The American Journal of Bioethics
known that she did not want them to act in a surrogate decision making role if she lost capacity. She had a number of chronic health issues and we got to know her through multiple hospitalizations. When her health deteriorated after a stroke, the patient lacked capacity and faced the prospect of never returning home. The ethics team, after a comprehensive discussion, recommended actions in accordance with the patient’s known wishes, including a transition to comfort care, all while trying to locate family members. The lead ethics consultant spent the night with the patient as she drew her last breath. Here, the ethics consultant did what felt right, so that the patient should not have to die alone. When the family learned what happened, they expressed gratitude that the team listened to the patient’s wishes and that she was not alone at the end. The ethics team’s efforts helped to facilitate closure for the family, the team, and the lead consultant, although closure for the survivors was not, nor should it have been, the aim. Closure happens across time, often in local communities where stories are told and rituals enacted. The rituals, such as a well-run family meeting, needed to support shared decision making are likely very different from the rituals needed for closure. And our professional academic rituals for closure for ourselves, such as a case review and seminars, are likely to be very different from the rituals and relationships used by patients and families in the community. The Clinical Ethics Consultation Service at Vanderbilt University Medical Center convenes a monthly conference to discuss an especially difficult case. Health care team members involved in the case are invited to share their experiences and to reflect on the morally vexing aspects of the situation. The case conferences have become ritualistic, with a standard format that invites open, nonjudgmental conversation while maintaining confidentiality of the patient and family. We have noticed that some people express a sense of relief after these case reviews; often team members express gratitude for having the time and
space to reflect and revisit the situation. The time that elapses between the end of a patient’s episode of care and the case conference, even if just a few weeks, gives the team members some distance to come back and reflect on what went well and what they could have done differently. Whether this event supports closure through the rehearsal of narratives in a local professional context is an important question for research. We suggest treating closure as a complex phenomenon that resists assessment and intervention within the limited scope of an ethics consultation. Stakeholders might begin the temporally laden process of closure within the confines of a family meeting or at a monthly case review, but their journey’s end extends well beyond the purview of bioethics mediation. &
REFERENCES Agich, G. J. 2005. What kind of doing is clinical ethics? Theoretical Medicine and Bioethics 26(1): 7–24. Churchill, L. R. 2014. Narrative awareness in ethics consultations: The ethics consultant as story-maker. Hastings Center Report 44(s1): S36–S39. Churchill, L. R., J. B. Fanning, and D. Schenck. 2013. What patients teach: The everyday ethics of health care. New York, NY: Oxford University Press. Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Kriston, L., I. Scholl, L. H€ olzel, D. Simon, A. Loh, and M. H€arter. 2010. The 9-item shared decision making questionnaire (SDM-Q9). Development and psychometric properties in a primary care sample. Patient Education and Counseling 80(1): 94–99. Walker, M. U. 1993. Keeping moral space open: New images of ethics consulting. Hastings Center Report 23(2): 33–40.
Closure But No Cigar Leah Eisenberg, University of Arkansas for Medical Sciences Thomas V. Cunningham, University of Arkansas for Medical Sciences D. Micah Hester, University of Arkansas for Medical Sciences Over the past year, the authors of this commentary have been reorganizing their institutions’ clinical ethics program. Merging and revitalizing two distinct services involved researching different consult service models, incorporating feedback of other stakeholders, and modifying ethics committee bylaws. Through this, we chose a
hub-and-spoke model for our new consult service (MacRae et al. 2005). At the core of this model lies a lead clinical ethicist (LCE), who is responsible for interacting with patients, families, and providers during consultation. LCEs may also identify experts in the hospital and broader communities to serve as “spokes” in the hub-and-spoke
Address correspondence to Thomas V. Cunningham, University of Arkansas for Medical Sciences, Division of Medical Humanities, UAMS College of Medicine, 4301 W. Markam St., Little Rock, AR 72205, USA. E-mail: [email protected]
44 ajob
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Clinical Ethics Consultation and Closure
strategy: they are recruited as needed to aid in conceptualizing particular aspects of complex ethical problems and assist in resolving them. LCEs are also liaisons to institutional ethics committees, serving ex officio and reporting consult service activities. It is in light of our experience redesigning our services and in our practice as LCEs that we react to Autumn Fiester’s (2015) proposal in this issue suggesting that “closure” is the proper end of an ethics consultation and that bioethics mediation is the sole method for generating closure. We are concerned that Fiester’s proposal could lead to substantive problems in practice for a typical consultation service like our own. We begin with Fiester’s view that ethics consultations are insufficient if they only result in a “recommendation” or “plan.” For Fiester, a consultant is obligated “to attend to the affective, relational, or moral concerns that stakeholders want to express as they work to resolve serious ethical conflict” (29). That is, consults require “closure,” a state of completeness or peace of mind, which is the remedy for sentiments of “moral distress” or “moral emotions” (31). “Closure,” she says, “must be seen as the necessary condition for deeming the consult complete when the [consultation] revolves around deep-seated moral disagreement among the parties” (32, italics added). To our minds, this statement is, at best, hyperbolic. Neither normative argument nor empirical evidence grounds the claim that closure is necessary for a complete act of consultation. We believe that consultations are, by their nature, situations where consultants are concerned with many individuals’ interests and concerns, such that one individual’s concerns often cannot and should not be prioritized above the needs of others. An ethics consultant has the obligation to begin by defining the problem with a wide scope, surveying the multiple, often conflicting, personal and moral interests of different stakeholders. This then serves as the starting point from which other obligations arise. Closure may be one of them—but not necessarily. Its necessity, like all other potential ends in a consultation, can only be determined in light of case details. It cannot be necessitated or prioritized beforehand. While we laud Fiester for proposing a role for closure in consultation and for using the concept to give meaning to moments where complex moral sentiments arise, linger, and remain unassuaged within the consultation process, the significance she places on closure entails that the clinical ethicist’s scope of practice is far broader than is reasonable. Specifically, we believe it would require training and resources that are unattainable for all but the most wellfunded consult services. Fiester defines closure in terms of moral emotions, which “require the expertise of an ethics consultant—not clergy or a therapist” to resolve (35). Why the qualification of “emotions” by the term “moral” makes the ethics consultant solely expert is not well described. As a practical matter, Fiester’s position implies that although consultation in today’s multidisciplinary health care environment is such that ethics consultants often work with other professionals who are trained specifically in therapy,
January, Volume 15, Number 1, 2015
ethics consultants need not call for their aid in cases in order to bring closure. This is deeply problematic. Relatedly, given that emotions are involved, it is unclear whether Fiester would require clinical ethicists to develop expertise in counseling or therapy, and whether she thinks ethicists are obligated to work over long periods of time with stakeholders on their “moral” emotions. She may instead assume that because of one’s training in theoretical or applied ethics—presumably disciplines with unique scope for morality—a consultant has exclusive competency for working with individuals to resolve moral problems. We reject both ideas. Though competency in counseling and therapy might be useful, we are unconvinced that is required for expert clinical ethicist consultations. Furthermore, we are skeptical of the implication that training in academic philosophy is in and of itself sufficient for gaining competency in resolving problems of closure. If moral emotions require significant attention, this, like any other emotive condition, can take weeks to months to affect positively. As such, we believe that chaplains, psychologists, psychiatrists, social workers, or even, perhaps, philosophical counselors (see Martin 2001) have expertise in healing emotional distress over these longer range time scales, and are therefore best suited to work with patients who suffer from the emotional distress that closure mitigates. To do otherwise places an undue burden of long-term care on clinical ethicists and devalues the professional training many of our colleagues could contribute to our interdisciplinary team. Our second disagreement with Fiester’s proposal is her characterization of bioethics mediation. To make her case, Fiester contrasts two consultation styles she calls the “Recommendation-Focused Session” (R-FS) and the “Dialogue-Focused Model” (D-FM). On her view, R-FS is described as a process where consultants work apart from other providers, piecing together recommendations by stitching together isolated discussions with individual stakeholders. In contrast, D-FM occurs when consultants facilitate communication among stakeholders, using dialogue to reach acceptable consult outcomes. Given these two contrasting, straw-person characterizations of consultation, it is not difficult to see D-FM as superior. The problem, though, does not rest solely with Fiester’s mischaracterization of what may otherwise be seen as two reasonable methods of consultation; the problem lies with Fiester’s insistence that D-FM is simply another name for the practice of bioethics mediation. Bioethics mediation is an important method for both individual consultants and consult services, providing tools and methods for reaching agreement when ethically charged conflict arises in health care. As a service in transition, we have examined common models of consultation (cf. Rushton et al. 2003), and participated in a 3-day bioethics mediation training (see Morreim 2014). We chose to train in mediation precisely because of the important tools it offers to help resolve moral conflict in health care. The mediator’s role is to facilitate, and thereby improve, communication between parties in order to resolve existing
ajob 45
The American Journal of Bioethics
conflict, reaching an agreement to break through impasses. In other words, the aim of mediation is not simply to resolve moral sentiments or to reach closure; rather, bioethics mediation aims to establish a course of action that is agreed upon and ratified by all parties (cf. Dubler and Liebman 2011). Although bioethics mediation may produce closure in some cases, it neither aims at nor requires it to be successful. Further, mediation is typically not a long-term process over weeks or months, as the sort of therapy Fiester’s position would require of ethics consultation. If it did, then mediation would be logistically impossible in the inpatient hospital setting of typical consultation services. We are drawn to mediation because of the constraints that are part of the method. It is constrained temporally in that occurs over the time spans of hours or days. It is also constrained in terms of content, in that it focuses on specific conflicts and seeks their resolution. However, bioethics mediation may be repeated with the same parties, or different stakeholders related to a shared circumstance, if conflict is complex or persistent. But a particular round of bioethics mediation has a circumscribed aim of addressing and (hopefully) resolving specific ethical conflicts between parties. To be clear, we believe there is a role for therapeutic intervention in complex moral problems that arise in health care. What we object to is making resolution of such problems the primary concern of ethics consultants. We should not blur the lines between typical consultation models, mediation-style interventions, and therapeutic interventions. We are attracted to mediation precisely because of its limited and defined scope, meant to resolve discrete ethical issue(s). Similarly, we believe that a consultant’s primary obligation is to get the whole story and
to develop a strategy to resolve proximate moral dilemmas. Therapeutic interventions are often crucial to the overall well-being of participants in consultations; however, such interventions are already the responsibility of other health care professionals or interprofessional teams, rather than ethics consultants, qua mediators. So while we agree with Fiester that (a) some situations warrant an ethics consultant seeking closure and (b) that mediation can accomplish closure in some situations, we find the universalizing of both the obligation for closure and the scope of mediation to be unwarranted. &
REFERENCES Dubler, N., and C. Liebman. 2011. Bioethics mediation. Nashville, TN: Vanderbilt University Press. Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. MacRae, S., et al. 2005. Clinical bioethics integration, sustainability, and accountability: The hub and spokes strategy. Journal of Medical Ethics 31: 256–261. Martin, M. W. 2001. Ethics as therapy: Philosophical counseling and psychological health. International Journal of Philosophical Practice 1: 1–31. Morreim, H. 2014. Conflict resolution in health care. AHLA Connections January: 28–32. Rushton, C., et al. 2003. Models for ethics consultation: Individual, team, or committee? In M. Aulisio et al., Ethics consultation: From theory to practice, ed. M. Aulisio et al., 88–95. Baltimore, MD: Johns Hopkins University Press.
Attend to the Middle Denise M. Dudzinski, University of Washington School of Medicine Autumn Fiester (2015) aptly distinguishes common practice (Recommendation-Focused Model) from best practice (Assisted Conversation Model) ethics consultation. She emphasizes the end, closure, suggesting that the latter process will produce it. Her recommendations about practice are exactly right, but the goal of an ethics consultation should not be closure. Closure means achieving “harmonious completion,” “a comforting or satisfying sense of finality,” and “peace of mind,” and Fiester calls it “the necessary condition for deeming a consult complete” (32). Fiester believes that identifying the appropriate goal is critical. “If the case
ending is defined as the moment when a recommendation or plan is offered, consultants may recognize no obligation to attend to the affective, relational, or moral concerns that stakeholders want to express as they work to resolve to serious ethical conflict” (29). Herein lies my disagreement. There are perils in aiming for closure. Closure suggests emotional satisfaction. Ethics consultants should demonstrate compassion, a certain comfort with conflict, and an aptitude for carving compromise. We certainly want to demonstrate respect (Core Competencies Task Force 2010, 60). An effective ethics consultation may bring relief from unrelenting strife and greater mutual understanding. We
Address correspondence to Denise M. Dudzinski, PhD, MTS, Professor and Acting Chair, Department of Bioethics and Humanities, University of Washington School of Medicine, Room A204 Health Science Center, Box 357120, Seattle, WA 98195-7120, USA. E-mail: [email protected]
46 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.
known that she did not want them to act in a surrogate decision making role if she lost capacity. She had a number of chronic health issues and we got to know her through multiple hospitalizations. When her health deteriorated after a stroke, the patient lacked capacity and faced the prospect of never returning home. The ethics team, after a comprehensive discussion, recommended actions in accordance with the patient’s known wishes, including a transition to comfort care, all while trying to locate family members. The lead ethics consultant spent the night with the patient as she drew her last breath. Here, the ethics consultant did what felt right, so that the patient should not have to die alone. When the family learned what happened, they expressed gratitude that the team listened to the patient’s wishes and that she was not alone at the end. The ethics team’s efforts helped to facilitate closure for the family, the team, and the lead consultant, although closure for the survivors was not, nor should it have been, the aim. Closure happens across time, often in local communities where stories are told and rituals enacted. The rituals, such as a well-run family meeting, needed to support shared decision making are likely very different from the rituals needed for closure. And our professional academic rituals for closure for ourselves, such as a case review and seminars, are likely to be very different from the rituals and relationships used by patients and families in the community. The Clinical Ethics Consultation Service at Vanderbilt University Medical Center convenes a monthly conference to discuss an especially difficult case. Health care team members involved in the case are invited to share their experiences and to reflect on the morally vexing aspects of the situation. The case conferences have become ritualistic, with a standard format that invites open, nonjudgmental conversation while maintaining confidentiality of the patient and family. We have noticed that some people express a sense of relief after these case reviews; often team members express gratitude for having the time and
space to reflect and revisit the situation. The time that elapses between the end of a patient’s episode of care and the case conference, even if just a few weeks, gives the team members some distance to come back and reflect on what went well and what they could have done differently. Whether this event supports closure through the rehearsal of narratives in a local professional context is an important question for research. We suggest treating closure as a complex phenomenon that resists assessment and intervention within the limited scope of an ethics consultation. Stakeholders might begin the temporally laden process of closure within the confines of a family meeting or at a monthly case review, but their journey’s end extends well beyond the purview of bioethics mediation. &
REFERENCES Agich, G. J. 2005. What kind of doing is clinical ethics? Theoretical Medicine and Bioethics 26(1): 7–24. Churchill, L. R. 2014. Narrative awareness in ethics consultations: The ethics consultant as story-maker. Hastings Center Report 44(s1): S36–S39. Churchill, L. R., J. B. Fanning, and D. Schenck. 2013. What patients teach: The everyday ethics of health care. New York, NY: Oxford University Press. Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Kriston, L., I. Scholl, L. H€ olzel, D. Simon, A. Loh, and M. H€arter. 2010. The 9-item shared decision making questionnaire (SDM-Q9). Development and psychometric properties in a primary care sample. Patient Education and Counseling 80(1): 94–99. Walker, M. U. 1993. Keeping moral space open: New images of ethics consulting. Hastings Center Report 23(2): 33–40.
Closure But No Cigar Leah Eisenberg, University of Arkansas for Medical Sciences Thomas V. Cunningham, University of Arkansas for Medical Sciences D. Micah Hester, University of Arkansas for Medical Sciences Over the past year, the authors of this commentary have been reorganizing their institutions’ clinical ethics program. Merging and revitalizing two distinct services involved researching different consult service models, incorporating feedback of other stakeholders, and modifying ethics committee bylaws. Through this, we chose a
hub-and-spoke model for our new consult service (MacRae et al. 2005). At the core of this model lies a lead clinical ethicist (LCE), who is responsible for interacting with patients, families, and providers during consultation. LCEs may also identify experts in the hospital and broader communities to serve as “spokes” in the hub-and-spoke
Address correspondence to Thomas V. Cunningham, University of Arkansas for Medical Sciences, Division of Medical Humanities, UAMS College of Medicine, 4301 W. Markam St., Little Rock, AR 72205, USA. E-mail: [email protected]
44 ajob
January, Volume 15, Number 1, 2015
Clinical Ethics Consultation and Closure
strategy: they are recruited as needed to aid in conceptualizing particular aspects of complex ethical problems and assist in resolving them. LCEs are also liaisons to institutional ethics committees, serving ex officio and reporting consult service activities. It is in light of our experience redesigning our services and in our practice as LCEs that we react to Autumn Fiester’s (2015) proposal in this issue suggesting that “closure” is the proper end of an ethics consultation and that bioethics mediation is the sole method for generating closure. We are concerned that Fiester’s proposal could lead to substantive problems in practice for a typical consultation service like our own. We begin with Fiester’s view that ethics consultations are insufficient if they only result in a “recommendation” or “plan.” For Fiester, a consultant is obligated “to attend to the affective, relational, or moral concerns that stakeholders want to express as they work to resolve serious ethical conflict” (29). That is, consults require “closure,” a state of completeness or peace of mind, which is the remedy for sentiments of “moral distress” or “moral emotions” (31). “Closure,” she says, “must be seen as the necessary condition for deeming the consult complete when the [consultation] revolves around deep-seated moral disagreement among the parties” (32, italics added). To our minds, this statement is, at best, hyperbolic. Neither normative argument nor empirical evidence grounds the claim that closure is necessary for a complete act of consultation. We believe that consultations are, by their nature, situations where consultants are concerned with many individuals’ interests and concerns, such that one individual’s concerns often cannot and should not be prioritized above the needs of others. An ethics consultant has the obligation to begin by defining the problem with a wide scope, surveying the multiple, often conflicting, personal and moral interests of different stakeholders. This then serves as the starting point from which other obligations arise. Closure may be one of them—but not necessarily. Its necessity, like all other potential ends in a consultation, can only be determined in light of case details. It cannot be necessitated or prioritized beforehand. While we laud Fiester for proposing a role for closure in consultation and for using the concept to give meaning to moments where complex moral sentiments arise, linger, and remain unassuaged within the consultation process, the significance she places on closure entails that the clinical ethicist’s scope of practice is far broader than is reasonable. Specifically, we believe it would require training and resources that are unattainable for all but the most wellfunded consult services. Fiester defines closure in terms of moral emotions, which “require the expertise of an ethics consultant—not clergy or a therapist” to resolve (35). Why the qualification of “emotions” by the term “moral” makes the ethics consultant solely expert is not well described. As a practical matter, Fiester’s position implies that although consultation in today’s multidisciplinary health care environment is such that ethics consultants often work with other professionals who are trained specifically in therapy,
January, Volume 15, Number 1, 2015
ethics consultants need not call for their aid in cases in order to bring closure. This is deeply problematic. Relatedly, given that emotions are involved, it is unclear whether Fiester would require clinical ethicists to develop expertise in counseling or therapy, and whether she thinks ethicists are obligated to work over long periods of time with stakeholders on their “moral” emotions. She may instead assume that because of one’s training in theoretical or applied ethics—presumably disciplines with unique scope for morality—a consultant has exclusive competency for working with individuals to resolve moral problems. We reject both ideas. Though competency in counseling and therapy might be useful, we are unconvinced that is required for expert clinical ethicist consultations. Furthermore, we are skeptical of the implication that training in academic philosophy is in and of itself sufficient for gaining competency in resolving problems of closure. If moral emotions require significant attention, this, like any other emotive condition, can take weeks to months to affect positively. As such, we believe that chaplains, psychologists, psychiatrists, social workers, or even, perhaps, philosophical counselors (see Martin 2001) have expertise in healing emotional distress over these longer range time scales, and are therefore best suited to work with patients who suffer from the emotional distress that closure mitigates. To do otherwise places an undue burden of long-term care on clinical ethicists and devalues the professional training many of our colleagues could contribute to our interdisciplinary team. Our second disagreement with Fiester’s proposal is her characterization of bioethics mediation. To make her case, Fiester contrasts two consultation styles she calls the “Recommendation-Focused Session” (R-FS) and the “Dialogue-Focused Model” (D-FM). On her view, R-FS is described as a process where consultants work apart from other providers, piecing together recommendations by stitching together isolated discussions with individual stakeholders. In contrast, D-FM occurs when consultants facilitate communication among stakeholders, using dialogue to reach acceptable consult outcomes. Given these two contrasting, straw-person characterizations of consultation, it is not difficult to see D-FM as superior. The problem, though, does not rest solely with Fiester’s mischaracterization of what may otherwise be seen as two reasonable methods of consultation; the problem lies with Fiester’s insistence that D-FM is simply another name for the practice of bioethics mediation. Bioethics mediation is an important method for both individual consultants and consult services, providing tools and methods for reaching agreement when ethically charged conflict arises in health care. As a service in transition, we have examined common models of consultation (cf. Rushton et al. 2003), and participated in a 3-day bioethics mediation training (see Morreim 2014). We chose to train in mediation precisely because of the important tools it offers to help resolve moral conflict in health care. The mediator’s role is to facilitate, and thereby improve, communication between parties in order to resolve existing
ajob 45
The American Journal of Bioethics
conflict, reaching an agreement to break through impasses. In other words, the aim of mediation is not simply to resolve moral sentiments or to reach closure; rather, bioethics mediation aims to establish a course of action that is agreed upon and ratified by all parties (cf. Dubler and Liebman 2011). Although bioethics mediation may produce closure in some cases, it neither aims at nor requires it to be successful. Further, mediation is typically not a long-term process over weeks or months, as the sort of therapy Fiester’s position would require of ethics consultation. If it did, then mediation would be logistically impossible in the inpatient hospital setting of typical consultation services. We are drawn to mediation because of the constraints that are part of the method. It is constrained temporally in that occurs over the time spans of hours or days. It is also constrained in terms of content, in that it focuses on specific conflicts and seeks their resolution. However, bioethics mediation may be repeated with the same parties, or different stakeholders related to a shared circumstance, if conflict is complex or persistent. But a particular round of bioethics mediation has a circumscribed aim of addressing and (hopefully) resolving specific ethical conflicts between parties. To be clear, we believe there is a role for therapeutic intervention in complex moral problems that arise in health care. What we object to is making resolution of such problems the primary concern of ethics consultants. We should not blur the lines between typical consultation models, mediation-style interventions, and therapeutic interventions. We are attracted to mediation precisely because of its limited and defined scope, meant to resolve discrete ethical issue(s). Similarly, we believe that a consultant’s primary obligation is to get the whole story and
to develop a strategy to resolve proximate moral dilemmas. Therapeutic interventions are often crucial to the overall well-being of participants in consultations; however, such interventions are already the responsibility of other health care professionals or interprofessional teams, rather than ethics consultants, qua mediators. So while we agree with Fiester that (a) some situations warrant an ethics consultant seeking closure and (b) that mediation can accomplish closure in some situations, we find the universalizing of both the obligation for closure and the scope of mediation to be unwarranted. &
REFERENCES Dubler, N., and C. Liebman. 2011. Bioethics mediation. Nashville, TN: Vanderbilt University Press. Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. MacRae, S., et al. 2005. Clinical bioethics integration, sustainability, and accountability: The hub and spokes strategy. Journal of Medical Ethics 31: 256–261. Martin, M. W. 2001. Ethics as therapy: Philosophical counseling and psychological health. International Journal of Philosophical Practice 1: 1–31. Morreim, H. 2014. Conflict resolution in health care. AHLA Connections January: 28–32. Rushton, C., et al. 2003. Models for ethics consultation: Individual, team, or committee? In M. Aulisio et al., Ethics consultation: From theory to practice, ed. M. Aulisio et al., 88–95. Baltimore, MD: Johns Hopkins University Press.
Attend to the Middle Denise M. Dudzinski, University of Washington School of Medicine Autumn Fiester (2015) aptly distinguishes common practice (Recommendation-Focused Model) from best practice (Assisted Conversation Model) ethics consultation. She emphasizes the end, closure, suggesting that the latter process will produce it. Her recommendations about practice are exactly right, but the goal of an ethics consultation should not be closure. Closure means achieving “harmonious completion,” “a comforting or satisfying sense of finality,” and “peace of mind,” and Fiester calls it “the necessary condition for deeming a consult complete” (32). Fiester believes that identifying the appropriate goal is critical. “If the case
ending is defined as the moment when a recommendation or plan is offered, consultants may recognize no obligation to attend to the affective, relational, or moral concerns that stakeholders want to express as they work to resolve to serious ethical conflict” (29). Herein lies my disagreement. There are perils in aiming for closure. Closure suggests emotional satisfaction. Ethics consultants should demonstrate compassion, a certain comfort with conflict, and an aptitude for carving compromise. We certainly want to demonstrate respect (Core Competencies Task Force 2010, 60). An effective ethics consultation may bring relief from unrelenting strife and greater mutual understanding. We
Address correspondence to Denise M. Dudzinski, PhD, MTS, Professor and Acting Chair, Department of Bioethics and Humanities, University of Washington School of Medicine, Room A204 Health Science Center, Box 357120, Seattle, WA 98195-7120, USA. E-mail: [email protected]
46 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.
