Moral Midwifery

In this brief reflection on the nature and purpose of Clinical Ethics Consultation (CEC), I propose that we think of the ethics consultation process as analogous to ‘moral midwifery.’ However, before explaining why I chose this particular analogy for explaining my understanding and approach to ethics consultation, I want to emphasize that this is only ‘one way’ of thinking about CEC. I emphasize this because if there is consensus on anything when it comes to understanding the nature and purpose of CEC, it is that there is no consensus on this subject.

The origins of what was to become the current practice of CEC in North America can be traced to the early 1960s in Seattle, Washington. In the early days of kidney dialysis demand far exceeded the extremely limited supply of dialysis units available. In order to deal with the ethically fraught questions regarding who would or would not receive dialysis, Seattle’s Swedish Hospital organized a committee consisting of both lay and professional members to review individual cases. Labelled the ‘God committee,’ this body literally determined who would live and who would die.¹

Dialysis was only one of many high tech interventions making their way into mainstream medicine in the 1960s and 70s. Such technological marvels increased the power of medicine to extend the lifespan, but also presented the ethical challenge of ‘unnatural selection;’ where once we could only provide care and comfort while nature took its course, we now had the power to curtail and in some cases even reverse the natural course of disease. Governments and healthcare authorities began looking to the field of ethics for guidance. Hence the emergence of modern bioethics and with it CEC.²

However, as more hospitals and health authorities established ethics committees and ethics consultation services, questions arose about how to evaluate the effectiveness of the consultation process. The theme of a conference held in Chicago in 1995 was ostensibly the ‘Evaluation of Ethics Case Consultation,’ but the organizers acknowledged the difficulty of evaluating efficacy when there was no consensus on what the goals of CEC were in the first place.³

There are complex reasons for requesting a CEC including issues of resource allocation, differences of opinion amongst the clinical team, or tensions between clinicians and patients and/or their families about an appropriate course of treatment. The challenge of specifying clear goals for CEC is exacerbated by the diverse backgrounds of those involved in performing this service. While some clinical ethics consultants are medically trained, others are not. There is also wide variation among models for providing CEC and the practice of ethics consultants within these models. Institutions may conduct CECs through a hospital ethics committee or a formal ethics consultation service, while others rely on a single ‘ethics consultant’ to provide guidance.

Ambiguities about what it means to be a clinical ethics consultant and how to assess effectiveness have persisted. In 2022, BMC Medical Ethics published an extensive scoping review of reported outcomes for CEC.⁴ The review concluded that CEC suffered from a lack of standardization that was hindering “the provision of high quality intervention and CEC scientific progress.” It seems not much has changed since the Chicago conference a quarter of a century earlier.

The scoping review closes with a quotation from Aristotle’s Nicomachean Ethics. Aristotle states: “Our discussion will be adequate if it has as much clearness as the subject matter admits of, for precision is not to be sought for alike in all discussions . . .” Aristotle understood that we should not expect to quantify and measure outcomes in ethics in the same way that we measure scientific progress. Medicine is both art and science. Much in the realm of ethics is about the art of medicine; it deals with matters of the heart as well as the intellect. The modern penchant, while understandable, for ‘evidence based medicine’ comes up short when attempting to categorize, quantify and measure CEC. The authors of the scoping review acknowledge Aristotle’s wisdom but seem reluctant to apply it to their own study.

This brings me to my characterization of CEC as analogous to ‘moral midwifery.’ While I have worked as a clinical ethics consultant for over three decades, early on I struggled with these very issues. How would I measure whether or not I was making a difference? Modern medicine has become a system of highly specialized fields, and it is common practice to rely on specialist consultants. Although I lacked formal medical training, I had extensive post-graduate training in philosophical and applied ethics. Did I want to be seen as the ‘ethics expert’ who advised on all things ethical? While my ethics training provided certain tools for assisting in sorting through the complexities of various ethical conundrums, I resisted being characterized as the ‘moral expert.’

Socrates struggled with similar issues when approached to advice on various matters. He resisted being viewed as the expert, claiming (somewhat improbably) that he really did not know anything. He insisted that those who sought him out already knew the answers to the questions that perplexed them; his role was to act as a ‘midwife’ to assist in delivering the wisdom already residing within them.

References:

1. http://www.nephjc.com/news/godpanel
2. Bell, J.A.H., Salis, M., Tong, E. et al. (2022) Clinical ethics consultation: a scoping review of reported outcomes. BMC Medical Ethics. 23,99: 1-65.
3. Fletcher, J.C., Siegler, M. (1996) What are the goals of ethics consultation? A consensus statement. Journal of Clinical Ethics 7,2: 122-6.
4. Jonsen, A.R. (1998) The Birth of Bioethics. New York: Oxford U Press.