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03/04/2016

Clinical Ethics Consultation As Practical Philosophy


As a philosopher who works in a large health science center
where the scientific method and perspective reign supreme, it is common to hear
comments about the abstract and ideal nature of philosophy. As though those who
think about human problems from a philosophical perspective do so from an abstract,
insular perspective with little or no practical impact. Though I hear such
dismissive comments about philosophy less often than I used to, say 20 or more
years ago, I sense there is still a commonly held view that those who think
from a philosophical perspective as not well oriented to practical affairs. And
with some justification do people have this view of philosophy.


 


As I have written in previous blogs, philosophy has long and
even proud part of its tradition for being, well, useless. If we assume that
the basis of philosophical truth and wisdom lay in some ultimate, objective
form that only those who think in certain ways can grasp, then knowledge
becomes privileged to the philosophical few as an end it itself. This type of
Platonic philosophical truth quickly divides the here and now inferior world
from the more exclusive understandings of reality. Because of this basic
influence of Platonic philosophy, much of the history of philosophy in the
Western tradition has been focused on the search for a rational, objective
basis of truth, value, and reality. Not surprisingly, the goal has not been
reached. But the quest continued through most of last century and philosophical
got its more or less justified reputation for being an insulated, esoteric, and
detached form of intellectual activity. Put bluntly, philosophers, with a few
exceptions, rarely got their hands dirty in the real world of practical
activity.


 


The role of philosophy vis-à-vis practical life began to
change with the advent of applied ethics in the 1970’s. In the field of
bioethics and clinical ethics, after a few decades of many philosophers
actually working closely with practitioners, learning their language and the
nature of their concerns about value laden dilemmas that arise in the
experience of carrying out their responsibilities to patients and to society,
philosophers I think are less useless. In fact I am pretty sure we are helpful,
at least at times. Most of the time I interact with physicians and nurses about
clinical cases in the hospital, or even with basic scientists about issues
related to scientific integrity, I feel pretty sure we usually have
constructive conversations and there is a sense of mutual respect as I attempt
to make a recommendation that might help manage problematic situations. As
someone nearing retirement (nothing definite) I am part of the first generation
of bioethicists or as I prefer to think of myself, clinical ethics consultants,
who were first trained as philosophers and then went on to become deeply
involved in the practical and complex world of medicine and scientific
research.


 


As I think about my work during the past 25 years and the
nature of the problems that I now think about in my work experience, I am
becoming more convinced that I am getting in touch with philosophy in a way I
did not expect as a gradate student: as a natural human, practical activity
meant to make a difference for the better. To be honest, I have always been
attracted to a less influential lineage of philosophers, who believed
philosophy is grounded in the most human concerns. Philosophy from this view,
beginning in pre-Socratic philosophy, was very much like a medical art—in the
same way medicine sought to treat bodily ills, philosophy sought to treat
illnesses of the soul. Epicurus (
341–270 BC) for example, famously said, “empty is that philosopher’s
argument by which no human suffering is therapeutically treated.” Schools of
philosophy sought to understand the world and human beings for the purpose of
living a better life and relieving the soul of its natural tendency to be
disturbed in a myriad of ways.
Thus, philosophers who followed the
teachings of Epicureanism, Stoicism, Skepticism, as well as Aristotelianism,
were trained individuals who could be helpful in this regard—who could coach
their students and prepare them for a life that brought out the most important
characteristics necessary for well being, which always included prominently the
emotions. In all of these philosophies, there is a keen focus on how the
emotions could be regulated by correct or constructive belief, which leads to
desired action and habit formation, and a change of internal disposition. The
central focus for these schools of philosophy was eudaimonia, which generally
means for those who study ethics, those actions that lead to a state of well-being
or ataraxia (undisturbed soul or inner tranquility). The task of being a
philosopher from this perspective is to learn those methods and approaches that
would lead those being served or taught to such ends.


 


Perhaps the closest iteration of such a philosophy in recent
times is American Pragmatism, particularly the works of William James and John
Dewey, which unlike the pre-Socratics, particularly Dewey, is colored
profoundly by the modern scientific method. Truth becomes a matter of what
works based in experimental methods and that can bring about desire ends for
better human living. Dewey’s hope was that philosophy would become part of the
fabric of democratic life and be used to make a positive practical difference
in society. His hope did not happen during his lifetime, but with the rise of
applied ethics, this philosophical perspective of philosophy being connected
the practical world, much like the ancient pre-Socratics, is now able to take a
new contemporary shape in bioethics.


 


In spite of the obvious constraints of working in a
contemporary hospital where patients have well articulated ethical and legal
rights and physicians have clear professional obligations and responsibilities,
many of the encounters I have as an ethics consultant involve individuals
facing many of the same challenges that motivated ancient philosophers to
develop remedies for treating their distressed emotions. When a family member
of a dying patient is facing the loss of a loved one and the obligation to make
excruciatingly difficult decisions about when to discontinue life supportive
treatments, there is a deep emotional disturbance. Individuals in these
situations are stressing, grieving, and often confused. The beliefs they have
relative to the decisions they must make can have an enormous impact on their
emotional state. For example if someone falsely believes that their making a
decision to follow their loved one’s wishes and to withdraw ventilatory support
for a dying patient was tantamount to them being personally responsible for the
patient’s demise, the feelings of guilt and indecisiveness can be overwhelming.


 


In talking to individuals in these situations, much my goal
is to help ease their emotional suffering if possible, or as Epicurus would
say, is to offer words that provide therapy for the soul. There is nothing
necessarily deeply philosophical to grasp. I start by seeing where the
individual is. Why he or she is so distressed. What is the source of the
disturbed emotions? Then a dialogue can occur to examine the beliefs he or she
has that is connects to those emotions. As the ethics consultant, my role is
facilitate, lead the dialogue, and allow the individual to critically examine
his or her belief and to come to new understandings. Following someone’s stated
wishes, for example, can be construed as a way of showing respect for your
loved one; permitting the physicians to disconnect artificial life supports is
not the cause of the patient’s death; it is rather the removal of burdens that
are only prolong his terminal illness. A new narrative can often emerge. A new
understanding that sheds light on one’s former beliefs and that brings some
relief to suffering.


 


In a very different historical context than ancient
philosophy, one of high technology and democratic life, applied ethicists have
similar functions and practice with similar methods as practical philosophers
of the past. The next time you hear someone disparaging philosophy as
irrelevant or impractical, don’t believe them.

 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.


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