Despite the growing interest in and practice of clinical ethics consultation, important questions remain about its purpose, requisite skills, methods, specific responsibilities, evaluation, and effect. Unlike traditional medical consultants, clinical ethics consultants are not subject to widely accepted standards and procedures for training, credentialing, maintaining accountability, charging fees, obtaining informed consent, or providing liability coverage (Purtilo; Agich).
While the role of the ethics consultant generally has been pragmatic, that is, to provide practical assistance with actual patient-care decisions (Cranford; Glover et al.; Siegler and Singer; Fletcher, 1986), there has been little consensus about how this role should be implemented. For example, although some see the ethics consultant, like the traditional medical consultant, as an expert who uses specific skills and knowledge to help "answer" ethical questions, exactly what constitutes the appropriate skills and knowledge base is a matter of debate. Does the expertise come from the wisdom of practical clinical experience (La Puma et al.), or is it derived from a knowledge of moral theory and ethical principles?
Others see the clinical ethics consultant's role not so much as an expert but as someone who facilitates decisions in a "community of reflective persons" (Glover et al., p. 24). This approach stresses the importance of involving all persons connected with the case—the patient, family members, physicians, nurses, medical students and residents, social workers, friends, and clergy. In this view, a shared decision-making process should extend beyond the physician—patient dyad so that a greater range of personal values and interests can be considered. This view is less compatible with the traditional model of medical consultation, which focuses more narrowly on the physician as decision maker.
Some commentators have worried that the individual ethics consultant, the ethics consultative group, or the ethics committee will act as moral "police" or "God Squad" (Siegler and Singer, p. 759), and erode the decision-making authority of the physician. Troyen Brennan has voiced a more subtle concern: that by turning increasingly to ethics consultants and ethics committees, we "run the risk of forcing the ethics of the caring relationship to the periphery of clinical practice as something that is best left to experts" (Brennan, p. 4). Furthermore, the role of the ethics consultant may be confused with other institutional roles, such as risk management, peer review, quality assurance, or resource allocation. Taking on these roles could create a conflict of interest for the ethics consultant.
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