The
Baker-Scofield Correspondence: 2 Letters to the editor(JLME) appear below.
To the Editor:
As I read Robert
Baker’s response to my essay, I thought that this must be one of this instances
in which, as Oliver Wendell Holmes once observed, a page of history is worth
more than a volume of logic. For
one thing, even if the field of ethics consultation has a brief history, I find
it hard to believe that anyone familiar with the primary source material
connected with that history, i.e. the articles about whether ethics
consultation ought to become a profession, would think that I am a
died-in-the-wool advocate of professionalization.1 By the same token, I find it hard to
believe that anyone familiar with the primary source material written by those
who were involved in or reported on ethics consultation could believe that the
Task Force concluded that professionalization ought to happen.2 John
Fletcher thought that the Core Competencies had put the entire matter to rest---and had proven me wrong to boot.3
Charles Bosk, another Task Force member, has gone so far as to explained that,
when the Task Force said that professionalization, certification and
accreditation were not advisable ‘at this time’, the Task Force did not mean that they would be advisable at a later time,
but that it was simply not trying to make an absolute and unqualified
statement.4 These things being so, when Baker says that he thinks the field ought to take
accreditation, professionalization and certification seriously, he confirms the
argument I made in my article, and demonstrates that it is he, not I, who needs to bone up on history.
As I further
pondered the cause of our
misunderstanding, I concluded that it boiled down to two words: formal, and new. Baker thinks that I am mistaken in
chastising ethics consultation having failed to professionalize, because he
thinks that I think it is a new, i.e. relatively young, profession. Regardless
of how new the field is—and I don’t think it is as young as Baker
does—I also don’t think about it simply in terms of its being a new, i.e.
young, profession. Rather, I think of it in terms of its being a ‘new’
profession.
One of the
characteristics of these new occupations is that they claim expertise in areas
of life that were previously outside the jurisdiction of any profession, areas
that may be loosely described as pertaining to the ‘life-styles’ of
individuals. The new professionals are constantly moving across boundaries, expanding
into new territory, disputing jurisdiction with others.
… The result of this fluidity is
what one may call a built-in imperialism[.] … This imperialistic propensity of
the new professions…has a more serious consequence than the self-aggrandizement
of this or that occupation group. … [T]he new life-style engineering is
potentially without limits.5
What this means is
that professions may now acquire their ultimate goals, i.e. power, status,
etc., in the old, formal way, i.e. visibly and overtly, as did law and
medicine, or in a new, informal way, i.e. invisibly and covertly, as ethics
consultation seems to be doing.
Whether it’s a new
or a ‘new’ profession, at bottom, ethics consultation is about the same thing:
the quest for power. I know I
clearly said that. And because saying
that ethics consultation is new cannot and does not refute the assertion that
the field is on a power-trip the gravamen of my ‘complaint’ still stands.
Baker’s attempt to change the subject and malign the messenger, which is what
those who hold the reins of power always do when they don’t like---but can’t
refute---the message, falls flat on its face. Although Baker may like to think that we are on the same
page, we could not be further apart. Only time will tell which of us is further
from the truth.
Yours sincerely,
Giles R. Scofield, J.D., M.A.
(Religion)
Clinical ethicist, Centre for
Clinical Ethics;
Clinical ethicist, Joint Centre for
Bioethics;
Associate Professor, Department of
Family & Community Medicine,
Faculty of Medicine, University of
Toronto
1.
G. R. Scofield, “Ethics Consultation: The Least Dangerous Profession?”, Cambridge
Quarterly of Healthcare Ethics 2, no.
4 (1993): 417-426.
2.
D.F. Phillips, “New Report Rejects Accrediting of Those Who Provide Ethics
Consultation Services”, Journal of the American Medical Association 281, no. 21 (1999): 1976.
3. J.C. Fletcher, R.J. Boyle, and E. M.
Spencer, “Error in Healthcare Ethics Consultation”, in S. Rubin and L. Zoloth,
eds., Margins of Error: The Ethics of Mistakes in the Practice of Medicine (Hagerstown, MD: University Press Group,
2000):343-372.
4.
C.L. Bosk, “The Licensing and Certification of Ethics Consultants: What Part of
‘No’ Was so Hard to Understand?”, in C.L. Bosk, What Would You Do?: Juggling
Bioethics and Ethnography” (Chicago,
IL: University of Chicago Press, 2008): 21-37.
5.
H. Kellner and P. Berger, “Life-style Engineering: Some Theoretical
Reflections”, in H. Kellner and F.W. Heuberger, eds., Hidden Technocrats:
The New Class and New Capitalism (New
Brunswick, NJ: Transaction Books, 1992): 3-4.
Response:
To
The Editor
Giles
Scofield appeared to be condemning bioethics for its failure to accredit
educational programs, certify the competency of clinical ethics consultants,
and develop a code of professional responsibility, when he wrote that clinical ethics
consultation “is and can only be what it purports not to be—a moral, if
not an ethics, disaster… because … of its failure to do what a profession
worthy of the name would do: formally accredit the programs that educate and train its practitioners, formally
certify and license its
practitioners, and formally
establish a meaningful, binding, and enforceable code of professional
misconduct.” [i]
Scofield now informs us that the “gravamen of [his] ‘complaint’” is that in
seeking to accredit training programs and to certify the competency of
practitioners “the field is on a power trip.”[ii] He buttresses this remark by observing
that a decade ago the Core Competencies for Health Care Ethics Consultation report issued by the American Society for Bioethics and
Humanities (ASBH) characterized the certification of clinical ethicists and the
accreditation of bioethics educational programs, “at this time,” as “premature”[iii]
because it “could encourage [an] authoritarian approach to ethics
consultation,”[iv] “undermine
disciplinary diversity, or “ lead to the institutionalization of a particular
substantive view of morality.”[v] Moreover, the report noted continued,
“it is unlikely at this time that a sufficiently reliable test could be
developed to measure the required competencies.”[vi]
Time
and experience tend to remedy prematurity; over the past decade the reasons for
concern about certification and accreditation noted in the 1998 Core
Competencies report have been
obviated. Due in no small measure
to a consensus inspired by the Core Competencies report itself, clinical ethics consultants today
embrace the multidisciplinary nature of their enterprise and reject
authoritarian models of the ethics consultation. A new report, soon to be issued by the ASBH, reiterates the
earlier report’s rejection of the authoritarian model of consultation, i.e.,
the notion of the ethics consultant as a moral dictator who authoritatively
pronouncing on matters of right and wrong. It endorses instead a version of the “ethics facilitation
model” proposed in the 1998 Core Competencies report: a procedural approach to analyzing the
sources of ethical conflict by identifying the nature of value uncertainty or
conflicts and the communication issues that give rise to requests for
consultation. The new report
portrays ethics consultants as gathering information, consulting with parties,
opening lines of communication, and facilitating the resolution of conflicts in
a respectful atmosphere with attention to the interests, rights, and
responsibilities of all involved. [vii]
On this model, ethicists serve to analyze, catalyze, inform, mediate,
facilitate, document and review ethical decision-making—not to dictate
outcomes.
The facilitation model presupposes a
series of specific skills, but in 1998 no reliable method of skills assessment
seemed apparent to the authors of the Core Competency report. Ironically,
in the very year in which the report was published the Education Commission for
Foreign Medical Graduates (ECFMG) became the first accrediting body to formally
integrate skills assessment into medical education (Step II, Clinical Skills
Assessment). The National Board of
Medical Examiners (NBME) and the Medical Council of Canada (MCC) soon
followed. Today, skills training
and assessment is commonplace in medical education. Moreover, drawing on the expertise of fellow medical
educators, leading contemporary bioethics graduate programs integrate skills
assessment, including the use of standardized patients, role-plays, and other
techniques, into clinical ethics training.
Developments in ethics consultation and
bioethics education over the past decade—the dominance of a
multi-disciplinary facilitation model, the development of skills assessment
methodologies—obviate the concerns about accreditation and certification
raised in the 1998 Core Competencies report. Not unreasonably,
the ASBH is now engaged in a professionalization project: developing standards
of professional responsibility for clinical ethics consultants, issuing a new
report on core competencies for clinical ethics consultation (due to be
published in 2009), and exploring the possibility of credentialing ethics
consultants and accrediting clinical ethics education programs.
Scofield characterizes the ASBH’s efforts as a “power
trip.” This characterization
inverts reality. In fact, clinical
ethics consultants are already empowered:
fellow healthcare professionals, the institutions that employ ethics consultants,
the patients and families who confide in them—society—have already
entrusted clinical ethics consultants with enormous advisory authority and
influence, “power,” so to speak.
The professionalization of clinical ethics consultation is thus not
about “power” but about the responsible and accountable use of the authority
and influence invested in clinical ethics consultants. Everyone who works in a clinical
context should be held accountable to standards of responsible conduct and
practice; every program that trains healthcare professionals should also be
held to educational standards.
Clinical ethics consultation is no exception. As Scofield aptly remarks, bioethicists are obligated to do
“what a profession worthy of the name would do: formally accredit the programs that educate and train its
practitioners, formally certify
and license its practitioners, and formally establish a meaningful, binding, and enforceable
code of professional misconduct.” [viii]
To reiterate, ethics consultants have already been
deeded “power” in the form of advisory influence and authority, the wisdom of
our culture, as parsed over the centuries by apostles (Luke 12:48), poets,
presidents and popular culture icons, is that “with great power, comes great
responsibility.” For the ASBH to
fail to professionalize as the field of clinical ethics consultation matures
would be irresponsible. However,
in the light of the concerns raised in the 1998 Core Competencies report, it is eminently reasonable for Scofield to
question whether those seeking to professionalize have addressed the concerns
about certification and accreditation raised a decade ago. As someone directly involved with the
ASBH’s professionalization project,[ix]
and as a member of the society’s Clinical Ethics Consultation Group, I would
like to thank Scofield for publicly raising the issue, thereby giving us the
opportunity to reassure him and the wider community that we have considered
these issues and we have concluded that now is the appropriate time for ethics consultation to
professionalize and that failure to do so would be irresponsible.
Robert
Baker, PhD
Director
& Professor of Bioethics
Union
Graduate College-Mount Sinai School of Medicine Bioethics Program
William
D. Williams of Philosophy, Union College
