Last fall readers of this magazine were invited to present “thorny professional situations” to a panel of “bioethics experts,” who would discuss the dilemmas raised in an article in Yale Medicine (“Two Alternatives, Each a Little Wrong,” Spring 2004). In that article, it was noted that the bioethics committee at Yale-New Haven Hospital includes “ethicists” in addition to doctors, nurses, lawyers, social workers, clergy and members of the community. The initial inquiry, the discussion and the description of the committee prompted me to ask, what exactly is a “bioethicist” anyway?
I have served on an ethics committee at the Columbia-Presbyterian Medical Center for more than 20 years, as chair of two institutional review boards for 18 and as director of the psychiatric consultation service in a general hospital for 35. I have been involved in attempts to resolve scores of ethical dilemmas. Does this qualify me as a bioethicist? Apparently it does, if I choose to anoint myself as one. And therein lies the problem.
In many situations the designation “bioethicist” grants individuals authority that they did not have the day before they assumed that role. In my opinion, studying bioethics as an academic discipline does not provide any special wisdom in the resolution of a clinical ethical dilemma, and it is wisdom that is most needed. Before I begin to sound like an academic Neanderthal, I want to make clear that I do believe such study is useful in identifying the basic principles that may underlie these clinical decisions. However, while the ability to identify paternalism, beneficence or autonomy as manifested in a particular decision may provide some clarity, it does not provide the analyst with any greater sagacity in making it.
As a psychiatrist, I am also particularly troubled to observe that emotional conflicts, which are often at the root of such problems, can be ignored in a quest for an overriding ethical principle. Even when emotional conflicts are acknowledged, they are often framed using a legal/business model requiring negotiation, mediation or arbitration. The American Society for Bioethics and Humanities includes among its core competencies for a clinical ethicist the skills needed to identify the conflict that underlies a need for consultation and the ability to recognize and attend to various relational barriers in communication. These skills are not easily acquired in a classroom or a brief clinical assignment.
In the examples presented in the Yale Medicine article, the bioethicists disagreed on an appropriate course of action or policy. This is not surprising, since such decisions are ultimately subjective and more likely to reflect personal beliefs than knowledge. For example, in the bioethics textbook Taking Sides: Clashing Views on Controversial Issues in Drugs and Society, opposing points of view are expressed on 21 out of 21 issues. At the symposium on clinical ethics at the 2004 Yale Medical School Reunion, Robert J. Levine, M.D., HS ’63, professor of medicine, co-founder of the hospital’s ethics committee and a leader in this field, stated that a medical decision should never rest on the advice of a single bioethicist, although hearing a pair of ethicists discuss their reasoning can be illuminating. Aristotle took this a step further, advising that in ethics it is often best to consult “the many” as well as the “wise.”
Therefore, it is particularly worrisome when bioethicists, especially those without clinical experience, overly influence medical decisions.
A similar problem, the influence of personal opinion rather than knowledge, also exists in the establishment of governmental health and research policy. We know that presidents have chosen to appoint to bioethics commissions individuals who share their personal beliefs. A recent article in The New England Journal of Medicine written by a former member of President Bush’s Council on Bioethics describes her experience as a politically incorrect council member who was not reappointed, which illustrates this only too well.
Nevertheless, I do believe that the discussion of ethical issues in clinical matters and public policy is useful. Scholars of bioethics add an intellectual dimension to such deliberations that can help participants arrive at useful consensus judgments. However, we should question the basis for attributing superior wisdom to bioethicists, thereby increasing their authority in finding resolutions to “thorny professional situations.”