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This is a short, punchy, book that sets out to make a single point – clinical ethics consultants need to be free to step beyond the boundaries of conceptual analysis and should be able to offer practical advice about how to act. The book develops an argument about why and how this can be achieved.
The book is set out in four chapters. Chapter 1 discusses the role and expertise of clinical ethics advisors. It locates the groundwork for the idea that clinical ethics needs to combine good problem analysis with prescriptive recommendations (p.12) in the developing context for ethics, to which philosophers bring particular skills. Awareness has changed on issues such as consent, confidentiality, protecting research participants, enhancing rights, children, respect for patients, the paternalism of medical care etc. We now commonly encourage all voices to participate in ethical discussion and decision making, so it is reasonable that the philosopher / ethicist will also bring their skills to bear on recommending solutions (thus moving from analysis to advocacy, but with care). "The analytic, conceptual, and theoretical skills ... serve as the intellectual core, but they clearly must be supplemented by experience based on moral wisdom; the ability to listen with care and discernment; the ability to speak and write with clarity and precision; skill at managing egos, emotions, and political environments ..." (p.29). The philosopher also needs background and experience in the clinical environment, and to be recognized as a valued team member, for their contributions to be effective.
The following three chapters give the context and application of this approach to clinical ethics consulting. Chapter 2 builds a model for ethics reasoning that guides the advocacy approach. Meyers discusses, albeit very briefly, ethics models and principles which lead him to propose a seven step reasoning process (p.42-3). This should in no way be viewed as a prescriptive process; rather it sets out the characteristics of the reasoning that underlies sound ethics advice. Meyers goes on to show how this process can be applied and how it affects other areas such as the educational role of the ethics advisor.
Chapter three argues that all of this advice and discussion occurs within a social context and that therefore ethics cases must be viewed within their social context. "Their causes, their potential solutions, their very identification as ethics cases are in large part determined by the context in which they are embedded. Context serves as the foundation for clinical ethics, and yet the literature gives it scant attention ..." (p.63). The chapter contains several case studies which outline particular context issues and point towards solutions. While I agree with the argument, I felt that the point was a little too labored; it is already widely accepted by philosophers.
The final chapter (Why Good People do Bad things) contextualizes the value of sound ethics advice. Traditionally poor ethical judgments are seen as emanating from mistakes, human weaknesses or simply a choice to do wrong (p.91). However, Meyers argues that organizational culture is at least as influential in decision making as personal values and ethics. "... the organizational ethos is considerably more complex and subtle. The observer is not just looking for explicit rules, power and turf, or even for body language and social approval; she is also trying to understand how the ethos determines institutionally grounded meaning. ... key ethical concepts, like autonomy, futility, and informed consent, derive their meaning in large part through the organizational culture." (p.95). The chapter discusses how to understand and address culture as part of ethics. While I take the point that Meyers is not seeking to provide a philosophical treatise but is defending a particular approach, I found this chapter somewhat problematic. It raises more philosophical issues than it addresses, including issues about meaning, communication (including incommensurability), the implementation of decisions, the busyness of medical professionals and so forth. Meyers offers an interesting ethnographic approach that I would like to see further developed.
Given that I work in the area of ethics advice, albeit in research, the argument of this book accords well with much of what I do. Meyers develops a theoretical basis or model for the work that I do (often intuitively). In this regard, I felt that the book is possibly a little too narrowly focused. Ethics advice is given more widely than just ethicists employed in clinical (hospital) settings. It would be interesting to see some additional material that draws on other areas of ethics advice e.g. in research or industry settings and shows how Meyer's model has wider applicability (as I am convinced it does).
All in all this is a worthwhile read for anyone involved in giving ethics advice, for chairs and members of ethics committees, and for the recipients of ethics advice (particularly professionals in clinical settings). The book offers a refreshing view of the role of ethics advice and articulates a model to broaden the function and relevance of this advice from analyst to advocate. An enjoyable read.
© 2008 Erich von Dietze
Erich von Dietze, Manager, Research Ethics, Murdoch University, Western Australia
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