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Dealing with the Normative Dimension in Clinical Ethics Consultation



Clinical ethics consultation (CEC) not only interprets moral issues at the bedside and is not restricted to giving support for the “technical” handling of these moral issues, but it has to substantively address moral values, norms, and conflicts in the process of discussing cases and problems. We call this the normative dimension and use normative in the sense of embracing moral values and convictions of persons and groups, norms, and relevant professional and ethical guidelines as well as legal frameworks. The roles and activities of the consultant as a person and the quality of CEC as a process are discussed in the American Society of Bioethics and Humanities’ (ASBH) Core Competences for Healthcare Ethics Consultation.



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1. The article focuses on the moral norms and on norms formulated in texts such as (ethics) guidelines, rather than on legal norms.

2. American Society for Bioethics and Humanities (ASBH). Core Competences for Health Care Ethics Consultation. Glenview, IL: ASBH; 1998; reprinted in: Auliso MP, Arnold RM, Youngner SJ, eds. Ethics Consultation. From Theory to Practice. Baltimore, MD: Johns Hopkins University Press; 2003: 165–209.

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4. Trachtman H. Bioethicist: Consultant or judge? American Journal of Bioethics; 2001:1(4): 1f; available at

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6. Kobert K, Pfaefflin M, Reiter-Theil S (2008/in press) Evaluation des klinischen Ethik-Beratungsdienstes. Hintergrund, Konzepte und Strategie im Ev. Krankenhaus Bielefeld. Ethik in der Medizin.

7. See note 4, Trachtman 2001.

8. Agich G. The question of method in ethics consultation. American Journal of Bioethics 2001;1(4):31–41.

9. Orr R. Methods of conflict resolution at the bedside. American Journal of Bioethics 2001;1(4):45–6.

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13. See note 8, Agich 2001.

14. Engelhardt TH. Psychotherapy as meta-ethics. Psychiatry 1973;36:440–5; Reiter L. Systematische Überlegungen zum Zielbegriff in der Psychotherapie. Praxis der Psychotherapie 1976;21:205–18.

15. Reiter-Theil S. Autonomie und Gerechtigkeit. Das Beispiel der Familientherapie für eine therapeutische Ethik. Heidelberg: Springer; 1988.

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19. See note 17, Reiter-Theil 1998.

20. See note 2, American Society for Bioethics and Humanities 1998.

21. To avoid misunderstanding, this inventory is not meant to guide the process of CEC as a stepwise “method”; rather, it should help in understanding the complex process of CEC and facilitating comparative discussion.

22. Reiter-Theil S. Klinische Ethikkonsultation—Eine methodische Orientierung zur ethischen Beratung am Krankenbett. Schweizerische Ärztezeitung 2005;86(6):346–51; Hurst S, Reiter-Theil S, Baumann-Hölzle R, Foppa C, Malacrida R, Bosshard G, et al. The growth of clinical ethics in a multilingual country: Challenges and opportunities. Bioethica Forum 2008;1(1):15–24.

23. See note 2, American Society for Bioethics and Humanities 1998.

24. Sulmasy DP, Sugarman J. The many methods of medical ethics. In: Sugarman J, Sulmasy DP, eds. Methods in Medical Ethics. Washington, DC: Georgetown University Press; 2001:3–18.

25. Bernal EW. Errors in ethics consultation. In: Rubin SB, Zoloth L, eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine, Hagerstown, MD: University Publishing Group; 2000:255–72.

26. Reitemeir PJ. Quality and error in bioethics consultation: A puzzle in pieces. In: Rubin SB, Zoloth L, eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown, MD: University Publishing Group; 2000:231–53.

27. See note 8, Agich 2001.

28. Fletcher J, Boyle RJ, Spencer EM. Errors in healthcare ethics consultation. In: Rubin SB, Zoloth L, eds. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown, MD: University Publishing Group; 2000:343–72.

29. Name and details anonymized.

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31. A relatively large audience of multidisciplinary healthcare professionals from German-speaking countries was familiarized with the model during case discussions in the context of training courses (of approximately 40 participants each) and small group work. Interestingly, they responded to the model because they found it particularly intuitive and applicable for the reflection on one's behavior and attitude in the context of learning ethics consultation (Distant Teaching Program “Clinical Ethics Consultation” Fernlehrgang Ethikberater/in im Gesundheitswesen, classes of 2006, 2007 and 2008).

32. The classes of the European Master in Bioethics and the Erasmus program have approximately 20 to 30 participants.

33. Reiter-Theil S, Agich GJ. Research on clinical ethics and consultation. Introduction to the thematic section. Medicine, Health Care and Philosophy 2008;11(1):3–5.

34. Beck S, van de Loo A, Reiter-Theil S. A “little bit illegal”: Withholding and withdrawing of mechanical ventilation in the eyes of German intensive care physicians. Medicine, Health Care and Philosophy 2008;11(1):7–16.

35. Danis M, Farrar A, Grady C, Taylor C, O'Donnell P, Soeken K, Ulrich C. Does fear of retaliation deter requests for ethics consultation? Medicine, Health Care and Philosophy 2008;11(1):27–34.

36. Foerde R, Pedersen R, Akre V. Clinicians’ evaluation of clinical ethics consultations in Norway: A tool for quality improvement. Medicine, Health Care and Philosophy 2008;11(1):17–25.

37. See note 6, Kobert et al. 2008.

The author is grateful for the helpful comments and editorial support of George Agich on an earlier version. The finalization of this paper was stimulated by a grant project supported by the Swiss National Science Foundation No. 3200B0-113724/1, and it will influence the ongoing project of developing a clinical ethics guideline on micro-allocation in vulnerable patient groups. The discussion with colleagues within ECEN, the Fernlehrgang (2006, 2007, 2008), the European Master in Bioethics (2006) and the Erasmus Mundus Master Bioethics (2006, 2007) have been extremely fruitful.

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Dealing with the Normative Dimension in Clinical Ethics Consultation



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