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Ethics Consultation: A Practical Guide
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John La Puma and David Schiedermayer. 234 pages. Boston: Jones and Bartlett; 1994. $29.95.
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The Health Care Ethics Consultant
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Francoise E. Baylis; ed. 209 pages. Totowa, New Jersey: Humana Press; 1994. $44.50.
Many persons working in clinical ethics will welcome these books. Read together, they illustrate many views and, thus, the range of the burgeoning discussion about what is at stake in clinical ethics consultation.
La Puma and Schiedermayer's book consolidates their previous efforts and provides their outline of the requirements, skills, and procedures needed for clinical ethics consultation. It has, however, several shortcomings. Although a full third of their text is a review of 25 cases, little clinical detail, moral reasoning, and ethical analysis is provided. The authors state that such detail would make the book "overly long"; this is unfortunate because it is precisely such details that are needed to understand their approach. Thus, beyond a brief reference to "modern medical casuistry," little explanation is given of the basis for the authors' presentation, procedures, and conclusions.
Whether "casuistic" or not, their stated method—"solving cases by considering the clinical circumstances"—suggests a "symptomatic" approach in which the ethics consultant gathers medical and social information and makes a recommendation. These recommendations are said to be "ethical," although what distinguishes them from, say, medical recommendations remains difficult to determine from the text.
The central flaw in the text is the lack of an account of the relation between clinical circumstances and what is to be considered the subject of ethical analysis, and how this is determined in particular situations. Without this, readers have little guidance to help them identify ethical issues in particular cases or to differentiate ethical from medical, social, or economic issues. The problem is that such differences are the primary basis for the book. Given its subtitle, A Practical Guide, this guidance is necessary to support the authors' claim that "teaching ethical decision-making to physicians is the central goal of ethics consultation"[53].
From a different vantage point, The Health Care Ethics Consultant documents the efforts of persons from different disciplines and the ways in which their ideas interact in their commitment to examining what it means to be an ethics consultant. In the penultimate chapter of this important text, Baylis undertakes the difficult task of listing the knowledge and abilities one needs to pursue ethical judgments about crucial moral issues in health care. Concerns about facilitation of ethics consultation as well as certification, education, placement, and support of ethics consultants are addressed by her colleagues in adjacent chapters.
Although Baylis has profiled constituent elements important to ethics consultation, accounts of how persons involved in health care decision making understand the ethics of their own deliberations and judgments are still lacking. Indeed, in his chapter on the avocation and working conditions of ethics consultants, Benjamin Freedman raises this issue by noting the "failure in the internal morality of describing internal moralities" when addressing what an ethics consultant is supposed to do. To talk about character traits—as Baylis does—as crucial requirements for an ethics consultant is to acknowledge that some account of these internal moralities is needed. Yet, Baylis does not bring into focus questions about what might compel such a person to be concerned about the traits and other aspects of internal morality. That compulsion seems to be critical for one who is actually willing to account for those moral features encountered in clinical health care settings. Because Baylis and her colleagues have yet to account for the central commitments that underlie their proposals, many issues await further discussion.
Both books can be praised and recommended because they eventually yield to this question—how do we discern the specifically moral complexities of judgment in health care settings? This is the critical question for understanding what is at stake in clinical ethics consultation.
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