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In this chapter we introduce the themes of the book and present our overall approach to clinical ethics for health professionals. Of special note is our assumption that the social sciences—especially history, sociology, and anthropology/psychology—can do much to enrich how health professionals think about clinical ethics. We also provide an overview of the book as a whole.

This book has its origins in the work of the first author (SS) as a researcher, teacher, and consultant in the 1980s. During that period, the growing interest in bioethics was coupled with a growing distrust of doctors and the medical profession. To capture that particular historical period and how the first author’s views about ethics and health care evolved—in particular, through his own, concrete experience with health professionals of various sorts and in various settings—this chapter is presented in the first person.

The bioethics movement did not arise and expand in a vacuum. As discussed in this chapter, advances within medicine were creating a need for ethical issues to be identified and addressed. Major new work in philosophy suggested that philosophically trained “bioethicists” could uniquely contribute to ethics in medicine. The growing momentum of the consumer rights movement lent its particular, rights-oriented contours to bioethics and the demands it placed on physicians. Likewise, courts were giving legal force to the rights of patients against doctors. These diverse forces coalesced into a worldwide movement—despite the mixed response in Europe and elsewhere—that came to dominate the scholarly literature in health care ethics (not just in medicine) and that set itself as a model for how health professionals were supposed to think about clinical ethics.

The bioethics movement, originating in the United States but then expanding to become a worldwide phenomenon, generated a conception of ethical reasoning that is oriented toward ethical (and legal) rights—and also, more abstractly, toward ethical principles. These modes of reasoning, though useful and even powerful tools for trained philosophers and bioethicists, do not mesh well with how clinicians think and work. The discontinuities arise in various contexts, and will often be discussed here and in subsequent chapters. In this chapter we focus on the development of the bioethical model of and the notion of ethics expertise to which it gave rise.

Unlike what happens in the classroom, where discussions can end in conflict, with agreement nowhere in sight, ethical problems in clinical health care require that decisions be made. Some form of closure is required in order to move forward. And closure can be elusive indeed. In this chapter we look at efforts to achieve closure through the use of multistep processes, as proposed by some bioethicists.

In this chapter we begin the process of rebuilding clinical ethics in health care—from the ground up. Clinical ethics, like all ethics, has its foundation in the self—in a full conception of the person whose thoughts, emotions, and actions must be understood as an integrated whole. It is from that foundation that one can then start building, for all health professionals as individuals, a mature professional ethic that incorporates each person’s own history and experience and that integrates those with each person’s growing knowledge of a particular field of health care. And because this conception of ethics is so thoroughly grounded in the self, it is a conception that inescapably connects with all health professionals as individuals and that enables them to understand, appreciate, and elaborate their own ethical thinking.

In this chapter we continue the exploration of ethics as embedded in thought, emotion, and action. We begin by discussing two cases, one of which presents a sharp conflict, one of which does not, and both of which use the goal-directed, concrete language of clinical medicine as the health professionals work out their differences, the challenges presented by the cases, and ultimately what to do. We then introduce the notion of as a way of understanding how ethics is embedded in the very framework of health care.

What to teach? How to teach it? These are the central questions for teaching professional ethics to trainees in health care, as they are for teaching any students in any subject in any field. The answers we present here and in the coming chapters build upon the criticisms of bioethics from sociology, history, and anthropology, as discussed briefly in our introductory chapter—and also on the discussions of the self, informal ethical discourse, and interpretive communities, as presented in Chapters and .

Presenting a full formal curriculum for teaching ethics to health professionals is obviously far beyond the scope of this single chapter. But what we can do here is discuss a range of teaching formats—core lecture course, discussion classes, and observational and participatory activities—that can be used in any field of health care, along with an explanation of how these formats can be used to implement an approach to health care ethics that is centered on the self, informal ethical discourse, and interpretive communities, as presented in Chapters through .

In this chapter we focus specifically on teaching health care ethics in clinical settings rather than the classroom, through formal courses. The clinical opportunities are diverse, often ad hoc, and usually connected up with current clinical cases. We also discuss the use of formal clinical modules and the role of mentoring as ways of enriching and reinforcing what has previously been taught through formal courses. The discussion here, as in the two earlier chapters on teaching clinical ethics, is centered on efforts to extend and enrich trainees’ informal ethical thinking within their respective interpretive communities, as discussed in Chapters and .