Ethical Issues

Which Medical
Ethics for the
21st Century?

The Bioethics Mess

Establishment
Bioethics

Summary
>Clinical ethics= is a discipline that arose following the 1976 recommendation in the Karen Ann Quninlan case that hospitals form >ethics committees=. >Unwieldly= committees are giving way to ethics consultants, part of a Anew layer of bureaucracy interposed between doctor and patient@.

These consultants claim an expertise in moral decision making that extends to life-and-death questions, even to the exclusion of doctors and families, whom they judge to be incompetent to tackle the complex issues involved. However, the author comments that clinical ethics Ais to a very large degree whatever anyone wants it to be@, citing studies that bring into question their expertise and the value of their work. She also notes that the new ethicists refuse to allow their work to be evaluated in controlled clinical trials.

HMO=s shop for clinical ethicists, who offer a variety of approaches to managing services, risks, and "noncompliant patients." Using some provocative examples, the author points out the potential for a conflict of interest when the insurer pays the ethicist making decisions about treatment coverage.

The most significant observation refers to the abject failure of ethical consultation in one situation, even though decision making was informed by standard secular ethical principles of autonomy, beneficence and non-maleficence. Angry family members believed that they had been Arailroaded@. An expert reviewing the case is quoted the effect that there had been a failure to agree about the practical application of ethical principles. The explanation is true as far as it goes, but inadequate. The root problem is better expressed by the author herself, in another part of the article:

AAs James Reagan belatedly discovered, the advice of an ethicist--unlike, say, the advice of a podiatrist -- falls squarely into the most contested domain of social and public policy. Rawlsians and feminists; casuists and communitarians: all have their divergent visions of what individuals should find life worth living for, or be willing to live with. And these visions will not always coincide with the wishes of the patient, much less the consensus of society.@

The article focuses on the activities of individual ethics consultants working within the U.S. framework of private medical coverage, but the concerns it raises are equally valid with respect to socialized medicine and ethics committee systems. Indeed: the activities and impact of ethical experts may be more problematic when they operate as unseen advisors to policy makers in state bureaucracies, and a committee decision may be more difficult to challenge than that of a single consultant.

The full text is available at http://www.tnr.com/archive/04/042897/shalit042897.html