The field of bioethics is currently in a state of creative ferment due to the fact that there has been an increasing shift of ethical thought from university classrooms and the offices of ethicists to the place of origin, the bedside, where the quandaries arise which are contemplated by ethicists and where ethical discussions take on the concrete shape of decisions keyed to specific measures. Ethical need, an intrinsic part of medical practice, arises in fact, with all its related problems, at the very moment of clinical decision, the result of an exquisitely human act which, though the expression of free will, presupposes a careful examination of all those cognitive elements that later make it possible to justify the measures taken. Clinical ethics thus represent a bridge between theoretical ethics and patient bedside ethics, and on this bridge ideas move not only in the direction of theory to practice, deductively, but also from practice to theory, inductively. Both subjects, bioethics and medical assistance, enrich one another reciprocally at the patient’s bedside because, on the one hand, the doctor is faced with a unique case, which is that of the specific patient, with his/her history, expectations and suffering, while on the other hand, there can be no clear “separation” from a more general reflection on the ethical values involved in the specific case and reference principles. Some sort of link with a more general reflection is therefore always needed, because only in this way, in the concrete decision, can a refined evaluative judgement be achieved, even though it is not just a question of adapting theoretical moral judgements to the single circumstances. The protagonists of clinical ethics, meaning those people who are called upon to take decisions, cannot refrain from taking such decisions or suspend their judgement for a moment: the decision must in any case be taken and even not deciding is an ethically important decision. The concrete situation is not just an exemplification of a principle but the existential and personal challenge of the people involved; and discussion does not bring to light simple opinions as regards what should be done, but leads to action according to what has to be done. Those involved in the clinical decision definitely have more responsibility than the academic ethicist because their personal relationship with the patient, his/her values and his/her way of reasoning have a significant effect on the decision. After setting formal reasoning aside, it is them who have to coexist with the decision, take it to its extreme consequences and face up to it in the event of similar cases in the future. Moreover, today clinical ethics have also become a matter for public debate. Every decision made by the doctor cannot but be justified with respect to the patient, to the members of his/her family, to colleagues, to judges. Consequently, all doctors feel the increasingly more impellent need for a greater systematic and formal knowledge as regards the ethical analysis of single cases; he/she must therefore start to learn to use the instruments and methods that are a part and parcel of bioethics, considering that adequate ethical training in the biomedical and clinical medical field also represents a basic factor and the guarantee for correctly exercising the medical profession. Improvised ethical decisions can therefore no longer be made at the patient’s bedside in a purely intuitive way and that is why there is a growing demand for the assistance of ethical consultants or Ethical Committees so that decisions can be pondered, analysed in all their various aspects and cleared up in terms of implied values and the consequences they can bring about. This does not cancel out the moral and civil responsibility of those who continue to be the final decision makers. This is just a help, an offer of competence that a consultant or Clinical Bioethical Service or an Ethics Committee can provide, giving concrete implementation to the interdisciplinary methodology which is part of bioethics.

 

Clinical bioethics grew up in the USA, the cradle where bioethics itself saw the light as a discipline. In 1971, the Kennedy Institute of Ethics was founded near Georgetown University, in Washington D.C. with the aim of systemising bioethics in terms of reference principles and emerging problems. Work ended a few years later (1978) with the publication of the first edition of the Encyclopaedia of Bioethics in four volumes. It was not long however before bioethics gained for itself a specific space within the Institute, which led to the establishment of the Center for Clinical Bioethics closely linked to the Faculty of Medicine and Hospital of Georgetown University and consequently in close contact with the “source” of clinical ethics problems. In this first and still one of the major “temples” of North-American clinical bioethics, we met professor Edmund Pellegrino, who was the first director of the Centre. We asked him to explain how clinical bioethics developed in the USA, (especially in the Faculty of Medicine of Georgetown University) and how this is organised inside the hospital, what type of relationship exists with the ethical committee and the possible changes in doctor-patient relationship.

Professor Pellegrino, clinical bioethics has been developing when medical ethics has moved from universities and ethicists’ offices to the places where real problems rise. In other words, the bedside. Has this development in some way changed the doctor’s decisional process? And has this change become an advantage or a disadvantage for the patient?

The shift of ethics to the clinical arena has changed the doctor’s decisional process in several ways. First, it has introduced some orderliness to the process. Physicians usually made, and still make, their ethical decisions in an intuitive way. Now they are beginning to use some of the rudiments of ethical analysis with some beginning acquaintance with ethical theory . Second, the clinical ethics consultation and the ethics committee have entered the picture and the difficult decisions are now made cooperatively. These consultations provide psychological as well as logical support for difficult decisions. As a result, physicians have had to develop greater skills in psychodynamics and conflict resolution. Third, physicians have been sensitized to the distinction between an ethical and non-ethical dilemma and therefore are better aware of the need for consultation. These are, for the most part, advantages to the patient. The disadvantages are as follows. First, physicians have come to rely too heavily on ethical “expertise” and to see ethics as growing more distant from the doctor’ s domain of interest and responsibility. Second, the close relationship between physician and patient is weakened when decisions are made in a group process. Some physicians simply accept the group decision rather than recognizing that ultimately they are responsible for any decision they make that affects the patient.

Many individuals find that the presence of an ethicist at bedside would be detrimental in the doctor-patient relationship in the sense that this would increase the number of people involved in this process, which should however remain a dyadic relation. How can the ethical consultant help this kind of relationship without altering its basis?

Ethicists can help to mitigate this diluiting influence by pointing out clearly at the outset that their function is to help the decision makers – doctor, patient, family – arrive at the ethically best decision for the patient. They must take it clear that they are not the ethics “police” and are not there to investigate or punish. Ethicists’ recommendations must be just that – recommendations – which the ultimate decisions makers (doctor, patient, family) may accept or reject. They must emphasize that no consultant, committee or expert can relieve the decision makers of their responsibility and accountability for the decisions they make.

Which qualities should a bioethics consultant have and what kind of education?

Bioethicists should be formally trained in philosophy or the logical bioethics. They must be skilled in human relationships. They must not force their opinions but state them confidently and with compassion for the difficulties the decision makers are encountering. They must avoid coercion, moral or psychological, while pointing out what they believe to be the right and the good decision. In the long run their abilities in group psychology and dynamics will be as important as their technical knowledge of bioethics.

What importance has nowadays, in American hospitals, the clinical ethics consultation?

Ethics consultations are increasingly important in American hospitals. They are required by accrediting agencies; they are used in almost every hospital; they are now recognized as an element in every day clinical practice, and patients and families in most institutions expect such a service to be available. There are as yet no broadly based empirical studies but these are my impressions on the basis of personal experiences and my travels throughout the US.

A recent study published on Journal of Clinical Ethics (2000, 11:31-38) has shown that ethics consultation can decrease health costs due to therapeutic overtreatment . Do you think that ethics consultation could actually help in avoiding medical futility?

I am very concerned when ethics consultations are linked to reduction in health costs. This is a liaison dangereuse. Economics and commodification are already too influential in American health care. Ethics consultations must focus on the ethical issue not on the possibility of saving money by discontinuing treatment. It is true that using unnecessary treatment in clinically futile cases is not ethically defensible, but this decision must be made on ethical not economic grounds. In the care of the individual patient, the economic factor is valid only if it is introduced by the patient, or his surrogate. It concerns the doctor only to the extent that he must not waste resources in futile treatment, determined on clinical, not economic, grounds. The doctor must also use a less expensive treatment provided it is as effective as the more expensive.

What kind of relationship is there between hospital clinical ethics service and the ethics Committee? Do these two bodies work independently or are (should be) linked together?

The hospital ethics committee and the clinical ethics service must be closely linked. The hospital ethics committee is responsible for policy information, in-service education in ethics, and oversight of the clinical ethics service. The hospital committee should delegate the actual conduct of consultations to the clinical ethics service. The clinical ethics service must report on its activities at regular intervals because the hospital ethics committee must be assured of the quality, extent, and nature of those consultations. An additional danger for both the ethicist and the clinician is to fall into the trap of identifying the task of the ethics consultation to be conflict resolution rather than finding the right and good decision for the patient for the patient now presenting. This is a tendency in America as a response to a pluralism, loss of religious consensus, and multiculturalism. It really is replacement of normative ethics by psychology. It neatly avoids taking a stand in difficult cases but it also avoids the difficulties of making an ethical judgement in complex issues. It is the beginning of the end of ethics as a formal search for the right and good inhuman actions

(traduzione Interpres sas-Giussano)

 

Antonio G. Spagnolo

Director of Bioethic Institute, Facoltà di Medicina and Chirurgia “A. Gemelli”, Università Cattolica del S. Cuore, Roma