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Visit us at https://bioethics.georgetown.edu/. Copyright É 1993 The Johns Hopkins University Press. This article first appeared in KennedyInstitute of Ethics Journal, Volume 3, Issue 4; December, 1993, pages 433-450 Collection Permanent Link: hdl.handle.net/10822/503786 This material is made available online with the permission of the author, and in accordance with publisher policies. No further reproduction or distribution of this copy is permitted by electronic transmission or any other means.

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Bioethics Consultation

PAT MILMOE McCARRICK

(John La Puma, M.D., from the Department of Medicine at Lutheran GeneralHospital in Chicago, contacted the National Reference Center for BioethicsLiterature and suggested bioethics consultation as a topic for the Scope NoteSeries. He provided an extensive list of citations about ethics consultations col-lected by him and by David Schiedermayer, M.D., for their new book EthicsConsultation: A Practical Guide.)

In Ethics Consultation in Health Care, editors John Fletcher, Norman Quist,and Albert R. Jonsen (I, 1989) define ethics consultation as "the provision ofspecialized help in identifying, analyzing, and resolving ethical problems thatarise in clinical care. In medical ethics the area of consultation has grown rapid-ly since 1978 when Edmund D. Pellegrino (II, 1978) noted, "we cannot separatetechnical-moral decisions from the philosophic principles we use to justify them.Medicine and ethics must be engaged with each other at every level."

In 1980 Albert Jonsen raised the question of whether an ethicist could be aconsultant and said that the ethicist as consultant is a casuist, one whose moralreasoning is based on a system of reasoning that is applied to particular cases.He describes historical casuistry in Western culture, comparing it to modernmoral philosophy, and suggests that a "new casuistry seems timely" for ethicsconsultation (II, Jonsen 1980). By 1984 ethicist Ruth Purtilo recorded herthoughts following an ethics consultation. She raised questions about the ethi-cist's place on a hospital staff and how to make that role appropriate and ben-eficial to all concerned, saying that "the ethicist retreats after the consultation;under no circumstances would the outcome of an ethics consultation be that theethicist became the primary care giver or assumed ongoing responsibility for theclinical management of a case" (II, Purtilo 1984). Nevertheless, in 1992 twophysician-ethicists who had been called as ethics consultants for a patient whohad requested that he be removed from his ventilator reported that they becamethe persons who turned off the ventilator and administered the drugs that easedhis dying (II, Edwards and Tolle 1992).

In recognition of the growing number of persons identifying themselves as

Produced at the National Reference Center for Bioethics Literature, Kennedy Institute of Ethics,Washington, DC 20057. It is supported by funds provided under grant number LM04492 from theNational Library of Medicine, National Institutes of Health. Literature available through September1993 is represented in this Scope Note.

Kennedy Institute of Ethics Journal Vol. 3, No. 4, 433-451 © 1993 bythe National Reference Center for Bioethics Literature

KENNEDY INSTITUTE OF ETHICS JOURNAL · DECEMBER 1993

consultants, the Society for Bioethics Consultation was founded in October1985 as a professional society of persons engaged in bioethics consultation. Itencourages and supports consultation, assists in establishing clinical educationprograms, and raises funds for consultation education. Although the Society hasno permanent office, the president (currently, George Kanoti in the ClevelandClinic Foundation's Bioethics Department) conducts its work and plans anannual meeting.

The Joint Commission on the Accreditation of Healthcare Organizations(JCAHO) established new criteria concerning ethics in its 1992 Manual (III,JCAHO 1992) and in a special issue of QRB devoted to ethics consultation (I,Defining Quality 1992). These publications undoubtedly have contributed tothe increased use of experts in medical ethics. The Manual notes that all orga-nizations seeking accreditation should have some sort of "mechanism for theconsideration of ethical issues arising in the care of patients and to provide edu-cation to care givers and patients on ethical issues in health care." A health careinstitution's eligibility for JCAHO accreditation, which is required for federalreimbursement, requires adherence to this specification (III, JCAHO 1992).

The new International Directory of Bioethics Organizations provides anindex of 129 different groups that indicated to the authors that they offerbioethics consultations. Of these, 83 are in the United States and 46 are in othercountries. The ethics consultants included in the directory encompass a broadgroup of professionals who will assist patients, families, and primary care med-ical staff in finding solutions to ethical dilemmas resulting from use of new tech-nologies or new treatments in health care. Consultants often come from thehealth fields: physicians, nurses, and other health personnel, but other profes-sionals are also active as ethics consultants. Lawyers, pastoral counselors,philosophers, and social workers also offer bioethics consultation services (III,Nolen and Coutts 1993).

Drs. Siegler, Pellegrino, and Singer wrote in 1990 that "Physician-ethicistsand professional ethicists will continue to work side by side in the future. Oneis not likely to replace the other, nor is this desirable, because each brings a dif-ferent perspective and different capabilities to the situation. Physician-ethicistsand professional ethicists must understand each others' potential contributions.Rather than competing, they must complement and supplement each other topromote the high quality of ethical decision making now required and desiredby patients" (II, Siegler, Pellegrino, and Singer 1990).

To educate this varied group of professionals, all of whom bring differentskills to the task, dozens of training programs have been established in colleges,universities, medical schools, and hospitals across the United States, and manyoffer undergraduate and graduate degrees, or certification programs, inbioethics. The oldest program operating is that of the Kennedy Institute ofEthics at Georgetown University, which awards a masters and a doctorate inbioethics. Its professors, many of whom are jointly appointed in the universityphilosophy department, have authored many texts in medical ethics. TheUniversity of Chicago established the first program in a clinical setting. The

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Center for Clinical Medical Ethics, part of the Pritzker School of Medicine, pro-vides clinical ethics fellowships to train ethicists to lead programs in medicalschools, to conduct clinical ethics research, and to study health policy.

Many institutions offer professional continuing education credits for shortcourses on the philosophical foundations of bioethics. Such training provides aprocess on which to base medical decisions for the very sick or perhaps in areasof genetic or reproductive health. Many bioethics consultation groups offer reg-ular educational seminars or courses, training programs for hospital ethics com-mittee development, formal education in ethical decision making, and otherethics programs (HI, Nolen and Coutts 1993).

The Journal of Clinical Ethics, which began publication in 1990, reports onactivities and provides information for the growing field of bioethics consulta-tion. Two other journals, HEC Forum and the Cambridge Quarterly ofHealthcare Ethics, also carry a large number of relevant articles. General med-ical journals, such as the Journal of the American Medical Association, the NewEngland Journal of Medicine, and the Annals of Internal Medicine, often pub-lish articles about bioethics. BIOETHICSLINE, an online database that is partof the MEDLARS system at the National Library of Medicine, NationalInstitutes of Health, indexes material relevant to the area, and computerizedsearches will produce citations about ethics consultations.

i. books/special issues

Ackerman, Terrence F.; Graber, GlennC; Reynolds, Charles H.; andThomasma, David C, eds. ClinicalMedical Ethics: Exploration andAssessment. Lanham, MD: Univer-sity Press of America, 1987. 179 p.Ten essays by noted bioethicists are

divided into sections on: (1) teachingmedical ethics in the clinical setting(objectives, strategies, qualifications,models, and training); (2) medicalethicists as consultants in the clinicalsetting (the patient's agent, rights andduties, and legitimate and illegitimateroles); (3) the relationship betweenmoral theory and clinical medicalethics; and (4) a critical review of con-sultative, pedagogical, and investiga-tive methods.

Baylis, Françoise, guest editor. Specialissue on standards and practices

relevant to health care ethics con-sultation. HEC Forum. 5 (3): 141-204, May 1993.Authors comment on ethics consul-

tation practices in Canada. (SeeSection II: Burgess, Coughlin, Downie,and Freedman.)

Culver, Charles, ed. Ethics at the Bed-side. Hanover, NH: University ofNew England Press, 1990. 214 p.Twelve bioethicists describe indi-

vidual ethical dilemmas in the medicalsetting. The writers include physi-cians, philosophers, theologians, anda legal expert.Defining Quality in Ethics Consulta-

tion: First Steps. Special Issue. QRB18(1): 4-32, January 1992.Troyen Brennan in the foreword to

this special issue says that quality

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improvement in medical care and clin-ical ethics consultation are currentconcerns in almost every hospital, andhe sees an interrelationship betweenthe two areas. (See Section II: Anzia,Brennan, La Puma, Scofield, andSiegler.)

Fletcher, John C; Quist, Norman;and Jonsen, Albert R., eds. EthicsConsultation in Health Care. AnnArbor, MI: Health AdministrationPress, 1989. 209 p.The editors' introduction provides

a rationale for and a brief history ofethics consultation in health care. Thebook has four sections—the role ofthe ethics consultant, the ethics con-sultant in the hospital, values, andlegal implications and standards—with 11 essays by different ethicists.Fry-Revere, Sigrid. The Accountability

of Bioethics Committees andConsultants. Frederick, MD: Uni-versity Publishing Group, 1992.145 p.The author examines why and how

bioethics committees and consultantsshould be held accountable for theiradvice. Fry-Revere says mechanismsthat ensure accountability and uni-form fairness are needed.

Jonsen, Albert R.; Siegler, Mark; andWinslade, William J. ClinicalEthics: A Practical Approach toEthical Decisions in ClinicalMedicine. 3d ed. New York:McGraw Hill, 1992. 202 p.Written for physicians, nurses, and

medical students, the work not onlydiscusses and analyzes the ethicalproblems, but also offers counselabout decisions. Dozens of individualcases are presented in this pocket-sizebook organized with a locator index.

La Puma, John, and Schiedermayer,David. Ethics Consultation: APractical Guide. Boston: Jones andBartlett, forthcoming 1994.Drawing upon their combined

experience with approximately 700formal ethics consultations, theauthors provide practical informationabout how ethics consultations areperformed in the clinical setting. Theyinclude professional, institutional,personal, and financial issues, andaddress consultants' relationshipswith institutional committees. Alengthy appendix contains many illus-trative cases.

McCullough, Laurence B., ed. Issuesin Clinical Ethics. Special Issue.Journal of Medicine and Philo-sophy 18(1): 1-98, February 1993.Bioethicists present the views of

both medicine and philosophy in writ-ing about the debate in clinical ethicson "attempts to close clinical ethicsand bioethics more generally either tomedicine and physicians, on the onehand, or to philosophy and academicphilosophers, on the other." (SeeSection II: McCullough, Wildes, andZaner.)

Skeel, Joy D., ed. Issues in ClinicalEthics Consultation. Special Issue.Theoretical Medicine 13 (1), March1992.

Five essays on ethics consultationare included in this special issue. (SeeSection II: Barnard, Doukas, Edinger,Frader, and Skeel.)

Weinstein, Bruce D. The Possibility ofEthical Expertise. Ann Arbor, MI:University Microfilms Internation-al, 1989. 177 p.Weinstein's doctoral thesis offers

arguments about the nature of the

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term "expertise" in the area of ethics.He holds that "the distinguishingcharacteristic of expert claims inethics is strong justification, not truth,while performative ethical expertise isdistinguished by the realization ofmoral virtues."

Young, Ernie W. D. Alpha and Ome-

ga: Ethics at the Frontiers of Lifeand Death. Reading, PA: Addison-Wesley, 1989. 209 p.A clinically-oriented university

chaplain uses cases dealing with issuesat the beginning and end of life to dis-cuss approaches for dealing with ethi-cal dilemmas.

Ï€. articles/chapters

Agich, George J. Clinical Ethics: ARole Theoretic Look. Social Scienceand Medicine 30 (4): 389-99,1990.The author analyzes clinical ethics

by looking at "consulting, teaching,watching, and witnessing." "Theproblem of legitimation of clinicalethics is discussed in terms of legal,professional and social accountabilityand authorization."

Anzia, Daniel J., and La Puma, John.Cultivating Ethics Consultation:Commentary on The Developmentof a Clinical Ethics ConsultationService in a Community Hospitalby Kenneth M. Simpson. Journal ofClinical Ethics 3 (2): 131-132,Summer 1992.Physicians Anzia and La Puma say

that the "clinical ethics consultantmust be both clinician and ethicist"and urge "a certification processbased on licensure, training, fund ofknowledge, and demonstrated skill...."Anzia, Daniel J., and La Puma, John.

Quality Care and Clinical Ethics.QRB 18(1): 21-23, January 1992.The authors discuss seven steps in

the consultation process: study thecase details, see the patient, interviewfamily or others associated with the

patient, assess and analyze data, iden-tify achievable goals, meet withpatient or surrogates and health careproviders about how to achieve goals,and finally, document the process andrecommendations in the medicalrecord.

Arnold, Robert M., and Forrow,Lachlan. Assessing Competence inClinical Ethics: Are We Measuringthe Right Behaviors? Editorial.Journal of General Internal Medi-cine 8(1): 52-54, January 1993.In assessing teaching programs in

medical schools concerned with med-ical ethics, the authors think that it isunclear how students' "ethics" casepresentations will integrate ethicsskills in routine clinical practice. Theyurge study of the knowledge, attitudes,and skills that constitute competencein ethics so that consultation methodscan be measured.

Barnard, David. Reflections of aReluctant Clinical Ethicist: EthicsConsultation and the Collapse ofCritical Distance. TheoreticalMedicine 13 (1): 15-22, March1992.

Using medical sociology for com-parison, Barnard says that sociologistshave found they can function as stu-

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dents and critics of medical practicesor as participants, but rarely as both.He suggests that ethicists may be mosteffective when not acting as "insid-ers," but as questioners of basicassumptions and values.

Baylis, Françoise E. BioethicsConsultations at the Hospital forSick Children: Initiative [and]Guidelines. HEC Forum 3 (5): 285-97, 1991.Pointing out that ethics consultants

are not moral police, Baylis describesher hospital's ethics policies. Sheexplains why she thinks that ethicscommittees are inappropriate consul-tants and describes: who should be aconsultant, when they would be uti-lized, and how a consultation wouldbe documented. The five-page guide-lines developed by her Toronto hospi-tal are included.

Brennan, Troyen A. Quality ofClinical Ethics Consultation. QRB18(1): 4-5, January 1992.In his foreword to this special issue

of QRB on consultation, Brennannotes the emerging prominence ofethics consultants. He raises questionsabout the possibility of future litiga-tion involving ethics consultants andasks how standards will be defined.

Burgess, Michael M.; Flagler,Elizabeth A.; and Dalla-Longa,Veronica. Point and Counterpoint:Should HECs Involved in CaseReview Have a Healthcare EthicsConsultant? HEC Forum 5 (3):196-204, March 1993.The authors present pros and cons

in the use of ethics consultants, as wellas discussing whether there is a requi-site level of bioethics expertise toensure that ethics consultations are

relevant to community values andlegal issues.Coughlin, Michael, and Watts, John.

A Descriptive Study of HealthcareEthics Consultants in Canada:Results of a National Survey. HECForum 5 (3): 144-64, March 1993.The authors surveyed 253 individu-

als and institutions involved in ethicsconsultation in Canada, looking atdemographics, educational back-ground, time spent on ethics, institu-tional affiliations, consultation roles,research issues, and attitudes towardcertification.

Cranford, Ronald E. The Neurologistas Ethics Consultant and as aMember of the Institutional EthicsCommittee: The Neuroethicist.Neurology Clinics 7 (4): 697-713,November 1989.Cranford thinks that neurologists

are well-suited to become ethics con-sultants since they can clarify diagnos-tic data and show others how to inte-grate such information through ethicalanalysis.Dagi, Teo Forcht. Role Responsibil-

ities in Clinical Bioethics: TheDialectic of Consultation: Com-ments on the Case Presented byBarbara Springer Edwards. Journalof Clinical Ethics 1 (1): 79-82,Spring 1990.Calling the role responsibilities of

ethics consultants "complex," Dagisays that physicians may act as ethicsconsultants whether or not they con-sider themselves professional ethicistsor philosophers. He says two sets ofstandards must be met: (1) philosoph-ic sophistication and validity of theanalytic method; and (2) criteria forthe consultant: define, explain,

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respond, resolve, and teach.DeRenzo, Evan G., and Wichman,

Alison. A Pilot Project: BioethicsConsultants as Non-Voting Mem-bers of IRBs at the NationalInstitutes of Health. IRB 12 (6): 6-8, November-December 1990.Eight persons from different back-

grounds were chosen as ethics consul-tants on 11 NIH clinical research sub-panels. The authors report results of asurvey of most of the panel chairper-sons, who answered various questionsabout the effectiveness of the project,which generally was thought to behelpful and useful.Doukas, David J. The Design and Use

of the Bioethics ConsultationForm. Theoretical Medicine 13 (1):5-14, March 1992.Doukas developed a Bioethics

Consultation Form with questionsabout a patient's values and priorities,which is included with the article. Hehas found it a useful asset for ethicscommittee discussions, committeerecord keeping, and contemplation ofissues.

Downie, Jocelyn, and Sherwin, Susan.Feminist Healthcare EthicsConsultation. HEC Forum 5 (3):165-75, March 1993.The authors think that new

approaches, new techniques, newgoals, and new questions will allbecome part of ethics consultationwhen feminist ethics and feministhealthcare ethics are introduced.

Drane, James F. Should a HospitalEthicist Have Clinical Experience?Health Progress 66 (6): 60-63,August 1985.Drane notes the need for trained

medical ethicists whom he says shouldbe "an inside aide" not an "outsideexpert." He recommends "interdisci-plinary cooperation" and says institu-tional ethicists should focus on "con-crete cases" not "abstract philosophiz-ing." Staff ethicists could serve onpolicymaking committees and helpphysicians and nurses explain certaindecisions and policies to patients andfamilies.

Edens, Myra J.; Eyler, Fonda D.;Wagner, James T.; and Eitzman,Donald V. Neonatal Ethics:Development of a ConsultativeGroup. Pediatrics 86 (6): 944-49,December 1990.The authors describe a group

whose consultation services were vol-untary and whose goals were to"develop trust, encourage collabora-tion and consensus, and facilitate ethi-cal decision making" for infants. Overa period of four years, 31 consulta-tions were requested.Edinger, Walter. Which Opinion

Should a Clinical Ethicist Give:Personal Viewpoint or ProfessionalConsensus? Theoretical Medicine13(1): 23-29, March 1992.The author suggests that consul-

tants should give the consensus view,their own dissenting view, if it differs,and the arguments supporting eachview.

Edwards, Miles J., and Tolle, SusanW. Disconnecting a Ventilator atthe Request of a Patient WhoKnows He Will Then Die: TheDoctor's Anguish. Annals ofInternal Medicine 117 (3): 254-56,1 August 1992. More on theDoctor's Anguish. Letters. Annalsof Internal Medicine 119 (3): 252-

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53, 1 August 1993.Two physician ethics consultants

describe their actions and their"anguish" in helping a patient die.They write that it is not the role of theethics consultant to "actually performventilator withdrawal" as they did.Fichtner, Christopher G., and

McKenny, Gerald P. ValuesInterpretation: A New Model forHospital Ministry. Journal ofReligion and Health. 30 (2): 109-18, Summer 1991.The authors develop a model

drawn from pastoral care and moraltheology, making the chaplain aninterpreter of patient values in clinicalconsultation situations.

Fletcher, John C; White, Margo L.;and Foubert, Philip J. BiomedicalEthics and an Ethics ConsultationService at the University ofVirginia. HEC Forum 2 (2): 88-89,1990.

Saying that ethics consultations atthe University emphasize resolvingethical problems with the participa-tion of patient, family, and physician,the authors describe different types ofproblems encountered in 91 consulta-tions. They also provide an overviewof the basic medical ethics course forthe medical students.

Fletcher, John C. Needed: A BroaderView of Ethics Consultation. QRB18 (1): 12-14, January 1992.Fletcher says that ethics commit-

tees offer most ethics consultations inhealth care and are the "proper locusof accountability; the presence ofcommunity members on the commit-tee can also serve as a check and bal-ance for consultants." He thinks thatrelying on individual consultants lim-

its the pool of potential consultants;the more persons in the institution andthe community involved in promotingethical goals, the greater the chance ofattaining them.Fought, Ronald J. Ethics Consultation

Process and a Time for Decisions.HEC Forum 2 (4): 273-78, 1990.Fought describes the ethics consul-

tation process and format at St. AgnesHospital in Fond du Lac, Wisconsin,which provides patients and familieswith definitions of terms that are oftenused in discussing ethical dilemmas inhealth care, including advance direc-tives, burden/benefits principle,informed consent, and no code(DNR).

Frader, Joel E. Political andInterpersonal Aspects of EthicsConsultation. Theoretical Medicine13 (1): 31-44, March 1992.Frader urges ethics consultants to

look at hospital staff attitudes con-cerning consultations in addition totheir own authority and conflicts ofinterest, the standing of their recom-mendations, and their communica-tions skills.

Freedman, Benjamin; Weijer, Charles;and Bereza, Eugene. Nota Bene:Case Notes and Charting ofBioethical Case Consultations.HEC Forum 5 (3): 176-95, March1993.

The authors describe the prepara-tion of a clinical case consultationrecord, presenting medical modelsthat they call the classical, problem-oriented, and narrative methods. Theysuggest guidelines for constructingnotes concerning the more commonethics consultations.

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Glover, Jacqueline J.; Ozar, David T.;and Thomasma, David C.Teaching Ethics on Rounds:Ethicist as Teacher, Consultant andDecisionmaker. Theoretical Medi-cine 7 (1) 13-32, February 1986.The authors analyze the relation-

ship between teaching and consulta-tion in the clinical setting and howthese activities relate to clinical deci-sion making. They identify threepotential roles for the ethicist: teach-ing students and staff about ethicalissues, advising about the ethical partof a patient's care, and clarifyingbroad moral issues.

Jonsen, Albert R. Can an Ethicist be aConsultant? In Frontiers inMedical Ethics: Applications in aMedical Setting, ed. Virginia Aber-nethy, pp. 151-71. Cambridge,MA: Ballinger Press, 1980.In this early work, Jonsen finds

that ethics is a central part of medi-cine and that medical ethicists have anecessary role.Jonsen, Albert R. Casuistry as

Methodology in Clinical Ethics.Theoretical Medicine 12 (4): 295-307, December 1991.Jonsen argues that casuistry, which

he defines as "the exercise of pruden-tial or practical reasoning in recogni-tion of the relationship between max-ims, circumstances and topics, as wellas the relationship of paradigms toanalogous cases," can become a use-ful technique for the clinical ethicistor ethics consultant.

Kjervik, Diane K. Legal and EthicalIssues: Law and Ethics Consul-tation. Journal of ProfessionalNursing 6 (4): 193, 246, July-August 1990.

In recommending that prudentnurses use the services of an ethicsconsultant if deemed necessary,Kjervik says that such consultantscome from a variety of backgrounds.A 1985 survey of 38 ethics consultantsreported "over half held PhD degrees,three JDs, four MDs, three RNs, andeleven master's degrees. Philosophyand divinity and theology were themost frequently represented disci-plines." The author describes theirwork.

La Puma, John; Stocking, Carol B.;Darling, Cheryl M.; and Siegler,Mark. Community Hospital EthicsConsultation: Evaluation andComparison with a UniversityHospital Service. American Journalof Medicine 92 (4): 346-51, 1992.Comments. American Journal ofMedicine 92 (4): 343-45, April1992 and 94 (1): 116, January1993.

The authors examine three aspectsof ethics consultation: the clinicalquestions asked, the consultation'shelpfulness, and the differencesbetween community and universityhospitals. During the two-year study,104 consultations were conducted atthe community hospital, with 86 per-cent of them seen as helpful to therequesting physician.La Puma, John; Stocking, Carol B.;

Silverstein, Marc D.; et al. AnEthics Consultation Service in aTeaching Hospital: Utilization andEvaluation. Journal of the Amer-ican Medical Association 260 (6):808-11, 12 August 1988.The ethics consultation service

received 51 requests over 12 months.The requesting physician in 36 cases(71 percent) found the consultation

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"very important" in patient manage-ment, in clarifying issues, or in learn-ing about medical ethics. The authorsconclude that ethics consultations per-formed by trained physician-ethicistsprovide useful, clinically acceptableassistance in a teaching hospital.La Puma, John, and Schiedermayer,

David L. Ethics Consultation:Skills, Roles and Training. Annalsof Internal Medicine 114 (2): 155-60, 15 January 1991.The authors hold that the physi-

cian-ethicist consultant's special clini-cal skills correlate with his or her rolesas professional colleague, negotiator,patient and physician advocate, casemanager, and educator. Trainingshould include substantial patient careexperience, instruction in health carelaw and moral reasoning, and prepa-ration in medical humanism.

La Puma, John, and Priest, E. Rush.Medical Staff Privileges for EthicsConsultants: An InstitutionalModel. QRB 18 (1): 17-20,January 1992.Saying that "no advanced degree

by itself (whether MD, MS, or PhD)equips participants with the roles andskills of a clinical ethics consultant,"the authors offer their criteria for aclinical ethics consultant.

Loewy, Erich H. Ethics Consultationand Ethics Committees. HECForum 2 (6): 351-59, 1990.Loewy thinks that conflict between

patients and physicians or betweenmembers of the health care team aregenerally the reason that ethics con-sultants are called. He discusses waysin which ethics committees and con-sultants can relate and offers a modelfor reaching consensus.

Lyons-Loftus, Gregory T. What Is aClinical Ethicist? TheoreticalMedicine 7 (1): 41-45, February1986.

Dr. Lyons-Loftus sees the clinicalethicist as providing value clarifica-tions, but no value judgments or pri-orities; assuming a role as a patientcounselor could damage the primaryphysician-patient relationship.Maciunas, Kristina, and Moss, Alvin

H. Learning the Patient's Narrativeto Determine Decision-MakingCapacity: The Role of EthicsConsultation. Journal of ClinicalEthics 3 (4): 287-89, Winter 1992.The authors present a case of a 32-

year-old man whose decision-makingcapacity was questioned and say thatit demonstrates the need to know thepatient's "narrative."

Marsh, Frank H. Why PhysiciansShould Not Do Ethics Consults.Theoretical Medicine 13 (3): 285-92, September 1992.Marsh thinks that the clinician's

mode of thinking as a physician giveshim "little room to maneuver as anobjective and detached third-partyethics consultant." Habits and colle-giality are important to a physician,according to Marsh, who thinks thatthese practices lessen objectivity. Healso points out that the practice ofdefensive medicine, in the current liti-gious environment, is now central topatient management.

McCullough, Laurence B. LayingClinical Ethics Open. Journal ofMedicine and Philosophy 18 (1): 1-8, February 1993.McCullough opposes the view that

physician ethicists are more effectivethan "professional ethicists" who

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have spent years in learning, teaching,and conducting research in clinicalethics. He thinks that physicians willtend to reinforce the status quo andbecome part of the problem instead ofthe solution.

Melley, Christopher D. ThePhilosopher in the Health CareSetting: Objections and Replies.HEC Forum 4 (4): 237-54, 1992.Melley advocates including philo-

sophers in the health care setting andsays the bioethics movement necessi-tates a new type of professional whois a philosopher and a scientist ormedical practitioner; that those whoare only one or the other are "severe-ly limited."Moreno, Jonathan D. Call Me

Doctor: Confessions of a HospitalPhilosopher. Journal of MedicalHumanities 12 (4): 183-96, Winter1991.

Writing autobiographically, Mor-eno raises questions about the contri-bution of philosophy to the clinicalsetting and about the implications forphilosophy. He says "philosopherscan occupy a certain moral highground, the same high ground thattheologians used to be able to claimbefore our hopelessly pluralistic valuesystem began to undermine theirclaim to voice a moral consensus."

Moreno, Jonathan D. EthicsConsultation as Moral Engage-ment. Bioethics 5 (1): 44-56,January 1991.Moreno notes the complexity of

moral decision making and says that a"substantial reconstruction of thenotion of clinical ethics and of ourunderstanding of the ethics consultan-t's role" is required. He recommends

that the ethicist should: (1) be a skilledparticipant-observer, (2) understandthe dynamics of small group behavior,and (3) be a competent mediator.Orr, Robert D., and Moon, Eliot.

Effectiveness of an Ethics Consul-tation Service. Journal of FamilyPractice 36 (1): 49-53, January1993.The authors collected data from the

first year of an ethics consultation ser-vice at Loma Linda University Schoolof Medicine. Consultations werefound to clarify ethical issues, educatethe health care givers, and increaseconfidence in decisions in 90 percentof the 46 cases studied. Direct medicalchanges in patient management weremade in 36 percent of cases.Orr, Robert D., and Moss, Robert.

The Family Physician and Ethics atthe Bedside. Journal of theAmerican Board of Family Practice6 (1): 49-54, January-February1993. Comment in: Journal of theAmerican Board of Family Practice6 (1): 80-82, January-February1993.

Family physicians who havereceived training in medical ethics andhealth care law are "uniquely qualifiedto serve as ethics consultants," accord-ing to Orr and Moss. They seeimproved physician-patient relation-ships and an enhanced decision mak-ing process resulting from clinical con-sultants in ethics.

Pellegrino, Edmund D. Clinical Ethics:Biomedical Ethics at the Bedside.Editorial. Journal of the AmericanMedical Association 260 (6): 837-39, 12 August 1988.Saying that clinical ethics "leaves

the calmer environs of ethical dis-

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course for the urgency, uncertainties,and emotional nexus of the bedside,"Pellegrino holds that participants aremorally accountable and that clinicalethics does not supplant formal ethi-cal analysis or theoretical ethics, butcomplements them. He hopes that theresolution of who shall consult, eitherphysician or nonphysician, will bedecided more by the capacity to func-tion effectively than by professionalidentification.

Pellegrino, Edmund D. Ethics and theMoment of Clinical Truth.Editorial. Journal of the AmericanMedical Association 239 (10): 960-61, 6 March 1978.In this early essay Pellegrino notes

a "recent resuscitation" of ethics andsuggests that "a certain constructivetension between ethicist and clinicianis essential as an antidote to the com-plaisance of too easy agreement."Pellegrino, Edmund D.; Siegler, Mark;

and Singer, Peter A. FutureDirections in Clinical Ethics.Journal of Clinical Ethics 2 (1): 5-9, 1991.The physician authors offer their

predictions for the next 20 years inthe field of clinical ethics. Raisingquestions about genetic research, theythink that new ethical responses willbecome necessary. Some standardiza-tion of educational credentials andsome certification of ethicists will benecessary, probably in the form of adegree or training certificate inbioethics. Counseling and negotiationskills will also be required, andbioethicists will become as active inpublic health and preventive medicineas in cases involving individualpatients.

Perkins, Henry S. Another EthicsConsultant Looks at Mr. B's Case:Commentary on "An EthicalDilemma." Journal of ClinicalEthics 1 (2): 126-32, Summer1990.

Perkins favors the concept of afiduciary consultant-patient relation-ship. He analyses informed consentand competency from this viewpoint.Perkins, Henry S. Clinical Ethics

Consultations: Reasons forOptimism, But Problems Exist.Journal of Clinical Ethics 3 (2):133-37, Summer 1992.Perkins discusses problems that can

affect clinical ethics cases in the hospi-tal, urging consultants to recognizethat difficult cases abound and thatthorough involvement in them is timeconsuming but worthwhile.Perkins, Henry S., and Saathoff,

Bunnie S. Impact of Medical EthicsConsultations on Physicians: AnExploratory Study. AmericanJournal of Medicine 85 (6): 761-65,December 1988.The authors report on a survey of

physician-requesters for ethics consul-tations and review patients' medicalrecords, evaluating 44 consultations.Fourteen consultations identified pre-viously unrecognized ethical issues,and 18 consultations changed patientmanagement.

Phillips, Donald M. Ethics Research:Ethics Consultations and Changesin Bioethics Come Under Scrutiny.Hospital Ethics 8 (5): 1-4,September-October 1992.Phillips reports on a July 1992

health law and ethics meeting inToronto where Dr. Mark Siegler pre-dicted changes for biomedical ethics

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including the development of anempirical research base, and theacquisition of counseling and negotia-tion skills that will enhance the deci-sion-making process. The article alsocalls attention to a fee-for-serviceethics consultation/education serviceheaded by an attorney specializing inmedical ethics.

Purtilo, Ruth B. Ethics Consultationsin the Hospital. New EnglandJournal of Medicine 311 (15): 983-86, 11 October 1984.Purtilo questions the term 'consul-

tant' and holds that "under no cir-cumstances would the outcome of anethics consultation be that the ethicistbecame the primary care giver orassumed ongoing responsibility forthe clinical management of a case."She also raises questions about legalimplications, remuneration, obtainingpertinent case information (includingaccess to patient records), and staffprivileges.Rodeheffer, Jane Kelley. Practical

Reasoning in Medicine and theRise of Clinical Ethics. Journal ofClinical Ethics 1 (3): 187-92, 1990.Philosopher Rodeheffer writes that

medical students are trained in moralvirtues, a "habituation into thevirtues," as well as Aristotelian prac-tical rationality, "means-end reason-ing." She says that to be effective, anethicist must be able to clarify theissues for physician, patient, and fam-ily. She concludes that "where there isno shared agreement on goods, therecan be no practically rational deliber-ation in clinical medicine."

Ross, Judith Wilson. Case Consul-tation: The Committee or theClinical Consultant? HEC Forum 2

(5): 289-98, 1990.Ross thinks that ethics committees,

not consultants, should be responsiblefor case consultations. While consulta-tion with an individual consultant maybe efficient and thus economic, shestates that "ethics and moral discus-sion lie within the community" andthat committees are part of the hospi-tal community, being "responsive tomultidimensional/interdisciplinaryunderstanding." She thinks the con-sultant has a more limited and narrowrole.

Schiedermayer, David L.; La Puma,John; and Miles, Steven H. EthicsConsultations Masking EconomicDilemmas in Patient Care. Archivesof Internal Medicine 149 (6): 1303-5, June 1989.Ethics consultants who are asked to

analyze and help resolve economicproblems in a patient's care shouldattempt to do so, according to theauthors. Ethics and economics over-lap, and consultants can act as patientadvocates.

Scofield, Giles R. The Problems of theImpaired Clinical Ethicist. QRB 18(1): 26-32, January 1992.Maintaining that clinical ethicists

"usually operate without the sort ofsupervision or accountability imposedon other health care workers,"Scofield says impairment may be indi-cated by missed meetings and assign-ments. Consultants who have conflictsof interest—duty to the institution andto the patient—may be unable to makeindependent judgments. He discusseshow an institution may respond.Self, Donnie J., and Skeel, Joy D. Legal

Liability and Clinical EthicsConsultations: Practical and

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Philosophical Considerations. InMedical Ethics: A Guide for HealthProfessionals, ed. John F. Monagleand David C. Thomasma, pp. 408-16. Rockville, MD: AspenPublishers, 1988.Self and Skeel discuss general clini-

cal conditions for medical malpracticeby an ethicist in a litigious society.They indicate that they think the dan-ger of risk is real, recommending thatall ethics consultants obtain profes-sional liability insurance.Self, Donnie J., and Skeel, Joy D. A

Study of the Foundations of EthicalDecisionmaking of Clinical MedicalEthicists. Theoretical Medicine 12(2): 117-27, June 1991.The authors report a study of 52

clinical medical ethicists indicatingthat most believe value judgments arecapable of being true or false and are"expressions of moral requirements...emanating from an external valuestructure or moral order in theworld."

Siegler, Mark. Defining the Goals ofEthics Consultations: A NecessaryStep for Improving Quality. QRB18 (1): 15-16, January 1992.Saying that "ethics consultants,

like all other consultants, shouldassist the patient, family, and primaryphysician by offering suggestions thatimprove the processes and outcomesof patient care," Siegler urges the pub-lication of more reports on the evalu-ation and outcome of ethics consulta-tion.

Siegler, Mark; Pellegrino, Edmund D.;and Singer, Peter A. ClinicalMedical Ethics. Journal of ClinicalEthics 1 (1): 5-9, Spring 1990.The authors assess the past and

future of the field of clinical medicalethics, saying that the central focus ofclinical ethics is "individual patient-physician decision making."Simpson, Kenneth H. The

Development of a Clinical EthicsConsultation Service in aCommunity Hospital. Journal ofClinical Ethics 3 (2): 124-30,Summer 1992.Simpson describes both his training

as an ethicist and the ethics consulta-tion model that he developed workingwith his hospital's legal counsel.Ethical issues raised in 59 consulta-tions are presented.Singer, Peter A.; Pellegrino, Edmund

P.; and Siegler, Mark. EthicsCommittees and Consultants.Journal of Clinical Ethics 1 (4):263-67, Winter 1990.The authors say that ethics commit-

tees and consultants offer differentapproaches to the goal of improvingboth care and outcomes. They discusseducation, policy development, andcase consultation, going on to say thata consultant should be both ethicallyand clinically competent. Finally, theypresent the advantages and disadvan-tages of committees and consultants,an evaluation of their services, andquestions concerning their futureroles.

Skeel, Joy D. Issues in Clinical EthicsConsultation: An Introduction.Theoretical Medicine 13 (1): 1-3,March 1992.Noting the rapid growth of

bioethics consultation, Skeel recom-mends reflection on and examinationof the possible pitfalls that lie ahead,since the issues raised are complex.

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Skeel, Joy D., and Self, Donnie J. AnAnalysis of Ethics Consultation inthe Clinical Setting. TheoreticalMedicine 10 (4): 289-99, December1989The authors look at issues related

to aggressiveness of treatment,informed consent, alternative treat-ment, and communication with thepatient. They discuss the role of theconsultant, including the risks andbenefits of formal ethics consulta-tions.

Spicker, Stuart F., and Kushner,Thomasine. HECs and Consul-tation. Editorial. HEC Forum 2 (2):71-73, 1990.Spicker and Kushner use the term

'consultation' to describe case analy-ses where an ethics committee hasappointed a representative "to deter-mine the nature of the ethical problemor conflict beyond the purview of theentire committee." They find thatsuch consultations are increasing andcan be more useful than discussions ofan entire ethics committee.

Stoddard, James. The Future of EthicsConsultation in the Kansas CityArea. Midwest Medical EthicsNewsletter 7 (2 & 3): 12-16,Spring-Summer 1991.Stoddard reviews the literature and

indicates that the future of consultantsin his geographic area is uncertain,based on a survey he conducted.Ethics committee members were morereceptive to using consultants thanwere hospital CEOs, but expressedconcerns about the consultant takingover the decision-making process andinterfering with the physician-patientrelationship.Swenson, Michael D., and Miller,

Ronald B. Ethics Case Review inHealth Care Institutions: Commit-tees, Consultants, or Teams?Archives of Internal Medicine 152(4): 694-97, April 1992.Saying that the need for consulta-

tions will increase and that consultantswill be an important resource forphysicians, patients, families, andother members of the health careteam, the authors present three modelsfor consultation and indicate theadvantages and disadvantages of each.Swenson and Miller prefer the use of asmall team of physicians from theethics committee who have clinicalexpertise and experience with moraldiscourse in the clinical setting.Thomasma, David C. Hospitals and

Moral Imperatives: Ethics Consultsat a University Medical Center.Cambridge Quarterly of HealthcareEthics 1 (3): 217-22, Summer 1992.Thomasma's first university con-

sulting service began in 1973 to pro-vide a "presence of philosophers in theclinical context." He discusses the roleof ethics consultation services in insti-tutional education, mission, con-science, and benefit to research design;concluding that consultants shoulddevelop standards for the field.Thomasma, David C. Why Philoso-

phers Should Offer EthicsConsultations. Theoretical Medicine12(2): 129-40, June 1991.Arguing that philosophers ought to

offer ethics consultations, Thomasmasays the position requires a view ofclinical medical ethics arising frommedical practice, not just a generalethical application. He notes that allconsultations take the form of recom-mendations that can be accepted or

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rejected; philosophers do not makedecisions in the clinical setting.Tulsky, James A., and Lo, Bernard.

Ethics Consultation: Time to Focuson Patients. Editorial. AmericanJournal of Medicine 92 (4): 343-45, April 1992. Comments inAmerican Journal of Medicine 92(4): 346-51, April 1992, and 94(1): 116, January 1993.The authors ask whether ethics

consultations are beneficial andwhether the patient is "lost in theprocess." They think that it is "pre-mature to promote widespread dis-semination [of consultations]" untilthey are "subjected to rigorous evalu-ation" regarding safety and effective-ness.

Walker, Margaret Urban. KeepingMoral Space Open: New Images ofEthics Consulting. Hastings CenterReport 23 (2): 33-40, March-April1993.

Saying that the ethicist is "neither avirtuoso of moral theory nor a moralvirtuoso, but is one among other par-ticipants in a process," Walker thinksof consultations as negotiations, notas puzzle solutions or answers. She

asks that one think of a consultingethicist as both an architect with toolsand training who has a sense of"moral space" and as a mediator whohelps achieve fruitful resolution.Wildes, Kevin Wm. The Priesthood of

Bioethics and the Return ofCasuistry. Journal of Medicine andPhilosophy 18(1): 33-49, February1993.

Wildes opposes casuistry as amodel for moral reasoning in clinicalethics since it requires shared moralvalues and structures for moralauthority. Without common valuesand rankings "there will be manycasuistries."

Zaner, Richard M. Voices and Time:The Venture of Clinical Ethics.Journal of Medicine and Philosophy18 (1): 9-31, February 1993.Zaner describes different kinds of

ethical consultants. He holds that allrelationships concern the ethicist, whosuggests a basic moral decision-mak-ing framework in an effort to helppatients, physicians, and families. Theconsultant facilitates decisions, butdoes not make them.

III. REFERENCES/ADDITIONAL READINGS

Fletcher, John C. The Goals of EthicsConsultation. Biolaw 2 (2): 36-37,1986.

Fowler, Marsha D. Reflections onEthics Consultation in Critical CareSettings. Critical Care NursingClinics of North America 2 (3): 431-35, September 1990.

Fowler, Marsha D. The Role of theClinical Ethicist. Heart and Lung

15 (3): 318-19, 1986.

Gramelspacher, Gregory P. Institution-al Ethics Committees and CaseConsultation: Is There a Role? Issuesin Law and Medicine 7 (1): 72-82,Summer 1991.

Grunfeld, Gerson B. Non-MD EthicsConsultants? Letter. Journal ofClinical Ethics 1 (4): 325-26, Winter1990.

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Joint Commission on Accreditation forHealthcare Organizations. 1992Accreditation Manual for Hospitals.Volume 1, Standards. Oakbrook, IL:Joint Commission, 1992.

Nolen, Anita L., and Coutts, MaryCarrington. International Direc-tory of Bioethics Organizations.Washington, DC: National Refer-ence Center for Bioethics Liter-ature, Kennedy Institute of Ethics,1993. 371 p.

O'Connell, Laurence J. An EmergingField Examines Itself. [Book reviewof Ethics Consultation in HealthCare edited by John C. Fletcher,Norman Quist, and Albert R.Jonsen.] Medical Humanities Re-view 5 (1): 68-71, January 1991.

Pyeritz, Reed E. Must EthicsConsultants See Patients? Letter.Journal of Clinical Ethics 1 (2):168-69, Summer 1990.

Pruzinsky, T. Definition and Evalu-ation of Biomedical Ethics Consulta-

tions: An Annotated Bibliography.BioLaw 2 (29) Special Sections:S:221-29, August 1989.

Self, Donnie J., and Skeel, Joy D.Potential Roles of the MedicalEthicist in the Clinical Setting.Theoretical Medicine 7 (1): 33-39,February 1986.

Self, Donnie J., and Skeel, Joy D.Professional Liability (Malpractice)Coverage of Humanist ScholarsFunctioning as Clinical MedicalEthicists. Journal of Medical Hu-manities and Bioethics 9 (2): 101-9,1988.

Skeel, Joy D. Varieties of EthicsConsultation. [Book review of Ethicsat the Bedside edited by CharlesCulver.] Medical Humanities Review6(1): 27-30, January 1992.

Siegler, Mark, and Singer, Peter A.Clinical Ethics Consultation:Godsend or "God Squad". Amer-ican Journal of Medicine 85 (6):759-60, December 1988.

SCOPE NOTE SERIES

The SCOPE NOTE Series is intendedto present a current overview ofissues and viewpoints related to spe-cific topics in biomedical ethics. It isnot designed as a comprehensivereview, but rather offers immediatereference to facts, opinion, and legalprecedents (if applicable) for schol-ars, journalists, medical and legalpractitioners, students, and interest-ed laypersons.

All sources cited in SCOPE NOTES areincluded in the collection of the Na-tional Reference Center for Bioethics

Literature, and may be obtainedthrough its document delivery service(subject to copyright law). Updatesof topics covered in the SCOPENOTE Series may be obtained bysearching the BIOETHICSLINEdatabase (accessed through theNational Library of Medicine'sMEDLARS system); or BIOETHICS-LINE Plus, Silver Platter's CD-ROMversion of the database; or by callingthe National Reference Center forBioethics Literature.

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KENNEDY INSTITUTE OF ETHICS JOURNAL · DECEMBER 1993

As noted in the list below, some of theScope Notes have appeared in theKennedy Institute of Ethics Journal(KIEJ); each is published separatelyas a reprint and is available for $5.00each prepaid from: National Refer-ence Center for Bioethics Literature,Kennedy Institute of Ethics, George-town University, Washington, DC20057-1065, or telephone 1-800-MED-ETHX (toll-free) or 1-202-687-6738. (Add $3 each for airmailoutside North America.) Series editor:Doris Mueller Goldstein. The follow-ing SCOPE NOTES are presentlyavailable:

No. 1. Dangerousness: Prediction andLegal Status. September 1982. 5 p.

No. 2. Living Wills and Durable Pow-ers of Attorney: AdvanceDirective Legislation and Issues.Revised April 1992. 19 p.

No. 3. Ethics Committees in Hospitals.(KIEJ 2 (3): 285-306, September1992). Revised September 1992.17 p.

No. 4. Diagnosis Related Groups(DRGs) and the Prospective Pay-ment System: Forecasting SocialImplications. June 1984. lip.

No. 5. Baby Fae: Ethical Issues Sur-rounding Cross-Species OrganTransplantation. January 1985. 19 p.

No. 6. Surrogate Motherhood: Ethicaland Legal Issues. Revised January1988.11 p.

No. 7. Withholding or WithdrawingNutrition or Hydration. RevisedMarch 1992. 17 p.

No. 8. AIDS: Law, Ethics, and PublicPolicy. April 1988. 12 p. Addendum,1988-midl991.20p.

No. 9. Bioethics Audiovisuals: 1982 toPresent. September 1988. 12 p.

No. 10. Ethical Issues in In VitroFertilization. December 1988. 12 p.

No. 11. Neonatal Intensive Care. May1989. 10 p.

No. 12. Anencephalic Infants as Po-tential Organ Sources: Ethical andLegal Issues. June 1989. lip.

No. 13. The Aged and Allocation ofHealth Care Resources. RevisedJanuary 1993. 13 p.

No. 14. Maternal-Fetal Conflict: Legaland Ethical Issues. August 1990.14 p.

No. 15. Basic Resources in Bioethics.(KIEJ 1 (1): 75-90, March 1991).September 1991. 14 p.

No. 16. Teaching Ethics in the HealthCare Setting: Survey of the Liter-ature and Sample Syllabus. (Part I,KIEJ 1 (2): 171-85, June 1991; PartII, KIEJ 1 (3): 263-73, September1991). September 1991. 19 p.

No. 17. The Human Genome Project.(KIEJ 1 (4): 347-62, December1991). December 1991. 11 p.

No. 18. Active Euthanasia and Assis-ted Suicide. (KIEJ 2 (1): 79-100,March 1992). March 1992. 17 p.

No. 19. Nursing Ethics. (KIEJ 2 (2): 177-98, June 1992). June 1992. 18 p.

No. 20. A Right to Health Care. (KIEJ2 (4): 389-405, December 1992).January 1993. 13 p.

No. 21. Fetal Tissue Research. (KIEJ 3(1): 81-101, March 1993). March1993.15 p.

No. 22. Genetic Testing and GeneticScreening. (KIEJ 3 (3): 333-354, Sep-tember 1993). September 1993. 17 p.

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