The Clinician's Voice and the Limits of Bioethics

Abstract

The bioethics movement has long promulgated a model of 'principled decisionmaking' in which ethical dilemmas and conflicts between various rights, interests, and ethical principles are central. In many respects this movement has had a laudatory impact on health care and on health professionals, but we will also argue that the bioethical model of ethical analysis has important limitations. The model's theoretical orientation is discontinuous with the training and skills of health professionals, the manner in which health professionals conceptualise and solve problems that arise in a clinical setting, and the time constraints inherent in most clinical situations. As such, the model is not readily applicable to much of the day-to-day work of clinicians and, in particular, to the routine ethical questions and situations that arise in caring for patients. What we suggest is that the bioethical model does not take into account that health care professionals, as part of their daily work, encounter and manage difficult, often conflictual situations and that they do so by bringing to bear conceptual frameworks and therapeutic techniques that have, embedded within them, the ethical values and goals of their own fields, as well as established ways of dealing with problems and addressing competing priorities. We further argue that from a systems perspective, the bioethical model and the pragmatic, problem-focused ethical decision-making of clinicians operate on different levels of complexity; whereas the former is especially appropriate for situations that resist consensus or that raise significant issues of public policy, the latter serves as an effective framework in less difficult or complex situations that can be moved effectively toward consensus and closure.

Thinking, Doing, and the Ethics of Family Therapy

“…As Grunebaum discusses (Grunebaum, 2006), and as we have argued elsewhere (with further elaboration below) (Scher & Kozlowska, 2011), the process of family therapy is inherently, though implicitly, ethical in character: in working with families, the therapist helps family members to understand and to work out, insofar as practicable, their often incompatible, sometimes strongly conflicting values, goals, interests, rights, and obligations (Grunebaum, 2006;Scher & Kozlowska, 2011). More broadly, family therapy inescapably involves a multitude of small decisions that take into account the social, cultural, and linguistic factors influencing the family (Scher & Kozlowska, 2011), that set the direction of therapy (Grunebaum, 2006;S.…”

“…More broadly, family therapy inescapably involves a multitude of small decisions that take into account the social, cultural, and linguistic factors influencing the family (Scher & Kozlowska, 2011), that set the direction of therapy (Grunebaum, 2006;S. B. Holmes, 2009), and that reflect the therapist's own judgments about family life, its appropriate contours and interactions, and the limits of her role in relation to the family (Grunebaum, 2006;Scher & Kozlowska, 2011).…”

“…More broadly, family therapy inescapably involves a multitude of small decisions that take into account the social, cultural, and linguistic factors influencing the family (Scher & Kozlowska, 2011), that set the direction of therapy (Grunebaum, 2006;S. B. Holmes, 2009), and that reflect the therapist's own judgments about family life, its appropriate contours and interactions, and the limits of her role in relation to the family (Grunebaum, 2006;Scher & Kozlowska, 2011). What is noteworthy, too, is that so many of these clinical decisions (other than those concerning the limits of the therapist's role) need to be made "on the fly," on the basis of incomplete information, and in clinical situations that are emotionally intense and interpersonally complex (Grunebaum, 2006;S.…”

“…It can also be potentially useful in the especially complex situations that can now arise in court-involved therapy-complexities that have led a task force to draft guidelines specifically oriented to this new subspecialty (AFCC Task Force on Court-Appointed Therapy, 2011). By contrast, informal discourse provides a flexible, workable approach to the ethics of day-to-day clinical practice (Scher & Kozlowska, 2011).…”

Empowering Clinicians

“…For situations that resist consensus or that raise significant, complex issues of ethics or public policy, the formal tools of bioethical discourse may well prove useful. For a flexible, workable approach to the ethical challenges, small and large, of day-to-day clinical practice, informal ethical discourse is sufficient and, indeed, preferable (Scher and Kozlowska 2011). What has been, and remains, unfortunate is that one domain has come so much to dominate the other over the history of the bioethics movement, and that the informal ethical discourse of health care trainees and clinicians has come to be considered not good enough.…”