Introduction: The Journal of Clinical Ethics, the MacLean Center, and the Future of Clinical Ethics.

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Previous articleNext article FreeIntroductionIntroduction: The Journal of Clinical Ethics, the MacLean Center, and the Future of Clinical EthicsPeter AngelosPeter Angelos Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreBeginning with the current issue, and after 33 years, the publication of The Journal of Clinical Ethics (JCE) has moved from the capable hands of founding publisher and executive editor Norman Quist to the University of Chicago Press, and it is now published on behalf of the MacLean Center for Clinical Medical Ethics. The MacLean Center was founded in 1983 by Mark Siegler with the generous support of his patient Dorothy J. MacLean and her family. The MacLean Center was the first ethics center to focus squarely on ethical issues at the bedside. It is not surprising that as one reads through early issues of JCE, Mark Siegler and many of his colleagues from the MacLean Center were regular contributors. As the scope of JCE has expanded over the years, so has the scope of inquiry of the faculty and fellows of the MacLean Center.A Reflection on the Journey in Clinical EthicsAs I assume the position of director of the MacLean Center and stewardship of JCE, I have been reflecting on the journey and the future of clinical ethics. Thirty-eight years ago, I entered graduate school to begin doctoral studies in philosophy. It was a big change for me after spending the prior two years in medical school in the traditional preclinical medical curriculum. For those who have not experienced how medical school courses were taught in the first two years back then, most of the day was spent in hours of lectures in anatomy, physiology, biochemistry, histology, pathophysiology, and so on. Most of the time outside of the lecture hall was spent in anatomy labs or other labs learning what the structures look like and memorizing large lists of essential facts. After two years of such a rigorous medical curriculum, the graduate curriculum in philosophy was diametrically different. Although equally intellectually rigorous, graduate studies in philosophy challenged a different part of my brain. Through the talents of many philosophy professors, I explored topics in metaphysics, epistemology, and ethics. Many of these courses were designed to help students think about the world differently. The life of the mind, as opposed to solutions of practical problems, was emphasized.As I sought to find a value in my time studying philosophy, it was not surprising that I gravitated to applied ethics, since I believed that medical ethics would be most applicable to my ultimate desire to become a practicing physician. What I was not fully aware of at that time was the shift in the theoretical analysis of ethical problems in medicine toward a more practical application of ethical analysis to try to solve clinical medical problems. Only many years later did I recognize the impact of this practical turn in medical ethics. Rather than focusing so much on the analysis of concepts of health and disease (that is, questions such as “How do we define illness?”), the practical shift in ethics was a move to make ethical analysis helpful in answering what to do for a specific patient. Clinical ethics was the term applied to the move from theoretical ethical issues to the “bedside” issues of what to do for a specific patient. It was to fill the void in this new area of applied ethics scholarship that JCE was started.The Novelty of Clinical EthicsIn the spring of 1990, volume 1, issue 1 of JCE was published. This new journal was novel in its unabashed focus on the ethical issues that arise in the care of patients. JCE was focused not on scholarly work in “armchair ethics” (i.e., the theoretical exploration of ethical views), but rather on the application of ethical inquiry to solve problems “at the bedside” to help clinicians and patients. As editor in chief, Edmund G. Howe wrote in 1990, “The journal should have two goals: to provide state-of-the-art information to front-line practitioners and to advance the field.”1The novelty of this approach in 1990 ought not be taken for granted. Although ethics was a central area of philosophical inquiry, applied ethics was, in many philosophy departments, considered to be too practical and pragmatic and thus not amenable to rigorous philosophical analysis. JCE sought to elevate the ethical issues faced by physicians and patients to a new level of discourse where thoughtful people could learn from the analyses of others.What Clinical Ethics WasIn the early days of clinical medical ethics, the primary focus of attention was the clinical encounter between the doctor and the patient. Certainly, many patients, especially near the end of their lives, were not able to participate in decision-making with physicians. As a result, it was immediately apparent that the attention of clinical medical ethics had to include not only the patient and the physician but also the family or surrogates to make decisions for patients when the patients were not able to do so themselves.Some selected titles from the early volumes of JCE make clear the journal’s attention to the ethical dimensions of the clinical encounter. Jeffry R. Botkin wrote “Delivery Room Decisions for Tiny Infants: An Ethical Analysis,”2 and Susan S. Braithwaite and colleagues wrote “The Ethics of Surreptitious Diagnostics for Factitious Hypoglycemia,”3 just to name two of many early examples. These articles explored ethical topics in the actual care of patients and were designed to help clinicians think about them more clearly and thus improve patient care. As one looks back at many of these early papers in JCE, one sees a common thread in identifying a set of challenging patient care decisions and recasting the issues raised as ethical issues. These many thoughtful early attempts at defining and unpacking “tough cases” as ethically challenging were instrumental in leading scholarship and establishing a method of analyses in clinical medical ethics.Over time, JCE also became an important place to publish empirical research that helped to inform the ethical issues arising in caring for many patients. For example, Janet M. Teno and colleagues wrote “Do Formal Advance Directives Affect Resuscitation Decisions and the Use of Resources for Seriously Ill Patients?”4 and Lawrence J. Schneiderman and colleagues wrote “Attitudes of Seriously Ill Patients toward Treatment That Involves High Costs and Burdens on Others,”5 both in 1994. Although these and other empirical studies did not use evidence to answer what was the “right” thing to do, they nevertheless clarified, and sometimes challenged, many of the assumptions about how patients and their surrogates actually made medical decisions.Early on, it became clear that clinical ethics could not be focused solely on physicians and patients/surrogates. In fact, there were many other “clinicians” involved in the care of patients. Nurses, therapists, medical assistants, social workers, ethics consultants, chaplains, and others interacted in meaningful ways with patients. Thus, the scope of inquiry of clinical ethics necessarily had to include these many other care providers who were involved with patients and part of the “clinical” team.Over time, it was also evident that clinical ethics could not focus solely on what happened in the patient’s room with the clinical team. Whether in the inpatient or outpatient setting, patients, families/surrogates, and clinicians were always interacting within a healthcare delivery environment and system that had a powerful impact on care: how decisions were made and who made them. Consequently, it became clear that questions of health policy were also frequently central to clinical medical ethics, and the scope of the field expanded accordingly.Most commentators in clinical ethics would argue that societal issues are also central to the field of clinical ethics. If anyone were to doubt this assertion, the events of the last two and a half years as the world has responded to the COVID pandemic have clearly shown that patients are cared for within individual societies, and the political and social issues that impact public policy also can dramatically impact the care of individual patients. Although years ago many clinicians who worked in resource-rich environments would have argued that rationing and other challenging decisions about allocating scarce resources were not central to clinical ethics (except perhaps in organ transplantation), we now all clearly see that the decisions about how we allocate resources are important in all societies and thus central to the concerns of clinical ethics.Contemporary Perspective on Clinical EthicsIn view of the broadening scope of clinical medical ethics over the past several decades, one can appropriately ask where the future of clinical ethics analysis is headed. Although none of us are good at predicting the future, many signs suggest that the scope of clinical ethics will continue to expand in response to “hard questions” and societal changes. Central to the future of clinical ethics will be not only a renewed engagement with some long-standing topics but also an openness to recognizing and exploring new territory and, in some instances, to navigating territory we have missed:1. How does racial and gender bias impact patient care?2. How can medicine overcome years of structural racism?3. How can disparities in access and outcomes be mitigated?4. How does the organization of a health system encourage or discourage meaningful interactions between clinicians and patients?5. In what ways does the country or clinical environment in which care is rendered affect the decisions that patients and clinicians make?6. How ought decision-making for individual patients be influenced by global climate change?The list above is not exhaustive but representative; it hints at the broad range of questions that scholarship and practice in clinical ethics must attend to in the future. All the issues noted above (and certainly many others) may be conceptualized in the realm of clinical ethics insofar as the decisions made (or deferred) will impact the care and outcomes of individual patients. Clinical ethics is about what ought to be done. Thus, although a purely theoretical analysis of gender bias, for example, has value, the extent to which the analysis affects individual patients and the decisions that are made by and on behalf of individual patients and families makes these topics central to clinical ethics.The Compelling Question of Clinical EthicsThe contemporary practice of medicine in complex systems within numerous societies in this interconnected world that we now live in requires us to adopt a more expansive view of clinical medical ethics than early proponents of the field might have considered. We are challenged to focus on how the decisions we make on multiple levels of healthcare impact the outcomes of patients. The goal of clinical ethics ought to be the improvement of the care of patients regardless of where among the many levels of a system the changes are being made.In the Summer 2015 issue of JCE, editor in chief Edmund G. Howe wrote the first of an ongoing series of commentaries entitled “At the Bedside.”6 This regular column of JCE that continues today exemplifies the central focus amid the large set of topics appropriately within the field of clinical ethics—namely, those items that have an impact on the patient.The MacLean Center and The Journal of Clinical EthicsHow will the acquisition of JCE by the University of Chicago Press and the new partnership with the MacLean Center for Clinical Medical Ethics affect the journal? I am hopeful that this collaboration will lead to significant advantages on both sides. We are very fortunate that Edmund G. Howe and Norman Quist will continue their central involvement in the journal. The high journalistic standards of double-blinded review of manuscripts will allow the editors and editorial board to continue to actively engage with authors to bring both important cases and analytical and empirical studies in the broad field of clinical ethics to the readers of JCE. Over the ensuing issues, readers will see changes in the editorial board, for example, as I discuss with my colleagues how to take full advantage of JCE to further the work and goals of the MacLean Center. The goal of broadening and strengthening scholarship and discussion in a broad range of areas of practical significance for patient care will remain central to the mission of JCE.In the years ahead, the MacLean Center will continue its important mission of training healthcare providers in clinical medical ethics to improve patient care. It will continue to focus on increasing the scholarship in clinical medical ethics and disseminating that scholarship widely to improve outcomes for patients. Just as JCE has broadened its scope of attention as the field of clinical ethics has grown, so has the MacLean Center widened its purview to address the many ways in which patient care is affected by the multiple levels on which decisions are made. In the years to come, the MacLean Center will continue to address new problems that affect patient care not only in the United States but throughout the world. The MacLean Center faculty will strive to increasingly engage in an interdisciplinary fashion with clinicians and scholars across the globe to improve the care of patients.ConclusionsThe scope of clinical ethics has broadened over the past 35 years. In that time, JCE has expanded its purview, and the MacLean Center has similarly expanded its scope of concern. In the first issue of JCE in 1990, Mark Siegler, Edmund D. Pellegrino, and Peter A. Singer wrote, “When we review the field of clinical ethics a decade from now, we hope that the focus will have shifted from ethics courses, committees, and consultants to an understanding on the part of most physicians and medical students that ethics is an inherent and inseparable part of good clinical medicine.”7 I believe that medical education and the practice of medicine today clearly acknowledge that ethics is essential to outstanding patient care. However, a continued focus on distinctive ethical issues in patient care remains warranted to ensure that we recognize new issues as they arise and equip clinicians and patients to address them in a thoughtful and ethical manner.In the decades to come, we hope that the formal collaboration between JCE and the MacLean Center will improve the care of patients and increase the level of scholarship in clinical ethics in the United States and internationally. Our goal will be consistent with that articulated in the first issue of JCE in 1990: “there should be a journal applying medical ethics to clinical practice primarily for care providers.”8 Although JCE will strive to engage medical ethics scholars and practitioners in thoughtful debate about substantive issues, it will also continue to focus on being valuable to clinicians, regardless of their discipline or type of clinical practice. Both JCE and the MacLean Center will continue to be guided by the very practical goal of clinical ethics: to improve the outcomes of patients and, in so doing, improve the world we live in.Notes1. E.G. Howe, “The Journal of Clinical Ethics: Genesis, Purposes, and Scope,” Journal of Clinical Ethics 1, no. 1 (Spring 1990): 3–4.2. J.R. Botkin, “Delivery Room Decisions for Tiny Infants: An Ethical Analysis,” Journal of Clinical Ethics 1, no. 4 (Winter 1990): 306–11.3. S.S. Braithwaite et al., “The Ethics of Surreptitious Diagnostics for Factitious Hypoglycemia,” Journal of Clinical Ethics 1, no. 2 (Summer 1990): 116–21.4. J.M. Teno et al., “Do Formal Advance Directives Affect Resuscitation Decisions and the Use of Resources for Seriously Ill Patients?,” Journal of Clinical Ethics 5, no. 1 (Spring 1994): 23–30.5. L.J. Schneiderman et al., “Attitudes of Seriously Ill Patients toward Treatment That Involves High Costs and Burdens on Others,” Journal of Clinical Ethics 5, no. 2 (Summer 1994): 109–12.6. E.G. Howe, “How to Retain the Trust of Patients and Families When We Will Not Provide the Treatment They Want,” Journal of Clinical Ethics 26, no. 2 (Summer 2015): 89–99.7. M.S. Siegler, E.D. Pellegrino, and P.A. Singer, “Clinical Medical Ethics,” Journal of Clinical Ethics 1, no. 1 (Spring 1990): 5–9.8. Howe, “The Journal of Clinical Ethics,” see note 1 above, p. 3. Previous articleNext article DetailsFiguresReferencesCited by Volume 34, Number 1Spring 2023 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/723843 © 2023 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.