Is consent necessary prior to the initiation of a specific clinical ethics consultation? This is not a question that has received much attention despite the fact that the issue of consent is one of the earliest considerations associated with bioethics. Perhaps this is because of how clinical ethics consultation, as a formidable clinical practice, came into being. Specifically, although the place and time of its conception is not readily identifiable, it is not unreasonable to say it was born on March 31, 1976, when the New Jersey Supreme Court stated, in its Quinlan decision, that consultation would be necessary with “the hospital ‘Ethics Committee’ or like body of the institution in which Karen is then hospitalized. [And i]f that consultative body agrees that there is no reasonable possibility of Karen's ever emerging from her present comatose condition [then her] life-support system may be withdrawn.”
1. Jonsen AR. A Short History of Medical Ethics. New York: Oxford University Press, 2000.
2. In the matter of Karen Quinlan, 70 NJ 10, 355 A(2d) 647 (1976):272.
3. Sargeant KJ. Withholding treatment from defective newborns: Substituted judgment, informed consent, and the Quinlan decision. Gonzaga Law Review 1978;13(3):781–811; Savage D. After Quinlan and Saikewicz: Death, life, and God committees. Critical Care Medicine 1980;8(2):87–93.
4. There were ethics committees before the Quinlan Opinion made reference to them, as Teel noted in her article, “The Physician's Dilemma: A Doctor's View: What the Law Should Be,” which appeared on pages 6–9 of the same issue of The Baylor Law Review cited in footnote 8 of the Quinlan Opinion in reference to the legitimate roles of ethics committees [1975;27(1)]. There, Teel explicitly notes that “the authority … and their official status is more that of an advisory body than of an enforcing body” (p. 9).
5. Oberdiek H. Who is to judge? Ethics 1976; 87(1):75–86; Cantor NL. Quinlan, privacy, and the handling of incompetent dying patients. Rutgers Law Review 1977;30(2):243–66; Veatch RM. Hospital ethics committees: Is there a role? The Hastings Center Report 1977;7(3):22–5; Levine C. Hospital ethics committees: A guarded prognosis. The Hastings Center Report 1977;7(3):25–7; Shannon TA. What guidance from the guidelines? The Hastings Center Report 1977;7(3):28–30; Ramsey P, Veatch RM. Stopping treatment: Who decides? The Hastings Center Report 1978;8(1):43; Annas GJ. Reconciling Quinlan and Saikewicz: Decision making for the terminally ill incompetent. American Journal of Law and Medicine 1979;4(4):367–96; Annas GJ. The Quinlan case: Death decision by committee. The New Physician 1979;28(2):53–4, 56; Buchanan A. Medical paternalism or legal imperialism: Not the only alternatives for handling Saikewicz-type cases. American Journal of Law and Medicine 1979;5(2):97–117; Annas GJ. Refusing treatment for incompetent patients; why Quinlan and Saikewicz cases agree on roles of guardians, physicians, judges, and ethics committees. New York State Journal of Medicine 1980;80(5):816–21.
6. Randal J. Are ethics committees alive and well? The Hastings Center Report 1983;13(6):10–2; Capron AM. Twenty questions about ethics committees. Ethics Committee Newsletter 1984;1(4):2–10; Rosner F. Hospital medical ethics committees: A review of their development. JAMA 1985;253(18):2693–7; Paris JJ, Reardon FE. Ethics committees in critical care. Critical Care Clinics 1986;2(1):111–21.
7. Heitman E. A proactive role for the ethics committee or ethics consultant: Meeting the JCAHO standards on patient rights. Trends in Health Care, Law and Ethics 1993;8(4):11–6.
8. Mitchell SM, Swartz MS. Is there a place for lawyers on ethics committees? A view from the inside. The Hastings Center Report 1990;20(2):32–3; LaPuma J, Schiedermayer DL. Ethics consultation: Skills, roles, training. Annals of Internal Medicine 1991;114(2):155–60; Moreno JD. Call me doctor? Confessions of a hospital philosopher. Journal of Medical Humanities 1991;12(4):183–96; Thomasma DC. Why philosophers should offer ethics consultations. Theoretical Medicine 1991;12(2):129–40; Marsh FH. Why philosophers should not do ethics consults. Theoretical Medicine 1992;13(3):285–92; Murphy PA. A nurse–ethicist model of ethics consultation. Trends in Health Care, Law and Ethics 1993;8(4):23–4.
9. O'Connell LJ, Yeide H. The many styles of clinical ethics. The Journal of Clinical Ethics 1990;1(1):82–4; Moreno JD. Ethics consultation as moral engagement. Bioethics 1991;5(1):44–56; Jonsen AR. Casuistry as methodology in clinical ethics. Theoretical Medicine 1991;12(4):295–307; Barnard D. Reflections of a reluctant clinical ethicist: Ethics consultation and the collapse of critical distance. Theoretical Medicine 1992;13(1):15–22; Zaner RM. Voices and time: The venture of clinical ethics. Journal of Medicine and Philosophy 1993;18(1):9–31; Walker MU. Keeping moral spaces open: New images of ethics consulting. The Hastings Center Report 1993;23(2):33–40.
10. Perkins HS, Saathoff BS. Impact of medical ethics consultation on physicians: An exploratory study. American Journal of Medicine 1988;85(12):761–5; Siegler M. Defining the goals of ethics consultations: A necessary step for improving quality. Quality Review Bulletin 1992;18(1):15–6; Orr RD, Moon E. Effectiveness of an ethics consultation service. Journal of Family Practice 1993;36(1):49–53; Fry-Revere S. Some suggestions for holding bioethics committees and consultants accountable. Cambridge Quarterly of Healthcare Ethics 1993;2(4):449–55; Fletcher JC, Siegler M. What are the goals of ethics consultation? A consensus statement. The Journal of Clinical Ethics 1994;7(2):122–6; Fox E, Arnold RM. Evaluating outcomes in ethics consultation research. The Journal of Clinical Ethics 1994;4(4):127–38.
11. Schiedermayer DL, LaPuma J, Miles SH. Ethics consultations masking economic dilemmas in patient care. Archives of Internal Medicine 1989;149(6):1303–5; Agich GJ. Clinical ethics: A role theoretic look. Social Science and Medicine 1990;30(4):389–99; Fletcher JC. Needed: A broader view of ethics consultation. Quality Review Bulletin 1992;18(1):12–4; Youngner SJ. Clinical ethics and cost containment: Promises and pitfalls. The Cleveland Clinics Journal of Medicine 1992;59(6):649–50; Forrow L, Arnold RM, Parker LS. Preventive ethics: Expanding the horizons of clinical ethics. The Journal of Clinical Ethics 1993;4(4):287–94.
12. Veatch RM. Ethics consultation: Permission from patients and other problems of methods. American Journal of Bioethics 2001;1(4):43–5.
13. Veatch RM. Advice and consent. The Hastings Center Report 1989;19(1):20–2; Wolf SM. Ethics committees and due process: Nesting rights in a community of caring. Maryland Law Review 1991;50:798–858; Fletcher JC. Ethics committees and due process. Law, Medicine and Health Care 1992;20(4):291–3; Arnold RM. Should competent patients or their families be notified before HECs review the patients’ cases? Yes. HEC Forum 1994;6(4):257–9; Roberts LW, McCarty T, Thaler GB. Should competent patients or their families be able to refuse to allow an HEC case review? Yes. HEC Forum 1995;7(1):549–50.
14. Bliton MJ, Finder SG. Strange, but not stranger: The peculiar visage of philosophy in clinical ethics consultation. Human Studies 1999;22(1):69–97; Finder SG, Bliton MJ. Responsibility in actual practice: Consent and participation in clinical ethics consultation. In: Hestor M, ed. Ethics by Committee: A Textbook on Consultation, Organization, and Education. Lantham, MD: Rowman & Littlefield; 2007:79–106.
15. Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New York: Oxford University Press; 1986.
16. See note 15, Faden, Beauchamp 1986: Part II (ch. 3–6).
17. Toombs KS. The Meaning of Illness: The Phenomenological Account of the Different Perspectives of Physician and Patient (Philosophy and Medicine Series, Vol. 42). Dordrecht, the Netherlands: Kluwer Academic Publishers; 1992.
18. Cassell EJ. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press; 1991.
19. Zaner RM. Power and hope in the clinical encounter: A meditation on vulnerability. Medicine, Health Care and Philosophy 2000;3(3):265–73.
20. See note 13, Veatch 1969:21; Arnold 1994:258; Roberts et al. 1995:549.
21. See note 13, Wolf 1991:803; Fletcher 1992:292; Roberts et al. 1995:548.
22. It should be noted that the merit of the two most common arguments favoring the need for consent prior to proceeding with ethics consultation, that is, concerns about information disclosure and due process, were not accepted by all; see, for instance, Agich GJ, Youngner SJ. For experts only? Access to hospital ethics committees. The Hastings Center Report 1991;21(5):17–25; Finder SG. Should competent patients or their families be able to refuse to allow HEC case review? No. HEC Forum 1995;7(1):51–3.
23. See note 18, Cassell 1991: ch. 7 and 8.
24. Zaner RM. Phenomenology and the clinical event. In: Daniel M, Embree L, eds. Phenomenology of the Cultural Disciplines. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1994:39–66.
25. Zaner RM. Ethics and the Clinical Encounter. Engelwood Cliffs, NJ: Prentice-Hall; 1988.
26. See note 14, Bliton, Finder 1999:73.
27. See note 8, Moreno, 1991:195.
28. Vailland G, Sorzorwales N, Macarthur C. Psychological vulnerabilities of physicians. New England Journal of Medicine 1972;287:372–7; McCue JD. The effects of stress on physicians and their medical practice. New England Journal of Medicine 1982;306:458–63; Rushton CH. Care-giver suffering in critical care nursing. Heart & Lung 1992;21(5):303–6; Miller MN, McGowen KR. The painful truth: Physicians are not invincible. Southern Medical Journal 2000;93(10):966–73; McLeod ME. The caring physician: A journey in self-exploration and self-care. American Journal of Gastroenterology 2003;98(10):2135–8; Malterud K, Hollnagel H. The doctor who cried: A qualitative study about the doctor's vulnerability. Annals of Family Medicine 2005;3(4):348–52; Murphy JF. The vulnerability of doctors. Irish Medical Journal 2005;98(7):196; Sulmasy DP. Dignity, vulnerability, and medical error. Health Progress 2006;87(1):12–4; Rushton CH. Defining and addressing moral distress: Tools for critical care nursing leaders. AACN Advanced Critical Care 2006;17(2):161–8; Sporrong SK, Hoglund AT, Arnetz B. Measuring moral distress in pharmacy and clinical practice. Nursing Ethic 2006;13(4):416–27; McCaffree D. Moral distress and the intensive care unit. Critical Care Medicine 2006;34(12):3049–50; Zuzelo PR. Exploring the moral distress of registered nurses. Nursing Ethic 2007;14(3):344–59.
29. See footnote 28, Sulmasy 2006.
30. See footnote 28, Murphy 2005.
31. See footnote 28, McLeod, 2003.
32. See footnote 28, Malterud, Hollnagel 2005.
33. See footnote 28, Rushton 2006.
34. MacIntyre A. Dependent Rational Animals. Chicago: Open Court; 1999; Rendtorff JD. Basic ethical principles in European bioethics and biolaw: Autonomy, dignity, integrity and vulnerability—Towards a foundation of bioethics and biolaw. Medicine, Health Care and Philosophy 2002;5(3):235–44; Kottow MH. The vulnerable and the susceptible. Bioethics 2003;17(5–6):460–71; Kottow MH. Vulnerability: What kind of principle is it? Medicine, Health Care and Philosophy 2004;7(3):281–7; Dodds S. Depending on care: Recognition of vulnerability and the social contribution of care provision. Bioethics 2007;21(9):500–10.
35. Levine C. The concept of vulnerability in disaster research. Journal of Traumatic Stress 2004;17(5):395–402; Hoffmaster B. What does vulnerability mean? The Hastings Center Report 2006;36(2):38–45; Perry J, Lynam MJ, Anderson JM. Resisting vulnerability: The experiences of families who have kin in hospital—A feminist ethnography. International Journal of Nursing Studies 2006;43(2):173–84.
36. Zaner RM. Interpretation and dialogue: Medicine as a moral discipline. In: Crowell SG, ed. The Prism of the Self: Philosophical Essays in Honor of Maurice Natanson. Dordrecht, the Netherlands: Kluwer Academic Publishers; 1995:147–68.
37. See note 25, Zaner 1988:30–6.
38. Bliton MJ, Finder SG. Traversing boundaries: Clinical ethics, moral experience, and the withdrawal of life supports. Theoretical Medicine 2002;23(3):233–58.
39. See note 25, Zaner 1988:30–2.
40. This brief example is based on an actual clinical ethics consultation. Although the details have been changed in order to protect the confidentiality of all participants, the core issue regarding why ethics consultation was requested is an accurate report from the physician requester.
41. Reiter-Theil S, Mertz M, Meyer-Zehnder B. The complex roles of relatives in end-of-life decision-making: An ethical analysis. HEC Forum 2007;19(4):338–61.
42. See note 14, Bliton, Finder 1999:72–5.
43. See note 25, Zaner 1988:69–71, 105.
44. See note 9, Walker 1993.
45. See note 19, Zaner 2000:271.
46. Zaner RM. Listening or telling? Thoughts on responsibility in clinical ethics consultation. Theoretical Medicine 1996;17(3):255–77.
47. Reiter-Theil S. Balancing the perspectives: The patient's role in clinical ethics consultation. Medicine, Health Care and Philosophy 2003;6(3):247–54.
48. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: A national survey. American Journal of Bioethics 2007;7(2):13–25.
49. Dudzinski DM. The practice of a clinical ethics consultant. Public Affairs Quarterly 2003;17(2):121–39.
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