Moral Expertise in the Clinic: Lessons Learned from Medicine and Science

A Guide to Establishing Ethics Committees in Behavioral Health Settings

Ethical statements typically involve rules. All rules can vary in accuracy and specificity depending on the context to which they are applied. Codes of ethics often involve ethical rules that are written generally to cover the wide-ranging set of possible situations that any one member of the profession may encounter. But, despite being written generally, codes of ethics are applied to specific situations that professional members encounter. The application of general rules to specific contexts can sometimes be challenging and complex. Health care organizations have several options to help their employees behave ethically. One approach is to appoint a single ethics coordinator. In contrast, the dominant approach in most health care organizations is to develop an organizational ethics committee (Moon Pediatrics, 143(5), e20190659, 2019). Despite the popularity of the ethics committee in other professions, the extent to which organizations that provide applied behavior analysis services have established and operate ethics committees is unknown. Ethics coordinator roles and ethics committees both have benefits and drawbacks. This article reviews the benefits and drawbacks of appointing an ethics coordinator and establishing an ethics committee. And, for interested organizations, this article outlines the steps and considerations that organizations can use to guide the creation of an ethics committee.

A pragmatist approach to clinical ethics support: overcoming the perils of ethical pluralism

In today's pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today's clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES.

Two Troubling Trends in the Conversation Over Whether Clinical Ethics Consultants Have Ethics Expertise

In a recent issue of the Journal of Medicine and Philosophy, several scholars wrote on the topic of ethics expertise in clinical ethics consultation. The articles in this issue exemplified what we consider to be two troubling trends in the quest to articulate a unique expertise for clinical ethicists. The first trend, exemplified in the work of Lisa Rasmussen, is an attempt to define a role for clinical ethicists that denies they have ethics expertise. Rasmussen cites the dependence of ethical expertise on irresolvable meta-ethical debates as the reason for this move. We argue against this deflationary strategy because it ends up smuggling in meta-ethical assumptions it claims to avoid. Specifically, we critique Rasmussen's distinction between the ethical and normative features of clinical ethics cases. The second trend, exemplified in the work of Dien Ho, also attempts to avoid meta-ethics. However, unlike Rasmussen, Ho tries to articulate a notion of ethics expertise that does not rely upon meta-ethics. Specifically, we critique Ho's attempts to explain how clinical ethicists can resolve moral disputes using what he calls the "Default Principle" and "arguments by parity." We show that these strategies do not work unless those with the moral disagreement already share certain meta-ethical assumptions. Ultimately, we argue that the two trends of (1) attempting to avoid meta-ethics by denying that clinical ethicists have ethics expertise, and (2) attempting to articulate how ethics expertise can be used to resolve disputes without meta-ethics both fail because they do not, in fact, avoid doing meta-ethics. We conclude that these trends detract from what clinical ethics consultation was founded to do and ought to still be doing-provide moral guidance, which requires ethics expertise, and engagement with meta-ethics. To speak of ethicists without ethics expertise leaves their role in the clinic dangerously unclear and unjustified.

The "Ethics" Expertise in Clinical Ethics Consultation

The nature, possibility, and implications of ethics expertise (or moral expertise) in general and of bioethics expertise in particular has been the focus of extensive debate for over thirty years. What is ethics expertise and what does it enable experts to do? Knowing what ethics expertise is can help answer another important question: What, if anything, makes a claim of expertise legitimate? In other words, how does someone earn the appellation "ethics expert?" There remains deep disagreement on whether ethics expertise is possible, and if so, what constitutes such expertise and what it entails and legitimates. Discussion of bioethics expertise has become particularly important given the growing presence of bioethicists in the clinical setting as well as efforts to professionalize bioethics through codes of ethics and certification (or quasi-certification) efforts. Unlike in the law or in engineering, where there may be a body of knowledge that professional organizations or others have articulated as important for education and training of experts, ethics expertise admits of no such body of knowledge or required experience. Nor is there an entity seen as having the authority to articulate the necessary scope of knowledge. Questions about whether there is such a body of knowledge for particular areas within bioethics have emerged and played a central role in professionalization efforts in recent years, especially in the area of clinical ethics.