The American Journal of Bioethics, 15(1): 37–61, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2015.975587
Open Peer Commentaries
An Ethicist’s Scope of Practice: Equipping Stakeholders for Closure Bryan Kibbe, Cleveland Clinic Patrick Schmitt, Cleveland Clinic Paul J. Ford, Cleveland Clinic Endings are difficult to do well. Perhaps this is because, as T.S. Eliot (1971/1943) observed, endings are also beginnings. The challenge is to strike the right balance in resolving various elements of the plot, while leaving enough open to imagine a potential future. Although it is often outside the clinical ethicist’s scope of practice to bring closure for stakeholders in an ethics consultation, the clinical ethicist ought to equip stakeholders so they may begin the process of closure. Fiester nonetheless makes the bold claim that “Closure must be seen as the necessary condition for deeming the consult complete when the CEC revolves around deepseated moral disagreement among the parties” (Fiester 2015, 32). Regarding “closure,” Fiester draws on others to define it generally as a sense of “harmonious completion,” achieving “peace of mind,” and/or offering a “satisfying sense of finality” (29). Closure, she argues, dissolves or substantially diminishes the harmful moral residues of moral distress and the negative moral emotions that sometimes result from ethically challenging clinical encounters. The claim, though, that closure is a necessary condition for the completion or end of an ethics consultation is problematic and should be revised. The ethicist’s scope of practice includes guiding and mediating challenging moral/ethical decisions regarding health and health care during a specific, potentially brief, epoch of the stakeholders’ lives. We are invited into their lives for specific roles of assistance. In this limited time for the case, we ought to provide fair and open communication about processes, analysis, and synthesis (Yoder 1998). This includes bringing together and facilitating communication between stakeholders, such as the medical team and surrogate decision makers, as found in Fiester’s (2015) example. However, the best we should be expected to consistently accomplish is that our attempts to resolve the ethical dilemmas should not impair the stakeholder’s ability to find closure and to provide them with the beginning of a pathway to closure.
A proposal, such as Fiester’s, to make closure a necessary condition for the completion of an ethics consultation risks blurring the medical and the moral if closure is meant to act as a kind of corollary to patients departing the hospital in a physiologically stable condition. While patients should ideally leave the hospital in a stable physiological condition, the work that ethics consultants perform should not necessarily ensure that stakeholders in an ethics consultation leave with a sense of moral closure. Often the clinical ethics consultation is constructively the openended beginning of a longer moral reflection on what took place in the hospital. A requirement that ethics consultations achieve closure in order to be complete may actually encourage the short-circuiting of a process of moral reflection and deliberation that requires more time beyond any given clinical encounter. Instead of aiming to achieve closure during a clinical ethics consultation, ethics consultants should aim to equip stakeholders for their own journeys to achieve closure in time. The goal is to enable stakeholders to achieve closure in their ongoing efforts to think through various questions and issues since the clinical encounter. At times, Fiester seems to suggest something like this when she adopts the ambiguous language of “promoting closure,” but strong statements indicating that closure is a necessary condition for completion of an ethics consultation move in the opposite direction. Equipping stakeholders for closure will not necessarily require the alleviation or dissolution of all moral distress and negative moral emotions. Instead, it will require that efforts are made (1) to identify and discuss sources of distress and negative moral reactions, (2) to maintain transparency throughout the ethics consultation about steps that are taken to address pressing decisions amid medical care, and (3) to elicit questions and concerns from stakeholders throughout the ethics consultation. Most importantly, (4) it will involve encouraging (in the sense of imparting courage to) stakeholders to achieve
Address correspondence to Bryan Kibbe, PhD, Cleveland Clinic, Department of Bioethics, 9500 Euclid Ave., Office JJ60, Cleveland, OH 44195, USA. E-mail: [email protected]
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closure through sustained reflections on the ethical challenges prompted by the clinical encounter, and to draw on the discussions they had during an ethics consultation to eventually moderate and manage various moral emotions and feelings of distress. Chronic, unresolved regret, guilt, and anger can be pernicious and harmful. However, there is a difference between experiencing guilt, anger, or indignation over a limited time period, and being unable to ever overcome or manage these feelings. Part of what it means to equip stakeholders to achieve closure over time is to engage in a sufficiently transparent, accessible, rich, and encouraging discussion about the moral questions, issues, and options in a case so as to allow an individual to retrospectively take up different moral vantage points and establish a constructive internal dialogue that helps to manage, contain, and move beyond the experience of various negative moral emotions and distress and achieve closure over time. Given the complexity of ethical issues and questions raised in various cases, the ethics consultant alone is unlikely to be able to adequately equip any given stakeholder or all of the stakeholders to achieve closure over time. Contrary to what Fiester suggests, effectively equipping people to address the range of moral emotions they may feel and the moral distress they might experience will require the skill set of more than just the clinical ethicist. Clergy, therapists, social workers, ombudsmen, and other hospital services are important groups of people to recruit and mobilize for the effort to equip and empower stakeholders to ultimately achieve closure on any given ethical problem(s) that were raised in a particular case. The clinical ethicist ought to be familiar with the resources at hand when encountering stakeholders with a great amount of moral distress or negative moral emotions. During the week prior to this article being written, the authors of this commentary collaborated on a number of ethics consultations in which they referred people to, or recommended they consult, social work, spiritual care,
child life, psychologists, and others to help stakeholders process their ongoing emotional and moral consternation. We felt it is part of our jobs to know about these resources and know when they are appropriate to recommend. It was not in our scope to develop a moral, emotional, or psychological counseling relationship that would be ongoing in order for closure to occur. Hopefully, our clear, compassionate, and transparent processes provided the conditions for continued work by these other professionals and the stakeholders themselves. As clinical ethicists, we can acknowledge the good of closure, but also recognize that the ethical questions and issues raised in a case will often require thought and reflection beyond the duration of an ethics consultation. Within our scope of practice is an effort to equip stakeholders to achieve closure over time. However, just as the ethical issues and moral emotions raised in a case can linger with stakeholders, they can also haunt the clinical ethicist (Ford and Dudzinski 2008). This raises the question: If the clinical ethicist is working to equip stakeholders in an ethics consultation to achieve closure in time, who is equipping the clinical ethicist to achieve closure? As a profession we should be sure that clinical ethicists are provided the same tools for the beginnings of closure as we provide the other stakeholders in these cases. &
REFERENCES Eliot, T. S. 1971. Four quartets. New York, NY: Harcourt. Original work published 1943. Fiester, A. 2015. Neglected ends: Clinical ethics consultation and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Ford, P., and D. Dudzinski, eds. 2008. Complex ethical consultations: Cases that haunt us. New York, NY: Cambridge University Press. Yoder, S. 1998. Experts in ethics? The nature of ethical expertise. Hastings Center Report 28(6): 11–17.
Moral Distress and Prospects for Closure Haavi Morreim, University of Tennessee Health Science Center Autumn Fiester (2015) argues that when an ethics consult simply issues a recommendation it may leave a vacuum then filled by moral distress or moral emotion. “Assisted conversation”—a dialogue-focused approach—
can better promote closure and reduce the negative effects of conflict. Overall, this commentary argues that although Fiester is right about the benefits of mediation, she (and the
Address correspondence to Haavi Morreim, University of Tennessee Health Science Center, 910 Madison Ave., Memphis, TN 38163, USA. E-mail: [email protected]
38 ajob
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Open Peer Commentaries
An Ethicist’s Scope of Practice: Equipping Stakeholders for Closure Bryan Kibbe, Cleveland Clinic Patrick Schmitt, Cleveland Clinic Paul J. Ford, Cleveland Clinic Endings are difficult to do well. Perhaps this is because, as T.S. Eliot (1971/1943) observed, endings are also beginnings. The challenge is to strike the right balance in resolving various elements of the plot, while leaving enough open to imagine a potential future. Although it is often outside the clinical ethicist’s scope of practice to bring closure for stakeholders in an ethics consultation, the clinical ethicist ought to equip stakeholders so they may begin the process of closure. Fiester nonetheless makes the bold claim that “Closure must be seen as the necessary condition for deeming the consult complete when the CEC revolves around deepseated moral disagreement among the parties” (Fiester 2015, 32). Regarding “closure,” Fiester draws on others to define it generally as a sense of “harmonious completion,” achieving “peace of mind,” and/or offering a “satisfying sense of finality” (29). Closure, she argues, dissolves or substantially diminishes the harmful moral residues of moral distress and the negative moral emotions that sometimes result from ethically challenging clinical encounters. The claim, though, that closure is a necessary condition for the completion or end of an ethics consultation is problematic and should be revised. The ethicist’s scope of practice includes guiding and mediating challenging moral/ethical decisions regarding health and health care during a specific, potentially brief, epoch of the stakeholders’ lives. We are invited into their lives for specific roles of assistance. In this limited time for the case, we ought to provide fair and open communication about processes, analysis, and synthesis (Yoder 1998). This includes bringing together and facilitating communication between stakeholders, such as the medical team and surrogate decision makers, as found in Fiester’s (2015) example. However, the best we should be expected to consistently accomplish is that our attempts to resolve the ethical dilemmas should not impair the stakeholder’s ability to find closure and to provide them with the beginning of a pathway to closure.
A proposal, such as Fiester’s, to make closure a necessary condition for the completion of an ethics consultation risks blurring the medical and the moral if closure is meant to act as a kind of corollary to patients departing the hospital in a physiologically stable condition. While patients should ideally leave the hospital in a stable physiological condition, the work that ethics consultants perform should not necessarily ensure that stakeholders in an ethics consultation leave with a sense of moral closure. Often the clinical ethics consultation is constructively the openended beginning of a longer moral reflection on what took place in the hospital. A requirement that ethics consultations achieve closure in order to be complete may actually encourage the short-circuiting of a process of moral reflection and deliberation that requires more time beyond any given clinical encounter. Instead of aiming to achieve closure during a clinical ethics consultation, ethics consultants should aim to equip stakeholders for their own journeys to achieve closure in time. The goal is to enable stakeholders to achieve closure in their ongoing efforts to think through various questions and issues since the clinical encounter. At times, Fiester seems to suggest something like this when she adopts the ambiguous language of “promoting closure,” but strong statements indicating that closure is a necessary condition for completion of an ethics consultation move in the opposite direction. Equipping stakeholders for closure will not necessarily require the alleviation or dissolution of all moral distress and negative moral emotions. Instead, it will require that efforts are made (1) to identify and discuss sources of distress and negative moral reactions, (2) to maintain transparency throughout the ethics consultation about steps that are taken to address pressing decisions amid medical care, and (3) to elicit questions and concerns from stakeholders throughout the ethics consultation. Most importantly, (4) it will involve encouraging (in the sense of imparting courage to) stakeholders to achieve
Address correspondence to Bryan Kibbe, PhD, Cleveland Clinic, Department of Bioethics, 9500 Euclid Ave., Office JJ60, Cleveland, OH 44195, USA. E-mail: [email protected]
ajob 37
The American Journal of Bioethics
closure through sustained reflections on the ethical challenges prompted by the clinical encounter, and to draw on the discussions they had during an ethics consultation to eventually moderate and manage various moral emotions and feelings of distress. Chronic, unresolved regret, guilt, and anger can be pernicious and harmful. However, there is a difference between experiencing guilt, anger, or indignation over a limited time period, and being unable to ever overcome or manage these feelings. Part of what it means to equip stakeholders to achieve closure over time is to engage in a sufficiently transparent, accessible, rich, and encouraging discussion about the moral questions, issues, and options in a case so as to allow an individual to retrospectively take up different moral vantage points and establish a constructive internal dialogue that helps to manage, contain, and move beyond the experience of various negative moral emotions and distress and achieve closure over time. Given the complexity of ethical issues and questions raised in various cases, the ethics consultant alone is unlikely to be able to adequately equip any given stakeholder or all of the stakeholders to achieve closure over time. Contrary to what Fiester suggests, effectively equipping people to address the range of moral emotions they may feel and the moral distress they might experience will require the skill set of more than just the clinical ethicist. Clergy, therapists, social workers, ombudsmen, and other hospital services are important groups of people to recruit and mobilize for the effort to equip and empower stakeholders to ultimately achieve closure on any given ethical problem(s) that were raised in a particular case. The clinical ethicist ought to be familiar with the resources at hand when encountering stakeholders with a great amount of moral distress or negative moral emotions. During the week prior to this article being written, the authors of this commentary collaborated on a number of ethics consultations in which they referred people to, or recommended they consult, social work, spiritual care,
child life, psychologists, and others to help stakeholders process their ongoing emotional and moral consternation. We felt it is part of our jobs to know about these resources and know when they are appropriate to recommend. It was not in our scope to develop a moral, emotional, or psychological counseling relationship that would be ongoing in order for closure to occur. Hopefully, our clear, compassionate, and transparent processes provided the conditions for continued work by these other professionals and the stakeholders themselves. As clinical ethicists, we can acknowledge the good of closure, but also recognize that the ethical questions and issues raised in a case will often require thought and reflection beyond the duration of an ethics consultation. Within our scope of practice is an effort to equip stakeholders to achieve closure over time. However, just as the ethical issues and moral emotions raised in a case can linger with stakeholders, they can also haunt the clinical ethicist (Ford and Dudzinski 2008). This raises the question: If the clinical ethicist is working to equip stakeholders in an ethics consultation to achieve closure in time, who is equipping the clinical ethicist to achieve closure? As a profession we should be sure that clinical ethicists are provided the same tools for the beginnings of closure as we provide the other stakeholders in these cases. &
REFERENCES Eliot, T. S. 1971. Four quartets. New York, NY: Harcourt. Original work published 1943. Fiester, A. 2015. Neglected ends: Clinical ethics consultation and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Ford, P., and D. Dudzinski, eds. 2008. Complex ethical consultations: Cases that haunt us. New York, NY: Cambridge University Press. Yoder, S. 1998. Experts in ethics? The nature of ethical expertise. Hastings Center Report 28(6): 11–17.
Moral Distress and Prospects for Closure Haavi Morreim, University of Tennessee Health Science Center Autumn Fiester (2015) argues that when an ethics consult simply issues a recommendation it may leave a vacuum then filled by moral distress or moral emotion. “Assisted conversation”—a dialogue-focused approach—
can better promote closure and reduce the negative effects of conflict. Overall, this commentary argues that although Fiester is right about the benefits of mediation, she (and the
Address correspondence to Haavi Morreim, University of Tennessee Health Science Center, 910 Madison Ave., Memphis, TN 38163, USA. E-mail: [email protected]
38 ajob
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
