Doing Ethics Consultation

George Agich, in "The Question of Method in Ethics Consultation" (2001) sounds the clarion call for careful attention to, and systematic treatment of, "the question of method in ethics consultation regarded as a practice," that is, "an ordered set of activities that involve distinctive beliefs, goods, purposes, or values that shape the activities comprised by the practice." For Agich, the concepts of "practice" and "rules of a practice" are deeply related insofar as the rules of a practice "provide(s) it with its distinctive order or structure." Two types of practice rules are central to Agich's schema:

1. constructed or formal rules; and
2. operative or enacted rules.

Neglect of the latter, according to Agich, is at the heart of the impoverishment of methodological discussion in ethics consultation. Herein, I argue that if Agich is correct, then what is needed is not more careful attention to and systematic discussion of method in ethics consultation regarded as a practice, but rather a certain approach to the training of consultants.

Agich tells us that the concept of rule in a practice is two sided:

On the one side there are constructed rules about the practice. They involve abstract concepts and judgments about the practice and are typically normative in character or contain a strong normative component. They also include ethical judgments and concepts that are often expressed summarily in terms of ethical principles or other theoretical statements. On the other side there are the rules that are enacted within the practice. These rules are furtively formative of the actions or processes that actually constitute the practice in question. These rules are part and parcel of the practice rather than being simply about it.

(emphasis in original)

Of these two aspects of rules in a practice, the constructed rules can be discussed apart fromthe actual ongoing experiences of and the doings that make up the practice. Enacted rules, however, are constitutive of the particular doings that make up the practice. They are inextricably enmeshed in it. They are evident in the actions and judgments of skilled participants in the practice, but have no separate existence apart fromthe various doings that they guide.

According to Agich, discussion of ethics consultation has tended to focus on formal or constructed rules. For example, the bioethics literature is rife with discussion of the "analytical application of concepts like futility or principles like patient autonomy" to clinical cases. Though not gainsaying the importance of these discussions, Agich stresses that "they provide remarkably little practical guidance to the consultant in negotiating the complex con-flicts and communication occlusions that surround actual cases and make each clinical case unique." According to Agich, such practical guidance might be gathered from systematic study and discussion of the rules operative in the activities of experienced and skilled consultants, that is, from the systematic treatment and discussion of what he terms "operative" or "enacted" rules. Indeed, he tells us that "identifying and categorizing the myriad types of operative rules utilized by skilled consultants is an important area for further exploration and discussion."

Agich's call for a systematic discussion of enacted or operative rules when combined with his characterization of such rules is, I think, profoundly problematic. Agich has already told us that while constructed rules can be discussed apart fromthe experiences and doings that make up the practice, enacted or operative rules are "constitutive of the particular doings that make up the practice" and "have no separate existence apart from the various doings that they guide" (emphasis added). If this is correct, then we should expect it to be nearly impossible to articulate such rules in a language that captures the practical guidance they are supposed to give—in other words, in a language that is meaningful and useful. Why? Any such articulation would already be an abstraction fromthe concrete, rich particularity of consultative action. Any such articulation will necessarily turn out to be more like a formal or constructed rule than an operative...