HEC Forum (2014) 26:325–341 DOI 10.1007/s10730-014-9240-x
Conceptualizing Boundaries for the Professionalization of Healthcare Ethics Practice: A Call for Empirical Research Nancy C. Brown • Summer Johnson McGee
Published online: 29 June 2014 Springer Science+Business Media Dordrecht 2014
Abstract One of the challenges of modern healthcare ethics practice is the navigation of boundaries. Practicing healthcare ethicists in the performance of their role must navigate meanings, choices, decisions and actions embedded in complex cultural and social relationships amongst diverse individuals. In light of the evolving state of modern healthcare ethics practice and the recent move toward professionalization via certification, understanding boundary navigation in healthcare ethics practice is critical. Because healthcare ethics is endowed with many boundaries which often delineate concerns about professional expertise and authority, epistemological reflection on the relationship between theory and practice points toward the social context as relevant to the conceptualization of boundaries. The skills of social scientists may prove helpful to provide data and insights into the Typically, when invited to a consult, we are asked to fill one or more particular roles including that of bioethicist, feminist, peer, expert consultant or moral observer…. As such, one of the issues we struggle with is how to set clear expectations for our participation in the consultation process and how to resolve tensions between roles without violating our own moral commitments or ending up at the margins, as a token or as an outsider. (p. 143). Canadian bioethicists Susan Sherwin and Francoise Baylis (2003) reflecting upon their own healthcare ethics consultation experiences. Public Affairs Quarterly 17 (2) April 141–158. Social scientists who remain observant outsiders and ask unsettling questions undoubtedly prove great benefit. Yet surely bioethicists should not hesitate to take social science perspectives and tools into greater account. In their role as advocates for certain visions of the good, bioethicists need what empirical researchers can offer: a variety of powerful means for getting from here to there. (p. 46). Bioethicist and social scientist Mildred Z. Solomon (2005) reflecting on her work as a social scientist in bioethics. Hastings Center Report 4 July–August 40–47. N. C. Brown (&) St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB R3H 2A6, Canada e-mail: [email protected]; [email protected] S. J. McGee Department of Public Management, College of Business, University of New Haven, 300 Boston Post Road, Gatehouse 202, West Haven, CT 06516, USA
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conceptualization and navigation of clinical ethics qua profession. Empirical ethics research, which combines empirical description (usually social scientific) with normative-ethical analysis and reflection, is a way forward as we engage and reflect upon issues which have implications for practice standards and professionalization of the role. This requires cooperative engagement of the descriptive and normative disciplines to explore our understandings of boundaries in healthcare ethics practice. This will contribute to the ongoing reflection not only as we envision the professional role but to ensure that it is enacted in practice. Keywords Boundaries Clinical Ethics Empirical Ethics Healthcare ethics practice Professionalization
Introduction One of the challenges of modern healthcare ethics practice is the navigation of boundaries. Practicing healthcare ethicists (PHEs)1 in the performance of their role must navigate the meanings, choices, decisions and resultant actions ‘‘embedded in complex webs of cultural and social relationships’’ amongst diverse individuals (Bliton and Finder 2002, p. 234). The field of healthcare ethics itself is endowed with many boundaries, which often delineate concerns about professional expertise and authority. Indeed, the reflection by Sherwin and Baylis (2003) above illustrates the tensions within and between these boundaries and the possible movement to the ‘‘margins’’ as an ‘‘outsider’’ as a result of their struggle to assert potentially conflicting roles. The idea of pursuing the ‘‘professionalization’’ of the healthcare ethics role has been explored in a number of arenas for a number of years2 and alongside this discussion, there have been needed and productive contributions towards delineating core competencies and characteristic attributes of healthcare ethicists.3 Calls for 1
It is acknowledged that there are a number of descriptors and references used to denote those who are in clinical ethics practice, including, but not limited to, ethics consultant, clinical ethicist, ethics practitioner, and related variations. In the Canadian context, the term Practicing healthcare ethicist (PHE) has been intentionally developed, in part to facilitate maintaining a broader focus. ‘‘A PHE has dedicated work responsibilities within a healthcare organization to provide a variety of ethics-related services which include one or more of the following: clinical and/or organizational ethics consultation; policy development and/or review; ethics education for staff; management of ethics programs (including clinical ethics committee); mentoring of staff/learners; and conducting research ethics consultations’’ (Simpson 2012, p. 149–150). Other descriptors will appear in relation to a specific reference or point of discussion as appropriate.
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See for example: Baker (2007, 2009); Bishop et al. (2010); Clinical Ethics Consultation and Affairs (2010); Engelhardt (2009); King (2007); Scofield (2008); Spike (2009); Simpson (2012); Steinkamp et al. (2008).
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Examples include: The Core Competencies for Healthcare Ethics Consultation (2011) developed by the ASBH, and the accompanying Improving Clinical Competencies in Clinical Ethics Consultation: An Education Guide (2009) as well and the Canadian Bioethics Society Task Force on Working Conditions for Bioethicists 2008, in Chidwick et al. (2010) and the Canadian based draft of the Draft: Model Code of Ethics for Bioethics (MacDonald), Draft Code of Professional Responsibilities of Health care ethics Consultants Clinical Ethics Consultation Affairs Committee, (2011).
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greater attention to the need for epistemological reflection on the relationship between theory and practice in the healthcare ethics realm have also been growing.4 As Chadwick et al. (2007) observe, in the last decade of the twentieth century, work in the social sciences in bioethics has become more prominent and has given rise to ‘‘an empirical turn’’ which points toward social context as relevant, calling for closer attention to the relationship between normative and descriptive ethics (p. xv). Sociologist Raymond De Vries (2003) distinguishes the social sciences of bioethics from the social sciences in bioethics. Those that work in bioethics are collaborative, lending their skills to bioethics in order to describe opinions and perspectives, explore how organizations work and describe the impact of policy, which can provide important contextual information (p. 283). Applied ethicists have increasingly combined empirical (usually social scientific) research with normativeethical analysis and reflection now commonly called ‘‘empirical ethics.’’ This is described not as a methodology of doing ethics, but as a ‘‘basic methodological attitude to using the findings from empirical research in ethical reflection and decision making’’ (De Vries and Gordijn 2009, p. 193).5 There is work underway with respect to the need to address practice standards for clinical ethics consultation throughout the U.S. and Canada. In Canada recent discussions have focused on the importance of ‘‘context, process and principles (not just outcomes) in the exploration of and possible movement towards professionalization’’ (Frolic 2012, p. 153). The movement to professionalize has resulted in some spirited exchanges, which have been reflected in the literature. This has included charges that PHEs have ‘‘studiously and self-interestedly evaded’’ discussions concerning the limits of expertise, methods and scope of practice. As Giles Scofield (2008) asserts, Turn to the medical ethics consultation, and what one discovers is not that discussions of boundary issues are absent, but that medical ethicists publically discuss the problems that boundary issues pose to other professionals, and try as best they can to bury those issues insofar as they concern them, what they do, or how they do it.6 (p. 105) While it is almost universally accepted that boundaries matter, particularly as health care ethicists are often charged with the task of instructing others on these questions, the boundaries that matter for PHEs (and for other healthcare providers) are multiple, poorly understood, and undefined or backed by empirical data. Moreover, the way forward in better understanding and defining these boundaries is not always obvious (Heesters 2012, p. 173). Empirical ethics research offers the best option for engaging these critical questions in theory and in practice. Cooperative engagement 4
Arnold and Forrow (1993); Aulisio (1999); Austin (2007); Birnbacher (1999); Crigger (1995); De Vries and Conrad (1998); De Vries (2003); Engelhardt (2003); Farmer and Gastineau Campos (2007); Hoffmaster (1992, 2001); Nelson Lindemann (2000); Marshall 1992; Musschenga (1999); Pearlman et al. (1993); Van der scheer and Widdershoven (2004); Zussman (2000).
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De Vries and Gordijn cite as examples, Sulmasy and Sugarman (2001); Holm and Jonas (2004); Borry et al. (2005); Musschenga (2005).
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Scofield uses the descriptor ‘‘medical ethics consultant’’ throughout his paper to describe ethicists working in healthcare settings.
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of empirical ethics research is required in order to explore understandings of boundaries and their relevance for PHEs. This will contribute to needed data and reflection as we move towards the professionalization of the PHE role as well as help to ensure that it is enacted in practice.
Embracing the ‘‘Empirical Turn’’ for Clinical Ethics As Light and McGee (1998) note, North American bioethics was patterned after the field of philosophy to produce a rational and decontextualized discourse. Bioethicists historically depicted sociological studies as irrelevant to their discipline because they feared being influenced too strongly by historical and sociological contextualization, putting them at risk of cultural and ethical relativism. Two decades ago Fox and Swazey (1984) voiced concerns regarding the limited interaction between sociology and bioethics arguing that as the field has evolved, it has lost sight of the importance of the groups and communities to which it belongs. As Borry et al. (2005) posit, the fundamental reason that bioethics keeps empirical approaches outside its borders has to do with the usually strict distinction between descriptive and normative ethics. Yet he reminds us that ‘‘[d]escriptive ethics is the field in which empirical data about moral issues are gathered. It is the domain par excellence of sociology, anthropology, psychology, and epidemiology, and it aims at describing peoples’ temporal values, rules, preferences, norms and actions’’ (p. 60). Because of this historical and conceptual divide between the normative and the empirical, the role of social context in healthcare ethics work has historically been under acknowledged and appreciated. It has been asserted that bioethical theory, itself, has failed to account for the actual experiences of practitioners in real time and space (Peter and Liaschenko 2003, p. 259). As Rubin and Zoloth (2004) observe, clinical ethics needs to evolve so that it is responsive to the larger context of healthcare practice and ‘‘doing’’ clinical ethics means making ethics an integral part of an organization with issues raised day-to-day, not just during crises (p. 223). As Borry et al. (2005) note, ‘‘from its inception, bioethics has developed as an interdisciplinary field with methodological and epistemological input from many different disciplines, including law, philosophy, theology, medicine, biology and the social sciences. This tradition of discourse seems to support the notion that input from different fields can improve analysis and the finding of solutions to various problems’’ (p. 54). As Henk et al. (1998) posit, ‘‘descriptive ethics is geography: it maps the moral domain…’’ (p. 270). Given the powerful effect of disciplinary and professional specialization, Verkerk and Walker (2009) advocate ‘‘not only for a view from below but also for varied horizontal views of disciplinary frameworks and professional practices.’’ In their estimation, this should encompass a variety of structured inquiries (social and natural sciences, philosophy, history, literature and criticism) and institutionally differentiated practices (research, clinical, public
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health and management practices), which holds potential to ‘‘provide revealing viewpoints on each other’s embedded evaluative assumptions’’ (p. 6). Further, as Chadwick et al. (2007) note, it has been generally recognized that no one discipline can deal with the full extent of the issues in bioethics, and disputes about which discipline is primary have occurred, which has given rise to controversy. As Borry et al. (2005) remind us, the interdisciplinarity of bioethics as a field is plagued with gaps between the disciplines related to cognitive and conceptual dissonance, culture or style, or lack of training to appropriately judge or assess research results of the various disciplines. Further, ethics and empirical approaches start from different research questions. Ethics is interested in conceptual clarification and normative justification, and empirical approaches are focused on description as well as reconstruction and analysis. These ‘‘divergent’’ orientations make bioethics a prescriptive discipline involved in moral evaluation and empirical sciences a descriptive discipline that stresses the setting. As Borry asserts, this ‘‘interdisciplinary gap also can result in opposing objectives that limit the conversing disciplines in their interaction’’ (p. 54) Yet, the so-called ‘‘empirical turn’’ related to the increasing prominence of the social sciences has pointed to the ways in which ‘‘social context is relevant in ethics and has demonstrated that there is a need for bioethics as a field to be reflexive, considering its own methods and theoretical approaches’’ (Chadwick et al. 2007, p. xv). Nelson Lindemann (2000) for example, has argued for an interactive model between normative and descriptive ethics which can contribute to not only our understanding of ethical issues, but also the understanding of social processes through which those issues become constituted as ethical concerns (p. 16). He proposes that there is a need to invert ‘‘common wisdom’’ about the relations between the normative and the descriptive, or how the ‘‘is,’’ relates to ‘‘ought’’ (p. 12). He also concurs with Urban Walker’s call for an ‘‘empirically saturated understanding of social life’’ which underscores the variety of ‘‘human motivations, arrangements, and forms of life and sees ethics largely as the effort collectively to build and renew social practices that make the ways in which responsibilities and rewards are distributed through societies as clear as possible’’ (p. 17). De Vries (2003) proposes that as the healthcare ethics profession ‘‘matures’’ the ‘‘voice and effect’’ of the role may be altered and as the field of bioethics grows and solidifies its position, the skills of social scientists will become more important. Acknowledging that the relationship between sociology and bioethics to date has been an ‘‘uneasy’’ one, he advocates for a relationship between the two disciplines, which might be helpful to bioethical practice (p. 289). As Haimes (2007) points out, ethicists as individual and collective practitioners of their discipline, however varied in their approaches and interests, are members of professional and other social groupings and are thus subject to the influences of, and in turn influence broader social changes and developments. ‘‘At the very least’’ she argues ‘‘there is some interest for bioethicists in seeing themselves in a social context, even if there is a resistance to seeing their subject in such a way’’ (p. 36).
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Boundary Navigation and the ‘‘Social Situation’’ of PHE Practice The notion of boundaries has been a theme in recent years for various sociological approaches to social inequality, collective and national identity, class, gender and ethnic relations, as well as for the sociology of science, knowledge and the professions (Lamont and Molnar, 2002). Sociologists of science, medicine and the professions have paid considerable attention to the processes of boundary demarcation by which scientific disciplines and modern professions seek to secure an autonomous stance, gain legitimacy, mark and defend ‘‘turf’’ and expand jurisdiction (Gieryn 1983, 1999; Freidson 1988, 2001; Abbott 1988). While these studies have drawn attention to the link between boundary demarcation and social domination and emphasize the dynamic nature of boundary formation, they have not situated their research in the day-to-day arenas where social actors negotiate social and symbolic boundaries. PHEs in their daily work necessarily negotiate, for better or worse, these social and symbolic boundaries by, for example, simultaneously filling the roles of clinician, patient educator, and ethics specialist and performing activities of each of these roles throughout the consultation process. Their experiences of role and boundary navigation, if explicated more fully through social science approaches, may provide valuable data that could foster opportunities for reflection on the conceptualization of boundaries as we work towards standardization and professionalization of the role. In making the case for greater understanding of boundaries in the day-to day practice of health care ethicists, this inevitably draws upon and is inclusive of not only bioethics as an (academic) field, but ‘‘ethics’’ as understood within our various diverse healthcare institutions and organizations. Chambliss’ (1996) study is illustrative of how social science research and its descriptions of institutional context can reveal factors that influence moral action within complex healthcare environments. His ethnography of nursing outlined the moral dimensions of hospital life and the many ways ‘‘ethics’’ is used in health care organizations. In the health care setting, it is commonly assumed that ethical problems can be resolved through reason and the application of abstract principles, for and by individuals. Chambliss viewed this conceptualization as theoretically compelling but lacking in empirical support. His research determined that ethical dilemmas often arose out of the organization of work and clash of worldviews of groups over what to do in specific cases and that ethical problems were often addressed not by reference to values or principles or even by the group closest to the situation at hand, but by the group with most power.7 Chambliss’ call for empirical approaches, which moves discussion away from ‘‘hypothetical scenarios to real settings’’, and draws attention to ‘‘the social and psychological realities of hospital life’’ (pp. 6–7), may also help to move health care ethics practice to a place of broader awareness and understanding concerning the structural challenges to moral action in current healthcare settings. 7
This includes conflicts amongst physicians and nurses, and physicians and administrators. Chambliss acknowledges that hospitals may have ethics consultation teams, which stand as proxies for the organization, but more often than not, ethics teams in his study saw these problems as ‘‘technical’’ and deferred to authority of physicians. His findings draw attention to how the ‘‘place’’ of the healthcare ethicists is defined and experienced in our diverse institutions and organizations in our current context.
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Margaret Urban Walker’s work (1993, 1998, 2007, 2009) has effectively drawn our attention to the relevance of the social aspects of healthcare ethics practice and the processes of boundary navigation. In her discussion of philosophical ethics, bioethics and the healthcare ethicist’s role from a feminist and naturalized bioethics perspective,8 she emphasizes the ‘‘social situation of morality.’’ In her discussion of the ‘‘moral spaces’’ of healthcare ethics consultative work, she has proposed that our ‘‘moral understandings are always embedded in and make sense of a particular social setting and its characteristic relationships, problems, and practices’’ (1993, p. 34).9 As she asserts, Since the mid-1980’s concerns about what the ethicist does have moved to the fore. Matters at issue include: different institutional functions of ethicists; the differing kinds of responsibility, authority, and accountability that should accompany them, how the ethicist fits within the criss-cross of relationships among healthcare providers, patients, families, and caretakers, and how moral deliberation within healthcare institutions connects to the larger social arenas of moral consensus and conflict. (p. 37) Urban Walker (1993) acknowledges the embedded routine and hierarchy of healthcare work settings, and in light of this situation, proposes that the ‘‘institutionalization’’ of the ethicist role is probably the only way to ‘‘reliably and authoritatively mark and open moral reflective spaces.’’ However, she also cautions that the effectiveness of these spaces and shared moral deliberation requires a ‘‘different kind of authority’’ (p. 38). She urges us to think of PHEs as ‘‘architects’’ of moral space within the healthcare setting, and as ‘‘mediators’’ of the conversations taking place within that space (p. 33). It is her hope that these two images might be further explored as we reflect upon the concept and practice of healthcare ethics work. Urban Walker’s perspective draws attention to how in dayto-day practice, boundaries are and should be conceptualized and whether this spatial metaphor even adequately captures the relevant aspects of the PHE role. Indeed, an added overlay of complexity to the embedded routine and hierarchy of healthcare settings is the fact that PHEs in our current healthcare context often serve in multiple and potentially overlapping roles. Further, when boundaries are utilized as an organizing metaphor for the ethics of relationships, certain discourses are necessarily brought into play while others are crowded out. Combs and Freedman (2002) for example, caution us that a focus on boundaries can oversimplify complex issues resulting in the discourse of ‘‘separation and individuation’’ being valued at 8
Urban Walker (1998, 2007,) has forwarded an ‘‘expressive-collaborative’’ model of morality, which is best revealed in practice through the socially accepted patterns of assigning and deflecting responsibility. In her view these practices reveal, ‘‘shared understandings’’ of who we are, what we value, and to whom we are required to account for our actions. In this view morality is ‘‘collaborative.’’ Along with Lindemann et al. (2009) she has also forwarded a ‘‘naturalized bioethics’’ espousing that ‘‘self-reflexive, socially inquisitive, politically critical, and inclusive’’ ethics that is ‘‘empirically nourished but acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments (p. 5).
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Emphasizing narrative as the pattern of moral thinking, she has asserted that it is ‘‘a way of seeing how morally relevant information is organized within particular episodes of deliberation… narratives in moral thinking come before, during, and after moral generalities’’ (p. 35).
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the expense of the discourses of ‘‘interdependence, collaboration, and community’’ (p. 205). Furthermore, ethical action necessarily takes place in community. As Austin (2007) emphasizes, this interdisciplinary understanding of the ‘‘moral space’’ of healthcare environments and the multifaceted challenges arising within them, holds potential for new ways of thinking about and of methods for addressing those challenges and responding to day-to-day experiences. (p. 85–86). Issues of power and authority in these healthcare communities requires our attention, not just as ethical issues, but as organizational and structural issues, as we reflect upon boundaries in PHE practice. This is a critical contribution that can be made by social scientific approaches employed by other fields like organizational behavior and industrial/organizational psychology as applied to the health care setting. Attention to the issue of authority and (moral) expertise in healthcare ethics practice is a necessary part of this reflective process. Tronto (2011) undertook a relational analysis and emphasized the political dimensions inherent in practice. In her recent discussion of ‘‘who’’ is authorized to do applied ethics she argues that it depends not upon ‘‘what justification practitioners of applied ethics offer, but rather on their social and political location, thus, where applied ethics occurs.’’ These locations Tronto asserts, ‘‘put people with different levels of social responsibility, respectability, and power in relationship with one another,’’ which ‘‘force[s] a genuine ethical encounter.’’ She advises that even though the dispute between ‘‘internalists’’ and ‘‘externalists’’10 may be unresolved, practitioners of applied ethics need to confront ‘‘theory’’ on another level. In her view, a thorough understanding of the grounding of the field will require that we also think about the inevitable political and democratic qualities of our principles and practices (p. 416). Closely related to this discussion about authority and expertise is the historical and ongoing tensions related to the ‘‘insider/outsider status’’ of health care ethicists. As Simpson (2012) observes, discussion in the literature seems to reflect relative advantages and disadvantages of being (seen to be) in either position. She draws attention to Rubin and Zoloth’s (2000) observation, that a significant portion of bioethics is ‘‘riddled with the covert presupposition that the ethicist, as outsider, can offer a helpful, critical perspective to those who are struggling more directly with the ethical dilemmas that arise in clinical practice’’ (p. 195). Frolic and Chidwick (2010a, b), in their study concerning conflicting interests of ethicists, found that PHEs might be particularly vulnerable to role conflicts in their first year in a new organization when boundaries and relationships are still forming. In light of these findings, how and whether the development of practice standards might facilitate the identification and assessment of the relative advantages and disadvantages of the 10 Beauchamp (2003) describes the ‘‘appropriate sources of content’’ in applied ethics as distinctive from ‘‘internal’’ and ‘‘external’’ perspectives. Proponents of the ‘‘internal’’ perspective view applied bioethics as arising from the issues, practices, questions and dilemmas that arise from within each practice itself. Proponents of the ‘‘external’’ perspective view applied bioethics as arising from the application of issues, precepts, and standards that have a place in another moral realm (such as deontological or utilitarian systems) or an account of ‘‘common morality’’ to issues, practices, questions, and dilemmas that arise in the practices under consideration. This difference in content also reflects a difference about the kinds of moral judgments that will count as ‘‘authoritative’’ (see Tronto, p. 409).
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‘‘insider/outsider’’ positions is relevant. This ‘‘tension between these two positions’’ is perhaps something that PHEs need to acknowledge and potentially even ‘‘embrace’’ as part of day-to-day practice (Simpson 2012, p. 223).
The PHE Professionalization Process: Why Boundaries Matter While PHE’s often occupy a unique position within their organization, the role to date has few authoritative practice guidelines (Tarzian 2009) and those performing this role have varied education and training (Fox et al. 2007). As Cline et al. (2013) point out, PHEs are often employed in circumstances where full understanding by even their employers of what they actually do or the value they can add to their work environments is lacking. These authors, writing in the Canadian context, acknowledge that the ‘‘unique facets of this role, the lack of defined standards for ethics services, the informal nature of ethics leaders’ leadership, and the political volatility of many of the issues that are de rigueur in ethics practice’’ have led some PHEs especially those early in their careers, to report (anecdotally) feeling as if they had been ‘‘cast into the wilderness with no one to guide them’’ (p. 212). As the role has evolved, PHE practice has expanded from clinical ethics consultation to include organizational ethics and policy work amongst other various duties and responsibilities. This situation urges us to critically think about, and reflect upon, the conceptual grounding and justification of our understanding of boundaries related to practice standards and the continued movement towards professionalization. This should include closer attention to the social context of practice and consideration of the possible value that might be drawn from the social sciences to ensure thorough reflection on this important issue. Social theorists have made calls to reframe the division of labor in the healthcare context in dynamic terms. Occupational roles in this view are not self-evident, but have to be actively negotiated within a system, or ‘‘jurisdiction’’ has to be claimed and sustained in the work area. Thus, merely performing ‘‘skilled acts’’ and justifying them ‘‘cognitively’’ is not necessarily to hold jurisdiction. As Andrew Abbott (1988) proposes, in claiming jurisdiction, a profession asks society to recognize its cognitive structure through exclusive rights; jurisdiction has not only a culture, but also a ‘‘social structure’’ (p. 59). He points to the ‘‘division of labor’’ in the ‘‘team concept of medicine and social services’’ as an example of the restructuring of professional work, positing that ‘‘professional knowledge’’ is now encoded in the structure of organizations themselves (pp. 325–326). As Abbott posits, to say, ‘‘that a set of closed boundaries exists is logically equivalent to saying that a social thing exists’’ (1995, p. 860). In his view, much expertise therefore resides in the ‘‘rules of these and other organizations of professionals’’ and he advocates for the study of ‘‘actual work’’ rather than of single professions, which he proposes, will bridge the gap between theory and empirical realities (p. 326). This type of theorizing is relevant to how we think about the process of professionalization of the PHE role and how boundaries are conceptualized because it advances beyond the conventional sociological literature. That is, it focuses on the processes through which occupations constitute themselves, relative to others, as
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professions. As Abbott (1988) emphasizes, the term profession is not ‘‘objectively’’ definable precisely because of its power and authority in our culture (p. 318). Previous contributions by Foucault have drawn the focus to those who have certain key positions in the knowledge economy, which has helped to illuminate the need to understand practices and the relations of power inherent in them (1963, 1966, 1969, 1975). This presents issues of particular interest to sociologists, which includes the formation of knowledge and disciplines, the nature and effects of practices of control, and the constitution of actors and identities (Power 2011, p. 52). Indeed, healthcare settings are not simply as they present themselves (places of treatment and cure), but they are also scenes in which ‘‘subjects [such as PHEs] are being created so as to fit into relations of power’’ (Frank and Jones 2003, p. 180). In order to address the field’s traditional boundary distinctions between normative and descriptive disciplines, cooperative engagement between the normative and descriptive disciplines is a way forward in the exploration of the field’s understanding of boundaries, both conceptually and in practice. This will help to foster reflection as we move toward professionalization of the role. For healthcare ethics to be informed both by what actually happens in healthcare practice and by the way in which practitioners think about moral issues is increasingly considered meaningful, and we need empirical accounts of PHE practice, boundary conditions, and settings. As Van der Scheer and Widdershoven (2004) point out, the meaning which practitioners give to their situation and the reasons they have for their actions are relevant issues for ethical consideration because they already contain a normative evaluation of the situation. Normative knowledge embodied in practice can be made explicit by ethical analysis. Thus, ethical analysis can enrich practical experience. (pp. 72–73) While these authors acknowledge that perhaps an integrated empirical approach is neither good nor necessary for each and every problem or question, it is a tool that may be used in dealing with problems for which a community, a practice or culture has not yet developed rules, principles or virtues (p. 78). This methodological stance may offer an opportunity to give critical examination to and to derive normative guidelines in experience within the specific praxis of the PHE role. While others may take issue with these assumptions about the nature of social scientific research (such as egalitarian approaches to social science data and narrative) it is crucial that any attempt to understand empirical ethics as a contributor or collaborator to health care ethics practice must accept the scientific method and concept of validity and reliability as given and non optional. It is acknowledged that collaborative and/ interdisciplinary research can be complicated by different disciplinary boundaries, paradigms and working practices. However, collaborative social science research into understandings of boundaries within the multidisciplinary and applied settings such as healthcare environments holds potential to illuminate the values inherent in health care ethics practice, rendering assumptions open to debate, stimulating reflection and development of critically oriented knowledge and ultimately, increasing the capacity of PHEs to influence the social, political and economic determinants in their health care institutions and systems.
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A Call for Cooperative Engagement: Engaging Descriptive and Normative Disciplines to Conceptualize Boundaries in Practice Past microanalyses of boundary demarcation and healthcare settings have highlighted the ways the actors’ professional, structural and spatial position in the hospital setting shape their epistemological, ideological and ethical views of their daily work (viz., Anspach 1990, 1993; Chambliss 1996). As Frolic (2011) observes, ‘‘few clinical bioethicists have provided ‘thick description’ of the lived experience of their practice’’. Instead, ‘‘articles on methods and roles in EC [ethics consultation] tend to function as homilies, arguing what ethics consultants ought to do, rather than describing the lived experience of the doing.’’ This practice in her view actually reinforces characterizations of healthcare ethicists as ‘‘experts’’ who stand at arm’s length from the messy world of health care, in order to offer balanced analysis and facilitate agreement between various stakeholders’’ (p. 372). While not discounting the need for normative characterizations of the role and method of healthcare ethics practice, it is not possible to evaluate these norms without knowledge of the ‘‘lived experience’’ of those engaged in the practice. As PHEs seek standardization and professionalization of their role it is important that there is exploration of and reflection upon what they do in their daily work. This includes a consideration of what differentiates them and what they share in common with the other professions with whom they engage. As Frolic acknowledges, the phenomenological, feminist and naturalized approaches have helped to draw attention to how context and power can contribute to the shaping and the analysis of cases, and to the agency of the actors involved. These approaches have helped to ‘‘situate’’ those involved in healthcare ethics work, encouraging patients, families and healthcare professionals to acknowledge their own moral contexts (p. 374). In order to describe the ‘‘situatedness’’ of the PHE role in healthcare institutions, a methodological attitude should be pursued which allows for the findings from empirical research to be used in ethical reflection and decision-making. While it is generally agreed that empirical data is relevant to ethical inquiry and practice, a key concern is how to gather reliable data and how to articulate it with normative analysis. Bioethics, when importing methodological tools from empirical disciplines, should continue to strive to work to meet standards for empirical normative validity similar to those used in the source disciplines for these methods. This requires engagement when needed with colleagues within these disciplines in order to articulate empirical and normative aspects clearly (Hurst 2010, p. 444). Put simply, empirical research in bioethics must be rigorous and methodologically sound. This requires that research studies be designed carefully with an eye toward construct validity as well as reliability. Because it is assumed that much of this empirical work in bioethics will be qualitative in nature, researchers must be prepared and able to defend the reliability and validity of their research and the strategies used to verify their findings (Morse et al. 2002). As Molewijk and Widdershoven (2012) assert, empirical ethics is a research approach, which emerged in the last decade as a response to the ‘‘problematic identification of bioethics as purely normative and of social sciences as purely empirical disciplines’’ (p. 448). The rise of this approach can be seen as an example
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of multidisciplinary engagement, which goes beyond ‘‘traditional distinctions.’’ Included within the domain of empirical ethics is the recognition and addressing of the traditional distinction between descriptive activities and normative analysis (p. 450). The diverse professional backgrounds involved often make it challenging to find a shared discourse in which professionals can understand one another. As these experts propose, empirical ethics research should ideally, be designed and executed by experts from both descriptive and normative disciplines. This therefore requires ‘‘strong multidisciplinary cooperation between ethicists and social scientists, for both methodological and theoretical reasons.’’ Generally, cooperation among ethicists and descriptive scientists falls into three rough categories: parallel, serial, and continuous cooperation.11 Serial cooperation has most frequently been the tradition between ethicists and descriptive scientists. They advocate for continuous cooperation however, which acknowledges the fact that descriptive and prescriptive sciences are ‘‘mutually constitutive.’’ Further, ‘‘[w]ith continuous cooperation participants are more able to be alert for discipline-specific epistemic values and claims’’ (p. 452). It is well accepted today that empirical observations and normative analyses are not separate enterprises. Collaborative engagement will continue to contribute to overcoming the past tradition of the ‘‘is-ought’’ distinction where empiricists supply the facts, moral philosophers, theologians and humanists provide the values, and philosophers clarify the concepts and offer valid argumentation (Solomon 2005, p. 40). This engagement should be inclusive of both bioethics as a field and practice and ‘‘ethics’’ generally as conceived in healthcare. Combined, they hold the potential to contribute to the appreciation, identification, assessment and exploration of PHE boundaries. As the foregoing discussion has endeavored to show, there is a need to describe more clearly the institutional and environmental context that mediates moral action related to understanding and navigation of boundaries and to collect data, which can contribute to reflection as we encourage individual and institutional moral accountability. Solomon (2005), reflecting upon how we might realize bioethics’ goals in practice, proposes that the ‘‘is can help ought’’ by providing individuals and institutions with data about their own behaviors and circumstances which can help to stimulate change. Further, she suggests that collaborative research will contribute to forging the connections between empirical research and ethical justification (p. 46). Ultimately this holds promise to address the gaps existing between espoused ideals of how boundaries should be understood within proposed standards of professional practice and actual day-to-day practice. While it may be clear that boundaries do indeed ‘‘matter’’ in the day-to-day role of the PHE, there remain a number of conceptual issues that must be addressed which are connected to boundaries as we explore professionalization. Simpson (2012) outlines a number of significant conceptual issues with an ‘‘invitation’’ for further critical reflection and examination of their relevance to and implications for practice standards. They are: diversity (from the perspective of training and 11
Parallel cooperation means that descriptive scientists and ethicists do their work simultaneously, but without influencing each other. Serial cooperation implies that one of the two disciplines carries out its work first and then the other reacts to it. In continuous cooperation, the two disciplines work together throughout the entire research process (p. 452).
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experience); moral expertise and authority/influence; being an insider or outsider; flexibility and adaptability (for local contexts of practice); the relative weighting of procedural and normative aspects of ethics practice; making mistakes or errors; and conflicts of interest in practice (p. 219).12 Within each of these issues dwell a variety of understandings of boundaries within day-to-day practice from which the descriptive and normative elements could be extracted to foster a more thorough reflection on standardization and the expectations of the professional role and to ensure it is actually enacted in practice. White et al. (2014) recent target article in The American Journal of Bioethics arguing for the structuring of examinations to assess ASBH ‘‘core knowledge competencies’’ continues to beg the question of how well the PHE role is understood in our current context. As Ellen Fox (2014) writes in her response, ‘‘… their approach—to begin the process by speculating about practice details and proffering completed tests—does not seem rigorous enough to do justice to such a serious endeavor’’ (p. 1). Empirical ethics research can contribute to deeper understandings of the contexts and conditions by capturing the interplay between normative and empirical elements embedded in current conceptualizations of boundaries within healthcare ethics practice environments. The study of moral beliefs, intuitions, behavior and reasoning can yield information that is meaningful for health care ethics practice. This approach acknowledges that the methodologies of the social sciences (quantitative and qualitative methods such as case studies, surveys, experiments, interviews, and participatory observation), is a way to ‘‘map this reality’’ (De Vries and Gordijn, 2009, p. 193). The ‘‘methodological attitude’’ of empirical ethics, is proposed as a way forward as we engage and reflect upon boundaries in practice alongside movements towards standardization and professionalization of the PHE role.
Conclusion As this paper has endeavored to demonstrate, boundary navigation in modern healthcare ethics practice is embedded in the complex ‘‘social situation’’ of the PHE role within institutions and organizations. Epistemological reflection on the relationship between theory and practice points toward the social context as relevant to our conceptualization of boundaries. In light of the evolving state of healthcare ethics practice, the skills of social scientists may prove helpful to provide data and insights into the day-to-day experiences and practices of PHEs. This ‘‘methodological attitude’’ of empirical ethics, which combines empirical (usually social scientific) research with normative-ethical analysis and reflection, is proposed as a way forward as we engage and reflect upon boundaries in practice. This requires cooperative engagement of the descriptive and normative disciplines to explore our understandings of boundaries in healthcare ethics practice in order to further contribute to the ongoing reflection as we envision the professional role as 12 Please see the special issue of HEC Forum (2012) 24 ‘‘Getting Engaged: Exploring Professionalization in Canada’’ for a discussion of these important issues.
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well as ensure that it is enacted in practice. Mildred Z. Solomon’s (2005) observation quoted at the beginning of this article seems especially apropos as we work to address the need to conceptualize boundaries: In their role as advocates for certain visions of the good, bioethicists need what empirical researchers can offer: a variety of means of getting from here to there. (p. 46)
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Conceptualizing Boundaries for the Professionalization of Healthcare Ethics Practice: A Call for Empirical Research Nancy C. Brown • Summer Johnson McGee
Published online: 29 June 2014 Springer Science+Business Media Dordrecht 2014
Abstract One of the challenges of modern healthcare ethics practice is the navigation of boundaries. Practicing healthcare ethicists in the performance of their role must navigate meanings, choices, decisions and actions embedded in complex cultural and social relationships amongst diverse individuals. In light of the evolving state of modern healthcare ethics practice and the recent move toward professionalization via certification, understanding boundary navigation in healthcare ethics practice is critical. Because healthcare ethics is endowed with many boundaries which often delineate concerns about professional expertise and authority, epistemological reflection on the relationship between theory and practice points toward the social context as relevant to the conceptualization of boundaries. The skills of social scientists may prove helpful to provide data and insights into the Typically, when invited to a consult, we are asked to fill one or more particular roles including that of bioethicist, feminist, peer, expert consultant or moral observer…. As such, one of the issues we struggle with is how to set clear expectations for our participation in the consultation process and how to resolve tensions between roles without violating our own moral commitments or ending up at the margins, as a token or as an outsider. (p. 143). Canadian bioethicists Susan Sherwin and Francoise Baylis (2003) reflecting upon their own healthcare ethics consultation experiences. Public Affairs Quarterly 17 (2) April 141–158. Social scientists who remain observant outsiders and ask unsettling questions undoubtedly prove great benefit. Yet surely bioethicists should not hesitate to take social science perspectives and tools into greater account. In their role as advocates for certain visions of the good, bioethicists need what empirical researchers can offer: a variety of powerful means for getting from here to there. (p. 46). Bioethicist and social scientist Mildred Z. Solomon (2005) reflecting on her work as a social scientist in bioethics. Hastings Center Report 4 July–August 40–47. N. C. Brown (&) St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB R3H 2A6, Canada e-mail: [email protected]; [email protected] S. J. McGee Department of Public Management, College of Business, University of New Haven, 300 Boston Post Road, Gatehouse 202, West Haven, CT 06516, USA
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conceptualization and navigation of clinical ethics qua profession. Empirical ethics research, which combines empirical description (usually social scientific) with normative-ethical analysis and reflection, is a way forward as we engage and reflect upon issues which have implications for practice standards and professionalization of the role. This requires cooperative engagement of the descriptive and normative disciplines to explore our understandings of boundaries in healthcare ethics practice. This will contribute to the ongoing reflection not only as we envision the professional role but to ensure that it is enacted in practice. Keywords Boundaries Clinical Ethics Empirical Ethics Healthcare ethics practice Professionalization
Introduction One of the challenges of modern healthcare ethics practice is the navigation of boundaries. Practicing healthcare ethicists (PHEs)1 in the performance of their role must navigate the meanings, choices, decisions and resultant actions ‘‘embedded in complex webs of cultural and social relationships’’ amongst diverse individuals (Bliton and Finder 2002, p. 234). The field of healthcare ethics itself is endowed with many boundaries, which often delineate concerns about professional expertise and authority. Indeed, the reflection by Sherwin and Baylis (2003) above illustrates the tensions within and between these boundaries and the possible movement to the ‘‘margins’’ as an ‘‘outsider’’ as a result of their struggle to assert potentially conflicting roles. The idea of pursuing the ‘‘professionalization’’ of the healthcare ethics role has been explored in a number of arenas for a number of years2 and alongside this discussion, there have been needed and productive contributions towards delineating core competencies and characteristic attributes of healthcare ethicists.3 Calls for 1
It is acknowledged that there are a number of descriptors and references used to denote those who are in clinical ethics practice, including, but not limited to, ethics consultant, clinical ethicist, ethics practitioner, and related variations. In the Canadian context, the term Practicing healthcare ethicist (PHE) has been intentionally developed, in part to facilitate maintaining a broader focus. ‘‘A PHE has dedicated work responsibilities within a healthcare organization to provide a variety of ethics-related services which include one or more of the following: clinical and/or organizational ethics consultation; policy development and/or review; ethics education for staff; management of ethics programs (including clinical ethics committee); mentoring of staff/learners; and conducting research ethics consultations’’ (Simpson 2012, p. 149–150). Other descriptors will appear in relation to a specific reference or point of discussion as appropriate.
2
See for example: Baker (2007, 2009); Bishop et al. (2010); Clinical Ethics Consultation and Affairs (2010); Engelhardt (2009); King (2007); Scofield (2008); Spike (2009); Simpson (2012); Steinkamp et al. (2008).
3
Examples include: The Core Competencies for Healthcare Ethics Consultation (2011) developed by the ASBH, and the accompanying Improving Clinical Competencies in Clinical Ethics Consultation: An Education Guide (2009) as well and the Canadian Bioethics Society Task Force on Working Conditions for Bioethicists 2008, in Chidwick et al. (2010) and the Canadian based draft of the Draft: Model Code of Ethics for Bioethics (MacDonald), Draft Code of Professional Responsibilities of Health care ethics Consultants Clinical Ethics Consultation Affairs Committee, (2011).
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greater attention to the need for epistemological reflection on the relationship between theory and practice in the healthcare ethics realm have also been growing.4 As Chadwick et al. (2007) observe, in the last decade of the twentieth century, work in the social sciences in bioethics has become more prominent and has given rise to ‘‘an empirical turn’’ which points toward social context as relevant, calling for closer attention to the relationship between normative and descriptive ethics (p. xv). Sociologist Raymond De Vries (2003) distinguishes the social sciences of bioethics from the social sciences in bioethics. Those that work in bioethics are collaborative, lending their skills to bioethics in order to describe opinions and perspectives, explore how organizations work and describe the impact of policy, which can provide important contextual information (p. 283). Applied ethicists have increasingly combined empirical (usually social scientific) research with normativeethical analysis and reflection now commonly called ‘‘empirical ethics.’’ This is described not as a methodology of doing ethics, but as a ‘‘basic methodological attitude to using the findings from empirical research in ethical reflection and decision making’’ (De Vries and Gordijn 2009, p. 193).5 There is work underway with respect to the need to address practice standards for clinical ethics consultation throughout the U.S. and Canada. In Canada recent discussions have focused on the importance of ‘‘context, process and principles (not just outcomes) in the exploration of and possible movement towards professionalization’’ (Frolic 2012, p. 153). The movement to professionalize has resulted in some spirited exchanges, which have been reflected in the literature. This has included charges that PHEs have ‘‘studiously and self-interestedly evaded’’ discussions concerning the limits of expertise, methods and scope of practice. As Giles Scofield (2008) asserts, Turn to the medical ethics consultation, and what one discovers is not that discussions of boundary issues are absent, but that medical ethicists publically discuss the problems that boundary issues pose to other professionals, and try as best they can to bury those issues insofar as they concern them, what they do, or how they do it.6 (p. 105) While it is almost universally accepted that boundaries matter, particularly as health care ethicists are often charged with the task of instructing others on these questions, the boundaries that matter for PHEs (and for other healthcare providers) are multiple, poorly understood, and undefined or backed by empirical data. Moreover, the way forward in better understanding and defining these boundaries is not always obvious (Heesters 2012, p. 173). Empirical ethics research offers the best option for engaging these critical questions in theory and in practice. Cooperative engagement 4
Arnold and Forrow (1993); Aulisio (1999); Austin (2007); Birnbacher (1999); Crigger (1995); De Vries and Conrad (1998); De Vries (2003); Engelhardt (2003); Farmer and Gastineau Campos (2007); Hoffmaster (1992, 2001); Nelson Lindemann (2000); Marshall 1992; Musschenga (1999); Pearlman et al. (1993); Van der scheer and Widdershoven (2004); Zussman (2000).
5
De Vries and Gordijn cite as examples, Sulmasy and Sugarman (2001); Holm and Jonas (2004); Borry et al. (2005); Musschenga (2005).
6
Scofield uses the descriptor ‘‘medical ethics consultant’’ throughout his paper to describe ethicists working in healthcare settings.
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of empirical ethics research is required in order to explore understandings of boundaries and their relevance for PHEs. This will contribute to needed data and reflection as we move towards the professionalization of the PHE role as well as help to ensure that it is enacted in practice.
Embracing the ‘‘Empirical Turn’’ for Clinical Ethics As Light and McGee (1998) note, North American bioethics was patterned after the field of philosophy to produce a rational and decontextualized discourse. Bioethicists historically depicted sociological studies as irrelevant to their discipline because they feared being influenced too strongly by historical and sociological contextualization, putting them at risk of cultural and ethical relativism. Two decades ago Fox and Swazey (1984) voiced concerns regarding the limited interaction between sociology and bioethics arguing that as the field has evolved, it has lost sight of the importance of the groups and communities to which it belongs. As Borry et al. (2005) posit, the fundamental reason that bioethics keeps empirical approaches outside its borders has to do with the usually strict distinction between descriptive and normative ethics. Yet he reminds us that ‘‘[d]escriptive ethics is the field in which empirical data about moral issues are gathered. It is the domain par excellence of sociology, anthropology, psychology, and epidemiology, and it aims at describing peoples’ temporal values, rules, preferences, norms and actions’’ (p. 60). Because of this historical and conceptual divide between the normative and the empirical, the role of social context in healthcare ethics work has historically been under acknowledged and appreciated. It has been asserted that bioethical theory, itself, has failed to account for the actual experiences of practitioners in real time and space (Peter and Liaschenko 2003, p. 259). As Rubin and Zoloth (2004) observe, clinical ethics needs to evolve so that it is responsive to the larger context of healthcare practice and ‘‘doing’’ clinical ethics means making ethics an integral part of an organization with issues raised day-to-day, not just during crises (p. 223). As Borry et al. (2005) note, ‘‘from its inception, bioethics has developed as an interdisciplinary field with methodological and epistemological input from many different disciplines, including law, philosophy, theology, medicine, biology and the social sciences. This tradition of discourse seems to support the notion that input from different fields can improve analysis and the finding of solutions to various problems’’ (p. 54). As Henk et al. (1998) posit, ‘‘descriptive ethics is geography: it maps the moral domain…’’ (p. 270). Given the powerful effect of disciplinary and professional specialization, Verkerk and Walker (2009) advocate ‘‘not only for a view from below but also for varied horizontal views of disciplinary frameworks and professional practices.’’ In their estimation, this should encompass a variety of structured inquiries (social and natural sciences, philosophy, history, literature and criticism) and institutionally differentiated practices (research, clinical, public
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health and management practices), which holds potential to ‘‘provide revealing viewpoints on each other’s embedded evaluative assumptions’’ (p. 6). Further, as Chadwick et al. (2007) note, it has been generally recognized that no one discipline can deal with the full extent of the issues in bioethics, and disputes about which discipline is primary have occurred, which has given rise to controversy. As Borry et al. (2005) remind us, the interdisciplinarity of bioethics as a field is plagued with gaps between the disciplines related to cognitive and conceptual dissonance, culture or style, or lack of training to appropriately judge or assess research results of the various disciplines. Further, ethics and empirical approaches start from different research questions. Ethics is interested in conceptual clarification and normative justification, and empirical approaches are focused on description as well as reconstruction and analysis. These ‘‘divergent’’ orientations make bioethics a prescriptive discipline involved in moral evaluation and empirical sciences a descriptive discipline that stresses the setting. As Borry asserts, this ‘‘interdisciplinary gap also can result in opposing objectives that limit the conversing disciplines in their interaction’’ (p. 54) Yet, the so-called ‘‘empirical turn’’ related to the increasing prominence of the social sciences has pointed to the ways in which ‘‘social context is relevant in ethics and has demonstrated that there is a need for bioethics as a field to be reflexive, considering its own methods and theoretical approaches’’ (Chadwick et al. 2007, p. xv). Nelson Lindemann (2000) for example, has argued for an interactive model between normative and descriptive ethics which can contribute to not only our understanding of ethical issues, but also the understanding of social processes through which those issues become constituted as ethical concerns (p. 16). He proposes that there is a need to invert ‘‘common wisdom’’ about the relations between the normative and the descriptive, or how the ‘‘is,’’ relates to ‘‘ought’’ (p. 12). He also concurs with Urban Walker’s call for an ‘‘empirically saturated understanding of social life’’ which underscores the variety of ‘‘human motivations, arrangements, and forms of life and sees ethics largely as the effort collectively to build and renew social practices that make the ways in which responsibilities and rewards are distributed through societies as clear as possible’’ (p. 17). De Vries (2003) proposes that as the healthcare ethics profession ‘‘matures’’ the ‘‘voice and effect’’ of the role may be altered and as the field of bioethics grows and solidifies its position, the skills of social scientists will become more important. Acknowledging that the relationship between sociology and bioethics to date has been an ‘‘uneasy’’ one, he advocates for a relationship between the two disciplines, which might be helpful to bioethical practice (p. 289). As Haimes (2007) points out, ethicists as individual and collective practitioners of their discipline, however varied in their approaches and interests, are members of professional and other social groupings and are thus subject to the influences of, and in turn influence broader social changes and developments. ‘‘At the very least’’ she argues ‘‘there is some interest for bioethicists in seeing themselves in a social context, even if there is a resistance to seeing their subject in such a way’’ (p. 36).
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Boundary Navigation and the ‘‘Social Situation’’ of PHE Practice The notion of boundaries has been a theme in recent years for various sociological approaches to social inequality, collective and national identity, class, gender and ethnic relations, as well as for the sociology of science, knowledge and the professions (Lamont and Molnar, 2002). Sociologists of science, medicine and the professions have paid considerable attention to the processes of boundary demarcation by which scientific disciplines and modern professions seek to secure an autonomous stance, gain legitimacy, mark and defend ‘‘turf’’ and expand jurisdiction (Gieryn 1983, 1999; Freidson 1988, 2001; Abbott 1988). While these studies have drawn attention to the link between boundary demarcation and social domination and emphasize the dynamic nature of boundary formation, they have not situated their research in the day-to-day arenas where social actors negotiate social and symbolic boundaries. PHEs in their daily work necessarily negotiate, for better or worse, these social and symbolic boundaries by, for example, simultaneously filling the roles of clinician, patient educator, and ethics specialist and performing activities of each of these roles throughout the consultation process. Their experiences of role and boundary navigation, if explicated more fully through social science approaches, may provide valuable data that could foster opportunities for reflection on the conceptualization of boundaries as we work towards standardization and professionalization of the role. In making the case for greater understanding of boundaries in the day-to day practice of health care ethicists, this inevitably draws upon and is inclusive of not only bioethics as an (academic) field, but ‘‘ethics’’ as understood within our various diverse healthcare institutions and organizations. Chambliss’ (1996) study is illustrative of how social science research and its descriptions of institutional context can reveal factors that influence moral action within complex healthcare environments. His ethnography of nursing outlined the moral dimensions of hospital life and the many ways ‘‘ethics’’ is used in health care organizations. In the health care setting, it is commonly assumed that ethical problems can be resolved through reason and the application of abstract principles, for and by individuals. Chambliss viewed this conceptualization as theoretically compelling but lacking in empirical support. His research determined that ethical dilemmas often arose out of the organization of work and clash of worldviews of groups over what to do in specific cases and that ethical problems were often addressed not by reference to values or principles or even by the group closest to the situation at hand, but by the group with most power.7 Chambliss’ call for empirical approaches, which moves discussion away from ‘‘hypothetical scenarios to real settings’’, and draws attention to ‘‘the social and psychological realities of hospital life’’ (pp. 6–7), may also help to move health care ethics practice to a place of broader awareness and understanding concerning the structural challenges to moral action in current healthcare settings. 7
This includes conflicts amongst physicians and nurses, and physicians and administrators. Chambliss acknowledges that hospitals may have ethics consultation teams, which stand as proxies for the organization, but more often than not, ethics teams in his study saw these problems as ‘‘technical’’ and deferred to authority of physicians. His findings draw attention to how the ‘‘place’’ of the healthcare ethicists is defined and experienced in our diverse institutions and organizations in our current context.
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Margaret Urban Walker’s work (1993, 1998, 2007, 2009) has effectively drawn our attention to the relevance of the social aspects of healthcare ethics practice and the processes of boundary navigation. In her discussion of philosophical ethics, bioethics and the healthcare ethicist’s role from a feminist and naturalized bioethics perspective,8 she emphasizes the ‘‘social situation of morality.’’ In her discussion of the ‘‘moral spaces’’ of healthcare ethics consultative work, she has proposed that our ‘‘moral understandings are always embedded in and make sense of a particular social setting and its characteristic relationships, problems, and practices’’ (1993, p. 34).9 As she asserts, Since the mid-1980’s concerns about what the ethicist does have moved to the fore. Matters at issue include: different institutional functions of ethicists; the differing kinds of responsibility, authority, and accountability that should accompany them, how the ethicist fits within the criss-cross of relationships among healthcare providers, patients, families, and caretakers, and how moral deliberation within healthcare institutions connects to the larger social arenas of moral consensus and conflict. (p. 37) Urban Walker (1993) acknowledges the embedded routine and hierarchy of healthcare work settings, and in light of this situation, proposes that the ‘‘institutionalization’’ of the ethicist role is probably the only way to ‘‘reliably and authoritatively mark and open moral reflective spaces.’’ However, she also cautions that the effectiveness of these spaces and shared moral deliberation requires a ‘‘different kind of authority’’ (p. 38). She urges us to think of PHEs as ‘‘architects’’ of moral space within the healthcare setting, and as ‘‘mediators’’ of the conversations taking place within that space (p. 33). It is her hope that these two images might be further explored as we reflect upon the concept and practice of healthcare ethics work. Urban Walker’s perspective draws attention to how in dayto-day practice, boundaries are and should be conceptualized and whether this spatial metaphor even adequately captures the relevant aspects of the PHE role. Indeed, an added overlay of complexity to the embedded routine and hierarchy of healthcare settings is the fact that PHEs in our current healthcare context often serve in multiple and potentially overlapping roles. Further, when boundaries are utilized as an organizing metaphor for the ethics of relationships, certain discourses are necessarily brought into play while others are crowded out. Combs and Freedman (2002) for example, caution us that a focus on boundaries can oversimplify complex issues resulting in the discourse of ‘‘separation and individuation’’ being valued at 8
Urban Walker (1998, 2007,) has forwarded an ‘‘expressive-collaborative’’ model of morality, which is best revealed in practice through the socially accepted patterns of assigning and deflecting responsibility. In her view these practices reveal, ‘‘shared understandings’’ of who we are, what we value, and to whom we are required to account for our actions. In this view morality is ‘‘collaborative.’’ Along with Lindemann et al. (2009) she has also forwarded a ‘‘naturalized bioethics’’ espousing that ‘‘self-reflexive, socially inquisitive, politically critical, and inclusive’’ ethics that is ‘‘empirically nourished but acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments (p. 5).
9
Emphasizing narrative as the pattern of moral thinking, she has asserted that it is ‘‘a way of seeing how morally relevant information is organized within particular episodes of deliberation… narratives in moral thinking come before, during, and after moral generalities’’ (p. 35).
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the expense of the discourses of ‘‘interdependence, collaboration, and community’’ (p. 205). Furthermore, ethical action necessarily takes place in community. As Austin (2007) emphasizes, this interdisciplinary understanding of the ‘‘moral space’’ of healthcare environments and the multifaceted challenges arising within them, holds potential for new ways of thinking about and of methods for addressing those challenges and responding to day-to-day experiences. (p. 85–86). Issues of power and authority in these healthcare communities requires our attention, not just as ethical issues, but as organizational and structural issues, as we reflect upon boundaries in PHE practice. This is a critical contribution that can be made by social scientific approaches employed by other fields like organizational behavior and industrial/organizational psychology as applied to the health care setting. Attention to the issue of authority and (moral) expertise in healthcare ethics practice is a necessary part of this reflective process. Tronto (2011) undertook a relational analysis and emphasized the political dimensions inherent in practice. In her recent discussion of ‘‘who’’ is authorized to do applied ethics she argues that it depends not upon ‘‘what justification practitioners of applied ethics offer, but rather on their social and political location, thus, where applied ethics occurs.’’ These locations Tronto asserts, ‘‘put people with different levels of social responsibility, respectability, and power in relationship with one another,’’ which ‘‘force[s] a genuine ethical encounter.’’ She advises that even though the dispute between ‘‘internalists’’ and ‘‘externalists’’10 may be unresolved, practitioners of applied ethics need to confront ‘‘theory’’ on another level. In her view, a thorough understanding of the grounding of the field will require that we also think about the inevitable political and democratic qualities of our principles and practices (p. 416). Closely related to this discussion about authority and expertise is the historical and ongoing tensions related to the ‘‘insider/outsider status’’ of health care ethicists. As Simpson (2012) observes, discussion in the literature seems to reflect relative advantages and disadvantages of being (seen to be) in either position. She draws attention to Rubin and Zoloth’s (2000) observation, that a significant portion of bioethics is ‘‘riddled with the covert presupposition that the ethicist, as outsider, can offer a helpful, critical perspective to those who are struggling more directly with the ethical dilemmas that arise in clinical practice’’ (p. 195). Frolic and Chidwick (2010a, b), in their study concerning conflicting interests of ethicists, found that PHEs might be particularly vulnerable to role conflicts in their first year in a new organization when boundaries and relationships are still forming. In light of these findings, how and whether the development of practice standards might facilitate the identification and assessment of the relative advantages and disadvantages of the 10 Beauchamp (2003) describes the ‘‘appropriate sources of content’’ in applied ethics as distinctive from ‘‘internal’’ and ‘‘external’’ perspectives. Proponents of the ‘‘internal’’ perspective view applied bioethics as arising from the issues, practices, questions and dilemmas that arise from within each practice itself. Proponents of the ‘‘external’’ perspective view applied bioethics as arising from the application of issues, precepts, and standards that have a place in another moral realm (such as deontological or utilitarian systems) or an account of ‘‘common morality’’ to issues, practices, questions, and dilemmas that arise in the practices under consideration. This difference in content also reflects a difference about the kinds of moral judgments that will count as ‘‘authoritative’’ (see Tronto, p. 409).
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‘‘insider/outsider’’ positions is relevant. This ‘‘tension between these two positions’’ is perhaps something that PHEs need to acknowledge and potentially even ‘‘embrace’’ as part of day-to-day practice (Simpson 2012, p. 223).
The PHE Professionalization Process: Why Boundaries Matter While PHE’s often occupy a unique position within their organization, the role to date has few authoritative practice guidelines (Tarzian 2009) and those performing this role have varied education and training (Fox et al. 2007). As Cline et al. (2013) point out, PHEs are often employed in circumstances where full understanding by even their employers of what they actually do or the value they can add to their work environments is lacking. These authors, writing in the Canadian context, acknowledge that the ‘‘unique facets of this role, the lack of defined standards for ethics services, the informal nature of ethics leaders’ leadership, and the political volatility of many of the issues that are de rigueur in ethics practice’’ have led some PHEs especially those early in their careers, to report (anecdotally) feeling as if they had been ‘‘cast into the wilderness with no one to guide them’’ (p. 212). As the role has evolved, PHE practice has expanded from clinical ethics consultation to include organizational ethics and policy work amongst other various duties and responsibilities. This situation urges us to critically think about, and reflect upon, the conceptual grounding and justification of our understanding of boundaries related to practice standards and the continued movement towards professionalization. This should include closer attention to the social context of practice and consideration of the possible value that might be drawn from the social sciences to ensure thorough reflection on this important issue. Social theorists have made calls to reframe the division of labor in the healthcare context in dynamic terms. Occupational roles in this view are not self-evident, but have to be actively negotiated within a system, or ‘‘jurisdiction’’ has to be claimed and sustained in the work area. Thus, merely performing ‘‘skilled acts’’ and justifying them ‘‘cognitively’’ is not necessarily to hold jurisdiction. As Andrew Abbott (1988) proposes, in claiming jurisdiction, a profession asks society to recognize its cognitive structure through exclusive rights; jurisdiction has not only a culture, but also a ‘‘social structure’’ (p. 59). He points to the ‘‘division of labor’’ in the ‘‘team concept of medicine and social services’’ as an example of the restructuring of professional work, positing that ‘‘professional knowledge’’ is now encoded in the structure of organizations themselves (pp. 325–326). As Abbott posits, to say, ‘‘that a set of closed boundaries exists is logically equivalent to saying that a social thing exists’’ (1995, p. 860). In his view, much expertise therefore resides in the ‘‘rules of these and other organizations of professionals’’ and he advocates for the study of ‘‘actual work’’ rather than of single professions, which he proposes, will bridge the gap between theory and empirical realities (p. 326). This type of theorizing is relevant to how we think about the process of professionalization of the PHE role and how boundaries are conceptualized because it advances beyond the conventional sociological literature. That is, it focuses on the processes through which occupations constitute themselves, relative to others, as
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professions. As Abbott (1988) emphasizes, the term profession is not ‘‘objectively’’ definable precisely because of its power and authority in our culture (p. 318). Previous contributions by Foucault have drawn the focus to those who have certain key positions in the knowledge economy, which has helped to illuminate the need to understand practices and the relations of power inherent in them (1963, 1966, 1969, 1975). This presents issues of particular interest to sociologists, which includes the formation of knowledge and disciplines, the nature and effects of practices of control, and the constitution of actors and identities (Power 2011, p. 52). Indeed, healthcare settings are not simply as they present themselves (places of treatment and cure), but they are also scenes in which ‘‘subjects [such as PHEs] are being created so as to fit into relations of power’’ (Frank and Jones 2003, p. 180). In order to address the field’s traditional boundary distinctions between normative and descriptive disciplines, cooperative engagement between the normative and descriptive disciplines is a way forward in the exploration of the field’s understanding of boundaries, both conceptually and in practice. This will help to foster reflection as we move toward professionalization of the role. For healthcare ethics to be informed both by what actually happens in healthcare practice and by the way in which practitioners think about moral issues is increasingly considered meaningful, and we need empirical accounts of PHE practice, boundary conditions, and settings. As Van der Scheer and Widdershoven (2004) point out, the meaning which practitioners give to their situation and the reasons they have for their actions are relevant issues for ethical consideration because they already contain a normative evaluation of the situation. Normative knowledge embodied in practice can be made explicit by ethical analysis. Thus, ethical analysis can enrich practical experience. (pp. 72–73) While these authors acknowledge that perhaps an integrated empirical approach is neither good nor necessary for each and every problem or question, it is a tool that may be used in dealing with problems for which a community, a practice or culture has not yet developed rules, principles or virtues (p. 78). This methodological stance may offer an opportunity to give critical examination to and to derive normative guidelines in experience within the specific praxis of the PHE role. While others may take issue with these assumptions about the nature of social scientific research (such as egalitarian approaches to social science data and narrative) it is crucial that any attempt to understand empirical ethics as a contributor or collaborator to health care ethics practice must accept the scientific method and concept of validity and reliability as given and non optional. It is acknowledged that collaborative and/ interdisciplinary research can be complicated by different disciplinary boundaries, paradigms and working practices. However, collaborative social science research into understandings of boundaries within the multidisciplinary and applied settings such as healthcare environments holds potential to illuminate the values inherent in health care ethics practice, rendering assumptions open to debate, stimulating reflection and development of critically oriented knowledge and ultimately, increasing the capacity of PHEs to influence the social, political and economic determinants in their health care institutions and systems.
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A Call for Cooperative Engagement: Engaging Descriptive and Normative Disciplines to Conceptualize Boundaries in Practice Past microanalyses of boundary demarcation and healthcare settings have highlighted the ways the actors’ professional, structural and spatial position in the hospital setting shape their epistemological, ideological and ethical views of their daily work (viz., Anspach 1990, 1993; Chambliss 1996). As Frolic (2011) observes, ‘‘few clinical bioethicists have provided ‘thick description’ of the lived experience of their practice’’. Instead, ‘‘articles on methods and roles in EC [ethics consultation] tend to function as homilies, arguing what ethics consultants ought to do, rather than describing the lived experience of the doing.’’ This practice in her view actually reinforces characterizations of healthcare ethicists as ‘‘experts’’ who stand at arm’s length from the messy world of health care, in order to offer balanced analysis and facilitate agreement between various stakeholders’’ (p. 372). While not discounting the need for normative characterizations of the role and method of healthcare ethics practice, it is not possible to evaluate these norms without knowledge of the ‘‘lived experience’’ of those engaged in the practice. As PHEs seek standardization and professionalization of their role it is important that there is exploration of and reflection upon what they do in their daily work. This includes a consideration of what differentiates them and what they share in common with the other professions with whom they engage. As Frolic acknowledges, the phenomenological, feminist and naturalized approaches have helped to draw attention to how context and power can contribute to the shaping and the analysis of cases, and to the agency of the actors involved. These approaches have helped to ‘‘situate’’ those involved in healthcare ethics work, encouraging patients, families and healthcare professionals to acknowledge their own moral contexts (p. 374). In order to describe the ‘‘situatedness’’ of the PHE role in healthcare institutions, a methodological attitude should be pursued which allows for the findings from empirical research to be used in ethical reflection and decision-making. While it is generally agreed that empirical data is relevant to ethical inquiry and practice, a key concern is how to gather reliable data and how to articulate it with normative analysis. Bioethics, when importing methodological tools from empirical disciplines, should continue to strive to work to meet standards for empirical normative validity similar to those used in the source disciplines for these methods. This requires engagement when needed with colleagues within these disciplines in order to articulate empirical and normative aspects clearly (Hurst 2010, p. 444). Put simply, empirical research in bioethics must be rigorous and methodologically sound. This requires that research studies be designed carefully with an eye toward construct validity as well as reliability. Because it is assumed that much of this empirical work in bioethics will be qualitative in nature, researchers must be prepared and able to defend the reliability and validity of their research and the strategies used to verify their findings (Morse et al. 2002). As Molewijk and Widdershoven (2012) assert, empirical ethics is a research approach, which emerged in the last decade as a response to the ‘‘problematic identification of bioethics as purely normative and of social sciences as purely empirical disciplines’’ (p. 448). The rise of this approach can be seen as an example
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of multidisciplinary engagement, which goes beyond ‘‘traditional distinctions.’’ Included within the domain of empirical ethics is the recognition and addressing of the traditional distinction between descriptive activities and normative analysis (p. 450). The diverse professional backgrounds involved often make it challenging to find a shared discourse in which professionals can understand one another. As these experts propose, empirical ethics research should ideally, be designed and executed by experts from both descriptive and normative disciplines. This therefore requires ‘‘strong multidisciplinary cooperation between ethicists and social scientists, for both methodological and theoretical reasons.’’ Generally, cooperation among ethicists and descriptive scientists falls into three rough categories: parallel, serial, and continuous cooperation.11 Serial cooperation has most frequently been the tradition between ethicists and descriptive scientists. They advocate for continuous cooperation however, which acknowledges the fact that descriptive and prescriptive sciences are ‘‘mutually constitutive.’’ Further, ‘‘[w]ith continuous cooperation participants are more able to be alert for discipline-specific epistemic values and claims’’ (p. 452). It is well accepted today that empirical observations and normative analyses are not separate enterprises. Collaborative engagement will continue to contribute to overcoming the past tradition of the ‘‘is-ought’’ distinction where empiricists supply the facts, moral philosophers, theologians and humanists provide the values, and philosophers clarify the concepts and offer valid argumentation (Solomon 2005, p. 40). This engagement should be inclusive of both bioethics as a field and practice and ‘‘ethics’’ generally as conceived in healthcare. Combined, they hold the potential to contribute to the appreciation, identification, assessment and exploration of PHE boundaries. As the foregoing discussion has endeavored to show, there is a need to describe more clearly the institutional and environmental context that mediates moral action related to understanding and navigation of boundaries and to collect data, which can contribute to reflection as we encourage individual and institutional moral accountability. Solomon (2005), reflecting upon how we might realize bioethics’ goals in practice, proposes that the ‘‘is can help ought’’ by providing individuals and institutions with data about their own behaviors and circumstances which can help to stimulate change. Further, she suggests that collaborative research will contribute to forging the connections between empirical research and ethical justification (p. 46). Ultimately this holds promise to address the gaps existing between espoused ideals of how boundaries should be understood within proposed standards of professional practice and actual day-to-day practice. While it may be clear that boundaries do indeed ‘‘matter’’ in the day-to-day role of the PHE, there remain a number of conceptual issues that must be addressed which are connected to boundaries as we explore professionalization. Simpson (2012) outlines a number of significant conceptual issues with an ‘‘invitation’’ for further critical reflection and examination of their relevance to and implications for practice standards. They are: diversity (from the perspective of training and 11
Parallel cooperation means that descriptive scientists and ethicists do their work simultaneously, but without influencing each other. Serial cooperation implies that one of the two disciplines carries out its work first and then the other reacts to it. In continuous cooperation, the two disciplines work together throughout the entire research process (p. 452).
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experience); moral expertise and authority/influence; being an insider or outsider; flexibility and adaptability (for local contexts of practice); the relative weighting of procedural and normative aspects of ethics practice; making mistakes or errors; and conflicts of interest in practice (p. 219).12 Within each of these issues dwell a variety of understandings of boundaries within day-to-day practice from which the descriptive and normative elements could be extracted to foster a more thorough reflection on standardization and the expectations of the professional role and to ensure it is actually enacted in practice. White et al. (2014) recent target article in The American Journal of Bioethics arguing for the structuring of examinations to assess ASBH ‘‘core knowledge competencies’’ continues to beg the question of how well the PHE role is understood in our current context. As Ellen Fox (2014) writes in her response, ‘‘… their approach—to begin the process by speculating about practice details and proffering completed tests—does not seem rigorous enough to do justice to such a serious endeavor’’ (p. 1). Empirical ethics research can contribute to deeper understandings of the contexts and conditions by capturing the interplay between normative and empirical elements embedded in current conceptualizations of boundaries within healthcare ethics practice environments. The study of moral beliefs, intuitions, behavior and reasoning can yield information that is meaningful for health care ethics practice. This approach acknowledges that the methodologies of the social sciences (quantitative and qualitative methods such as case studies, surveys, experiments, interviews, and participatory observation), is a way to ‘‘map this reality’’ (De Vries and Gordijn, 2009, p. 193). The ‘‘methodological attitude’’ of empirical ethics, is proposed as a way forward as we engage and reflect upon boundaries in practice alongside movements towards standardization and professionalization of the PHE role.
Conclusion As this paper has endeavored to demonstrate, boundary navigation in modern healthcare ethics practice is embedded in the complex ‘‘social situation’’ of the PHE role within institutions and organizations. Epistemological reflection on the relationship between theory and practice points toward the social context as relevant to our conceptualization of boundaries. In light of the evolving state of healthcare ethics practice, the skills of social scientists may prove helpful to provide data and insights into the day-to-day experiences and practices of PHEs. This ‘‘methodological attitude’’ of empirical ethics, which combines empirical (usually social scientific) research with normative-ethical analysis and reflection, is proposed as a way forward as we engage and reflect upon boundaries in practice. This requires cooperative engagement of the descriptive and normative disciplines to explore our understandings of boundaries in healthcare ethics practice in order to further contribute to the ongoing reflection as we envision the professional role as 12 Please see the special issue of HEC Forum (2012) 24 ‘‘Getting Engaged: Exploring Professionalization in Canada’’ for a discussion of these important issues.
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well as ensure that it is enacted in practice. Mildred Z. Solomon’s (2005) observation quoted at the beginning of this article seems especially apropos as we work to address the need to conceptualize boundaries: In their role as advocates for certain visions of the good, bioethicists need what empirical researchers can offer: a variety of means of getting from here to there. (p. 46)
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