Catálogo de publicaciones - libros

This chapter is a meta-commentary on case commentaries in the present volume, which highlight potential hazards of using case narratives to evaluate clinical ethics consultation. I argue that in several ways, the commentaries illustrate how important it is, given the attestation model currently used to evaluate the practice of clinical ethics consultation, to develop an idea of a standardized narrative in clinical ethics consultation. If we do not, we risk mistaking clear, eloquent, or rhetorically impressive case narratives for rigorous, ethically appropriate consultations.

In this chapter, we explore the question of on what grounds reports of clinical ethics support in general, including especially clinical ethics consultation, can or should be evaluated when using a peer review system. It is our contention that to evaluate clinical ethics consultation within a peer review system aiming at transparency and fairness, a defined and shared criteria of evaluation, i.e. an evaluation standard is required. When evaluating a performed ethics consultation (according to a given documentation), we can roughly distinguish between an internal standard, which refers to the conceptualization of clinical ethics consultation held by the respective consultant or by the assessed clinical ethics support service (CESS) themselves, and external standards. Most important is the way an external standard is being defined: Is it just the standard of another service or colleague? Or is it the result of a larger consensus-building process of a relevant body representing a larger group of colleagues, such as the ASBH? Or does it even rely on the “evidence” of related research? An external standard, however, may rest on criteria that are not – or not fully – accepted by the evaluated CESS or individual ethics consultant. Identifying the internal standard of an observed ethics consultant’s work may also be challenging. From the evaluator’s perspective the responsibility for making an internal standard known and unequivocal lies with the “author” of the material. The potential gap between internal and external standards marks a methodological difficulty that as such has to be addressed within peer review evaluation.

“The Zadeh Scenario,” when taken together with the subsequent layers of peer review and commentary on that peer review, highlights two crucial insights regarding peer review for clinical ethics. The first is one that most (but not all) of Finder’s peer reviewers miss: peer-reviewers who would give attestation to quality need to be critically attentive to, and reflective about, the evidence supplied to them by candidates. The second is a more significant point: the kind of doing that is clinical ethics consultation is a local form of moral enquiry, seeking not just to achieve medical – or clinical ethical – goals, but to enact human goods. Good peer review thus turns on being clear regarding the goods of ethics consultation. Buried inside “The Zadeh Scenario” one can find several goods of clinical ethics. These goods are subjective, idiosyncratically named and defined by patients, and embedded in an institution of healthcare that purports to be of service to the goods of health. The clinical ethics consultant, at her best, acts as a careful mid-wife, attempting to bring forth the goods desired, the goods possible, and perhaps even the goods that, while desired, are not possible. After all, some goods pursued by patients are not possible due to the limits of medicine. On the other hand, some goods pursued by medicine are not desired by patients. And equally, some goods pursued by clinical ethicists might be limited, provisional, and local. “The Zadeh Scenario” thus acts to problematize the goals of clinical ethics consultation, asking it to focus on the goods that the practice might bring forth.

In this chapter we reflect on the relevance of peer review for assessing the quality of clinical ethics consultation. We contend that peer review in the narrative form as presented in this book provides an alternative to the formal clinical ethics consultation review procedures typically found in the clinical ethics literature. We elaborate on peer review as a reflection on clinical ethics consultation practice, the elements which a story should contain in order to provide a basis for peer review, and the differences between the assessments of the peer reviewers. We argue that a narrative approach to assessing the quality of ethics consultation can be further developed by allowing all stakeholders who are involved in the clinical ethics practice to actively take part in the evaluation process, following a “responsive evaluation” approach. An example of this is creating a Community of Practice, the aim of which is to foster a joint learning process of all parties involved. At the end of this chapter, we draw conclusions on peer review as a dialogical tool for evaluating quality of clinical ethics consultation.

This chapter critically reflects on the critiques, reviews, and many proposals presented in Parts Two, Three, and Four, and provides a summary conclusion for the entire Zadeh Project. Obvious differences between experience and reporting on experience are highlighted, with particular attention to the ways such differences are detailed by the Zadeh Scenario and in our colleagues’ responses to it. In addition, we discuss a key challenge associated with clinical ethics practice and the peer review of such practice: identifying what actually matters for those engaged in these kinds of activities. In each case, we argue, the work of discovering what matters to the individuals actually involved cannot be overlooked. Furthermore, that work may even be the primary ingredient to responsible conduct for both consultation and peer review. Building on this idea that responding responsibly to that which is actually encountered in clinical practice serves as a primary activity of, and thus grounds responsibility in, clinical ethics practice, we then argue that ethical analysis of Finder’s activities in the Zadeh Scenario, and for clinical ethics peer review more generally, has at least three layers: that which addresses the immediate interactions between an ethics consultant and those whom the consultant engages; that which addresses the ethics consultant’s own sense of self-responsibility; that which addresses peer reviewers’ own frames for evaluating another’s clinical ethics practice. We conclude that the Zadeh Project exemplifies what is at stake in ethics consultation (as a practice) and peer review (as a form of peer engagement and education). Taken as a whole, then, the Zadeh Project reveals how peer review, in acknowledgement of the responsibility to create a context for peer education, rests upon a commitment to model – and demand critical engagement with – what is held to be most worthwhile for clinical ethics practice and the field of clinical ethics consultation as a whole.