a case review, there are attitudes that committee members might readily strike that do reflect these subtle cultural conditions. I would like to comment on two: a tendency toward ethical skepticism and relativism, and a tendency to consign ethical matters to one's "private life."

Ethical skepticism and ethical relativism are not twentieth century phenomena, nor are they creations of American culture. What is novel is the widespread acceptance and endorsement of these attitudes, particularly in the vehicles of popular culture. Today, for example, this skepticism and relativism are common fare in the dialogue of movies, talk shows, and many prime time television programs. Thus, it might not be the complicated difficulties of the ethical dilemmas of this age--for example, the bioethical dilemmas occasioned by the marvels of modern medical technology--that cause us to be unsure of solutions with general applicability. Rather, it could be the fact that Western culture in general, and American culture in particular, matured into the twentieth century without reaching any lasting, compelling consensus on what it means to live the ethical life. Technology did not outdistance our ethics; if anything, it became a substitute for having an ethical consensus.

These last statements may, in fact, be too strong. There may be a rather significant consensus, at least in this society, about what the ethical life entails; that it concerns the conduct of one's private affairs. For example, Richard McCormick has noted that from their inception there has been a widely shared suspicion these committees would be up to no good because inevitably they "will dictate rules on what is a private matter." This division of human existence into a private life and a public life is largely the result of sharing a common society and culture but not a common ethical vision or language. In the traditions of liberal political thought, the public-private distinction represents a solution to the problem that members of various religious communities must be politically organized and ruled in one common civil society. The dividing line between these two worlds is not, of course, the boundary of one's home or private property. It is the line between those matters in regard to which disagreements and uncertainty cannot be resolved to the satisfaction of most and those matters in regard to which they can. Thus ethical issues are matters properly consigned to one's private affairs and not to be judged by others sitting in committee.

Even if a committee were to overcome the political and psychological barriers to substantive case review, these cultural attitudes indicative of a morally fragmented world could undermine the consultative function. Those who initially promoted the hospital ethics committee as a substantive advisor on the everyday ethical dilemmas of clinical medicine may have underestimated--or simply ignored--the effects of these political, psychological, and cultural factors. They may have overestimated the committee's ability to neutralize these factors in providing the kind of concrete advice that gives effective guidance in the case at hand.

The Focus on Education

Some bioethicists always doubted the function of consultation or case review, and see in the current decline of this function a positive development. They argue that case reviews should be deemphasized and the functions of education and guideline development emphasized. [7] But why should a hospital ethics committee think that education in the field of bioethics is one function well within its competency when a case consultation is not?

One answer to this question is that what an ethics committee sees in the way of "education" is mostly simple and straightforward. This seems to be the view in most of the literature on these committees. For example, Ron Cranford and colleagues claim that "in its educational function, an IEC provides information and training." [8] But what does this "information" and "training" involve? Suppose the ethics committee were to run "informational" sessions about current state laws on advance directives. Could a Durable Power of Attorney for Health Care be presented in a way that suggests that the only real ethical issue in patient care is complying with a patient's wishes, and thus that the only real ethical complication in such care is determining the wishes of the incompetent patient? Would such a session be purely informational, or might it involve particular assumptions about what the ethics of health care should be? Indeed, is a hospital ethics committee competent to determine the ethical point of view on all such issues? My own view is that there is very little--if anything--in the field of bioethics that could pass for "purely informational." For this reason, I suspect that ethics committees, in their passion to educate, may unwittingly be promoting only one point of view--a relativistic account of the value of patient autonomy--among the many that might be taken on bioethical issues.

My point here, then, is to question the assumption that the committee's (possible) incompetency in case reviews does not affect the educational function, or for that matter the policy/guideline development function. In the matter of guidelines, there are two obvious questions. What particular ethical point of view does the committee assume in developing the guidelines? Is the committee competent to make this determination or to appreciate fully the implications of its selection?

In this debate over functions, there is yet another assumption I am even more anxious to challenge. It is the assumption that when properly understood and practiced, ethics or moral philosophy is an exercise in building and elaborating theories and in formulating and refining abstract or general principles. It is the assumption that ethics is a theoretical endeavor, and that practice--or "applied ethics"--is another matter. A committee might hope to avoid both the political and psychological problems that attend involvement with actual, concrete cases by accepting the distinction between the functions of education and policy development, on the one hand, and case review, on the other, as a distinction between theory and practice. But to practice this avoidance is to become impaled on the thorny issue of ethical pluralism and the fragmentation of American moral thought.

There are, however, good reasons for thinking that ethical theory and practice are not so easily distinguishable, and that one cannot competently engage in education or policy development without a competency for case reviews. If we were persuaded by these reasons, our understanding of ethics committees might be considerably altered. For example, we might see that a committee incompetent to give its ethical judgment on particular, concrete cases is equally incompetent to educate or to develop general policy directives. We might also begin to discern a link between the vitality of ethics committees and an approach to ethics that manages to avoid the unresolved pluralism of ethical theories by abandoning the mostly spurious distinction between ethical theory and applied ethics.

An Exercise in Moral Casuistry

How then might we begin to rethink the function of hospital ethics committees and the moral project that they originally represented? Sone commentators have already suggested how the standard three functions actually overlap or point to one common goal. [9] I would like to turn these suggestions in a slightly different direction by questioning the assumption that the proper part of ethics or moral philosophy is theoretical. To this end, I would like to propose that the responsibility of the hospital ethics committee be reconsidered in terms of Albert Jonsen's and Stephen Toulmin's recent efforts to revive the ancient moral art of casuistry. [10]

In The Abuse of Casuistry and elsewhere, Jonsen and Toulmin both critique modern moral philosophy and delineate a form of moral reasoning that was largely lost in the development of modern moral philosophy. In "The Recovery of Practical Philosophy," Toulmin is especially eloquent in identifying two critical elements in this shift between models of philosophizing regarding human conduct:

Starting with the Cambridge Platonists, philosophers turned ethics into abstract theory, ignoring the concrete problems of moral practice. The modern philosophers assumed that God and Freedom, Mind and Matter, Good and Justice, are governed by timeless, universal "principles" . . . In a phrase, General Principles were In, Particular Cases were Out.

And,

For sixteenth-century scholars, law was the model "rational enterprise," and the possibility of a universal natural philosophy seemed problematic. A century later, the shoe is on the other foot. Philosophy focuses on the permanent underlying structure of Nature: the transient affairs of human beings take second place. As a result . . . philosophers focus their attention . . . on timeless principles holding good, not at one time rather than another, but at all times. From this time on, then, the Permanent is In, the Transitory is Out. [11]

The art of casuistry that was lost in this parading shift is not simply some particular logical formula or calculus for determining the morally right course of conduct. It is, rather, an exercise in perceptive judgment about similarities and differences. As Jonsen and Toulmin present it, the casuist model of moral philosophy is a loosely organized set of argument strategies and rhetorical moves, and not at all a neatly formulated process of linear inference. Casuist moral philosophy is an exercise in "rhetoric" about timely and important matters.

There are a number of features to the model of casuistry that Jonsen and Toulmin attempt to revitalize as an alternative to modern, theory-based ethics, each generating an array of suggestions regarding how a casuist ethics committee might be formed and directed.

The first feature concerns the importance of paradigmatic cases--cases that can be paradigms of either right or wrong conduct. In either instance, the case represents very strong and widely accepted judgments to the effect that this particular conduct in these particular circumstances is right or wrong. The idea here is that our notions of right or wrong grow out of actual experiences of exemplary conduct, and thus are not the result of theoretical speculations about the nature of "the good" and "the right." While the paradigm case serves, then, as the objective source of our substantive notions of right or wrong, the judgment that the case elicits represents the moral sensibility that guides the profesional casuist.

In using the case and not a set of principles or theories as the touchstone for its work, an ethics committee might be able to circumvent the unresolved consequences of the fragmentation of theory-based moral philosophy. For example, a committee might begin its own education in the field of bioethics by first identifying the types of problems that define the field and then identifying paradigmatic cases for each type of problem. The initial exercise here in to see what might emerge as a strong, broad consensus of judgment on particular cases, as opposed to exploring the theoretical options the committee has in committing to some brand of moral philosophy.

The paradigm case is not, however, a benchmark of moral deliberations that excludes principles or generalized rules. a second feature of casuistry is the use of maxims or generalized directives that constitute the "warrants" drawn from the paradigms. These warrants carry the lesson of the paradigm and our experience of it and the paradigm case constitutes the real substantive meaning for the warrant or moral principle. The application of moral principles and generalized rules is not then a simple deduction from the general to the particular, because the principle or rule--the moral lesson--can be applied only through the case or cases that create the lesson. Thus, moral (and practical) reasoning is more properly understood as a form of "sideways" inference. We do not move from "better known" generalized directives to "lesser known" decisions on particular cases. Rather, we move, through a medium of rules and principles, from one relatively probable judgment about a case of right (or wrong) conduct to another relatively probable judgment about another case.

Perhaps the best way to relate this feature to the work of an ethics committee is to recall the debate over the meaning of the terms "extraordinary" or "disproportionate" treatment and the principles they entail. [12] Many find the distinction purely arbitrary or the terms mostly vacuous. But this might be only because we mistakenly expect these terms to have some abstract or idealized meaning apart from actual cases that would strike nearly everyone as moral paradigms of forgoing treatment. A casuist ethics committee could avoid this mistake by insuring that any policy or guideline it develops on forgoing medical treatment makes explicit reference to the cases that constitute the best judgment of the committee regarding when treatment may or may not be forgone.

Notice also that the development of policies or guidelines, in the form of moral principles and generalized rules, would be done in a way that grounds the policy or guideline in a consensus of judgment about some clear case and not in a theoretical commitment to either utilitarianism, or deontology, or natural rights. The committee's "principle" that extraordinary treatment should be forgone would mean this: in cases factually the same as or nearly similar to the case of X, treatment that is the same as or nearly similar to the treatment at issue in case X should be forgone.

It would be a mistake, however, to think of casuistry as an ethics of easy cases. In fact, the proper work of the professional casuist is to make easy cases hard. A third feature then of casuistry is the practice of progressively altering and complicating the paradigm so as to test the limits of the warrant's applicability.

There are a number of possibilities of hard or problematic cases. A case may be problematic because it is unclear and disputed under which paradigm the case falls. For example, is withdrawing a feeding tube from a particular patient more like the paradigm of letting die or more like the paradigm of intentional killing? A case may also be problematic because of its unusual fact-pattern, thereby making the application of the apparently closest paradigm extenuated at best. For example, how do you apply the paradigm of the next-of-kin as surrogate decisionmaker in the case of an incompetent patient who has been living a double life with two spouses and families? Finally, there are cases that are problematic because they involve revolutionary changes in technology and thereby previously unheard of possibilities. For example, how do we apply our paradigms of motherhood in the case of a "surrogate mother" carrying the fetus of an "intended mother," fertilized in vitro using the donated egg of a "biological mother?"

The casuist's task is not t invent the paradigms of conduct. A case should be considered a paradigm only when the considered and persistent sense of the community makes it so. The casuist's job is to give voice to this sensibility and then to explore its limits and conditions by imagining or finding new cases that more and less approximate the paradigm. In this exercise, the object is to better understand wha facts or patterns of facts make the moral difference. The result is the "taxonomy" of cases that distinguishes all traditions of casuistry.

The obvious vehicle by which the hospital ethics committee could develop this taxonomy of cases and educate the institution generally into the casuist analysis of cases, would be regularly scheduled "ethical grand rounds." [13] These rounds could be organized around familiar and recurring problem areas: no-code orders, withdrawing treatment, conflicts in surrogate decisionmaking, breaches of physician-patient confidentiality, infection risks in AIDS patient care, etc. In the course of a few years, an ethics committee could develop in each area a body of case reviews or precedents that would provide effective guidance in new cases. The development of this taxonomy should provide colleagues and staff with important insights into what facts matter and how, from an ethical perspective, facts can subtly change. In fact, the regularly scheduled ethical grand round could be committee meeting, educational forum, and policy development session all in one.

A fourth feature of the casuist model of moral philosophy is a willing acceptance of moral judgments as more or less probable but never axiomatically certain. This idea of moral probabilism is actually another angle on the claim that practical reason is more properly an exercise of judgment and analogical analysis than a simple, more or less straightforward syllogism based on self-evident general truths. Judgments made about newly presented cases can be more or less "probably correct," depending on the closeness to relevant paradigms, the arguments that can be mustered for the relevance of the paradigm, and even the considered judgment of others who have reflected on such cases.

The moral probabilism of casuistry should not, however, be confused with either ethical skepticism or ethical relativism. Casuistry is not a skepticism because it maintains the possibility that we can know with a sufficient degree of assurance how best to conduct our affairs in most instances. Casuistry is also not a relativism, to the extent that it rejects the claim that there are no objective grounds for moral deliberations. From the perspective of this probabilism, committee members might also ease the understandable discomfort of case reviews by remembering that their work in bioethics need not claim any infallibility of judgment in order for their judgment to be objectively sound and thus validly given to others. To have a legitimate opinion about the conduct of others one does not have to presume to be God, or in privity to Divine Wisdom. Nor need one assume that one's judgments are the result of a geometry-like inference drawn on absolutely certain premises. Moral discourse can be considered a fallible enterprise that is at the same time unavoidable.

The ethics committee would thus have to learn to be "judgmental" in all the right ways. This means doing its best to discern the facts of each case, to perceive the differences and similarities between cases it is most confident about and those less so, to listen to all arguments and considerations that bear upon any case, and finally to accept that it could make a sound and reasonable judgment about some case and still be wrong. The more problematic the case, the more responsible it is to accept disagreement. The fact that cases can often be problematic should not, however, persuade the committee to withhold judgments. It is in fact yet another (the fifth) distinguishing feature of casuistry to view indecision as the greater evil even in cases where there is serious doubt as to the proper course of conduct. Reasonableness requires action in the face of uncertainty and not retreat into theoretical attempts to resolve the uncertainty. Moreover, it is in making such judgments--even in the toughest of cases--that the committee might enhance the level of moral discourse in the institution and might assist others in being more reflective and serious-minded about their own conduct.

The sixth feature of casuistry is that the resolution of moral difficulties in problematic cases occurs by accumulating or "piling up" arguments and considerations for one side or the other. The weight of these accumulated arguments and considerations provides a kind of "internal probability" for a moral judgment. This might also be augmented by the "external probability" of the considered opinions of respected thinkers on such difficult cases.

The problematic case is actually the fit place for an appeal to moral theories. Of course, the casuist's view of moral discourse as a form of rhetoric does not regard these moral philosophies as rival intellectual theories, only one of which gives a uniquely correct analysis of moral reasoning. Rather, they are seen as "complementary practical theories, each of which is relevant to some specific types of moral problems." [14] Where utilitarianism might be more persuasive in a problematic case involving access to highly expensive treatment modalities, for example, Kant's categorical imperative might more effectively resolve one involving experimentation on human subjects. Casuistry counsels an equal respect for all theories and thus a commitment to none. The idea is that either the arguments mounted in analogizing the problematic case to some warrant and paradigm or the judgments of "authorities" in bioethics (or both) should tip the balance sufficiently to make some decision a reasonable one.

The Conscience of the Community

My proposal is then that hospital ethics committees should set case reviews, modeled on the practices of casuistry, as their essential and primary function. Rather than simply ignoring the other standard functions of these committees, this proposed recognizes that moral education as well as the development of moral "guidelines" is fatally flawed without a persistent and critical focus upon concrete cases and those actual fact-patterns that make the moral difference. In bioethcis and elsewhere, the task is to cultivate "the ability to see how and when strictness is the better course, how and when the deeper wisdom lies in tolerance of exceptions." This is an ability--a practical wisdom--that can be achieved, however, only by "constructive reflection about the practical lessons of concrete experience." [15] The heart of the casuist's practical wisdom is a profound seriousness that can be earned only by confronting the actual moral problems of the life we share with others.

The casuist model of moral philosophy assumes, of course, the existence of some manner of "moral community." The casuist is not an independent agent: her work as an ethicist is for and about the community f which she is a member. The relation between the casuist and the community is actually dynamic, perhaps even dialectical. While the community's most persistent and strongest judgments over concrete cases constitute the starting points for the casuist, it is the casuist's responsibility to educate the community regarding the boundaries, implications, weaknesses, and strengths of the moral judgments that bind the group into a moral community. In one sense, these primitive judgments of right and wrong constitute the "ethic" with which the casuist works; but in another sense, it is the casuist who creates or delineates the community's "ethic" in the development of a taxonomy of cases. Thus, casuistry begins with the reality of at least a nascent moral community, and its task is to make that community a fully self-conscious moral world.

Whether it makes sense to have a committee serve as the casuist conscience of a health care institution depends, then, on whether it makes sense to think of the contemporary hospital or medical center as even a nascent "moral community." As we all know, the more likely view of the hospital is as a place of business, where some have a "job" (not a calling) and others find "services" (not a community of caring). For this reason alone, I am not sanguine about my proposal for casuist ethics committees. I remain concerned, however, that the alternative is an ethics committee that might eventually become a white elephant in health care ethics.

References

[1] Robert M. Veatch, "Hospital Ethics Committees: Is There a Role?" Hastings Center Report 7, no. 3 (1977): 22-25, and Carol Levine, "Hospital Ethics Committees: A Guarded Prognosis," Hastings Center Report 7, no. 3 (1977): 25-27; Cynthia B. Cohen, "Interdisciplinary Consultation on the Care of the Critically Ill and Dying: The Role of One Hospital Ethics Committee," Critical Care Medicine 10, no. 11 (1982); Stuart J. Youngner et al., "Patients' Attitudes Toward Hospital Ethics Committees," Law, Medicine & Health Care 12, no. 7 (1984): 21-25; President's Commission for the Study of Ethical Problems in Medicine and biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions (Washington, D.C.: U.S. Government Printing Office, 1983), p. 165; Cynthia B. Cohen, "Is Case Consultation in Retreat?" Hastings Center Report 18, no. 4 (1988): 23.

[2] Mark Siegler, "Ethics Committees: Decisions by Bureaucracy," Hastings Center Report 16, no. 3 (1986): 22.

[3] Alan R. Fleischman, "An Infant Bioethical Review Committee in an Urban Medical Center," Hastings Center Report 16, no. 3 (1986): 18; and Fleischman, "Bioethical Review Committees in Perinatology," Clinics in Perinatology 17, no. 2 (1987): 389.

[4] Judith Wilson Ross, "Why Cases Sometimes Go Wrong," Hastings Center Report 19, no. 1 (1989): 22-23.

[5] Judith Wilson Ross et al., Handbook for Hospital Ethics Committees (Chicago: American Hospital Publishing, 1986).

[6] Richard McCormick, "Ethics Committees: Promise or Peril?" Law, Medicine & Health Care 12, no. 4 (1985): 150-55.

[7] Corrine Bayley, "Consultation Revisited," Ethical Currents, no. 18 (Spring 1989).

[8] Ronald Cranford et al., "Institutional Ethics Committees: Issues of Confidentiality and Immunity," Law, Medicine & Health Care 13, no. 2 (1985): 52-60.

[9] Ruth Macklin, "Consultative Roles and Responsibilities," in Institutional Ethics Committees and Health Care Decision Making, ed. Ronald Cranford and A. Edward Doudera (Ann Arbor: Health Administration Press, 1984), pp. 158, 166; and The Hastings Center, Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Bloomington: Indiana University Press, 1987), pp. 100, 103.

[10] Albert R. Jonsen and Stephen Toulmin, The Abuse of Casuistry: A History of Moral Reasonig (Berkeley and Los Angeles: University of California Press, 1988).

[11] Stephen Toulmin, "The Recovery of Practical Philosophy," The American Scholar 57, no. 3 (1988): 337-52, at 339-41; also see Albert R. Jonsen, "Casuistry and Clinical Ethics," Theoretical Medicine 7 (1986): 65-74; Jonsen , "Can an Ethicist Be a Consultant?" Frontiers in Medical Ethics, ed. Virginia Abernethy (Cambridge, Mass: Ballinger Publishing Co., 1980), pp. 157-71; and Stephen Toulmin, "Tyranny of Principles," Hastings Center Report 11, no. 6 (1981): 31-39.

[12] For example, The President's Commission, Deciding to Forego Life-Sustaining Treatment, pp. 82-89.

[13] Ross et al., Handbook, p. 50, and Cranford et al., "Institutional Ethics Committees," p. 55, also recommend the vehicle of ethical rounds.

[14] Jonsen and Toulmin, The Abuse of Casuistry, p 298.

[15] Jonsen, "Casuistry and Clinical Ethics," p. 329.

David C. Blake is associate professor, Loyola Marymount University, Los Angeles, Calif.
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Title Annotation:includes related article on Joseph Fletcher
Author:Blake, David C.
Publication:The Hastings Center Report
Date:Jan 1, 1992
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