Ethics Consultation: from Theory to Practice

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In the UK it would now be considered extraordinary to conduct research without consulting a research ethics committee. Yet clinical ethics consultation—arrangements for seeking advice about difficult questions of values in clinical practice—is almost unknown in this country. Despite the longstanding custom of consulting expert colleagues on difficult clinical issues, the idea seems strange to many. This is not so in the United States, where clinical ethics consultation services are well established. The conduct of such services is the subject of this book. The need for ethics consultation is taken as axiomatic, and the book covers a wide range of issues about the role and conduct of these services. What is the purpose of ethics consultation? Is it to clarify the issues in a particular case (a traditional role for moral philosophers), to facilitate decision-making for those involved, to help them communicate and resolve problems in personal relationships, or to offer an ‘expert opinion’? If the last, is this merely a matter of technical skill, or must practitioners also have a particular moral education and quality of moral character? Should ethics consultation be offered by individuals or by a committee? Should there be a formal system of certification for ethics consultants, as with other specialists? From what perspective does one offer ethical advice in a culturally and morally pluralistic society? How should such services be organized, and what support do they require? The United States is a very different culture from our own, but there are issues here for the UK. The rational analysis of ethical problems is as much an intellectual skill as clinical diagnosis, and training in this skill now forms part of the undergraduate curriculum of most UK medical schools. It does not seem unreasonable therefore that, faced with a particularly tricky ethical problem, a doctor should seek the advice of someone who has paid particular attention to learning this skill, any more than it is odd that I, as a general practitioner, should ask a cardiologist for help with a particularly recalcitrant case of hypertension. When faced with a tricky ethical problem, as with a clinical dilemma, most doctors will naturally discuss it with colleagues, but arrangements for doing this in the UK tend to be informal and unstructured. Might more formal structures lead to better decisions? Clinical work places tremendous psychological pressure on practitioners, and our culture does not always provide satisfactory mechanisms for dealing with these. Dinniss (BMJ 1999; 319: 929) has discussed the phenomenon whereby, when doctors meet at the dinner table, they are soon exchanging horrific stories about their medical experiences—a sort of catharsis, he judges, to cope with the emotional and psychological pressures. Among these, along with death and suffering, are conflicts of values, where a decision has to be made and all the options are wrong. The idea that doctors are omniscient, invulnerable superbeings is no longer dominant in our society. Yet paradoxically expectations of a perfect standard of service have risen, fuelled by political pressures, league tables and organizations promoting patients' rights. In this climate a more formal system for seeking help with difficult ethical problems might not only protect patients but also support doctors. In their book, Aulisio and his co-authors offer a good insight into how such systems work in practice. For the UK culture and healthcare system they would have to be very different, but the observations recorded here deserve close study by anyone who contemplates setting up a referral system for medical staff facing ethical dilemmas.