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6. A Contextual Approach to Clinical Ethics Consultation
- Temple University Press
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Patricia A. Marshall 6 A Contextual Approach to Clinical Ethics Consultation A lot of people say never give up. Others tell you to do . . . as best you can. How do you learn to accept? Or do you fight “till the absolute end”? Faith, a lung transplant patient CLINICAL ETHICS consultation has become increasingly prevalent in biomedical settings in the last decade. A recent consensus statement (Fletcher and Siegler 1996:125) defined ethics consultation as “a service provided by an individual consultant, team, or committee to address the ethical issues involved in a specific clinical case.” The primary goal of ethics consultation is to improve patient care by helping patients, their families, and health care providers to identify, analyze, and resolve ethical problems that occur in the course of medical treatment .1 Central to achieving the objectives of ethics consultations are the implementation of fair and accessible decision-making processes and the improvement of institutional ethics policies. The diverse professional backgrounds and skills of those involved in ethics consultation contribute to the heterogeneous forms these services assume (Baylis 1994; Fletcher, Quist, and Jonsen 1989; La Puma and Schiedermayer 1994; Ross et al. 1993). Despite such procedural variety, though, the content of ethics consultations generally conforms to, and thus is constrained by, the traditional principles-based approach of Western moral philosophy.2 A philosophical orientation that emphasizes the justification of ethical decisions in terms of general rules and principles limits the scope of the considerations that are deemed morally relevant and ignores the emotional experiences and the lived realities of patients and providers. It also extracts ethical problems from the broader social, cultural , and political forces that influence how those problems are defined and understood, how they are evaluated, and how eventually they are resolved (Hoffmaster 1990; Kleinman 1995; Marshall and Koenig 1996). And although a principles-based approach does, by giving priority to the 137 principle of respect for autonomy, promote patient choice, it evinces little concern for exploring the meaning of autonomy and the impact of choices within patients’ lives. Respecting patient autonomy often goes no further than eliciting superficial or simplistic answers to questions such as, “What does the patient want?” or “Does the patient have an advance directive or a living will?” Invoking rules and principles in search of justification might lend moral decision making an appearance of objectivity. Patients and their families and the providers who serve them are not, however, the neutral, impartial, independent, and rational agents this approach requires. The individuals who participate in ethics consultations can be immersed in long relationships suffused by love and affection, resentment and enmity, or a complicated hybrid of conflicting feelings, and they can be buffeted by the emotions of sorrow, fear, and guilt that surround an impending death. Moreover, they bring with them assumptions about good and bad and right and wrong that are deeply entrenched in the cultural and social traditions that shape our understandings of illness and health and our beliefs about the use of medical technologies. For ethics consultation to be meaningful and responsible, it must confront those histories and those emotions and venture into the traditions and background assumptions that generate and frame ethical issues. A contextual approach to ethics consultation follows this lead and situates ethical problems in the rich, complex experiences of patients, families , and health professionals and in the institutions and settings within which the parties in a consultation interact. During an ethics consultation, information about a patient’s social background and significant relationships is gathered along with clinical data, but this information usually is considered anecdotal or peripheral. In a contextual approach, information about a patient’s personal and social context becomes central to understanding the person upon whom the consultation focuses and to figuring out the reasons for and purposes of the consultation (Brody 1994a, 1994b; Hunter 1996). In this regard the “story” a patient tells can be invaluable. A contextual model thus reconfigures the form and content of ethics consultations by redefining and extending the boundaries of those consultations. And by engaging patients as individuals embedded in their physical and social worlds, an ethics consultant can be both an interpreter of and witness to a patient’s suffering. In this chapter, I use one of my own ethics consultations to illustrate the potential and the power of a contextual model. The consultation 138 Patricia A. Marshall [54.242.220.142] Project MUSE (2024-04-10 21:53...