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This book represents a unique contribution to the field of clinical ethics consultation. What might seem at first glance to be an anthology, that is, a collection of independent essays, is actually more akin to a conversation, a shared engagement, a mutual undertaking. At the center of this conversation is a steadfastness, abiding and serious in its orientation – exemplified in these voices and contributions collected from colleagues – to explore, identify, and examine the actual conduct of individuals who engage in ethics consultation practice. Although there is some helpful resemblance to an anthology, for example in the variety of ways these essays describe and depict a complex array of different standpoints regarding the practical and conceptual commitments in this growing field, more important to the Zadeh Project is the deliberate focus on explicating and probing the ways these commitments influence how a particular individual acting as an “ethics consultant” might understand and interpret the roles and prevalent expectations represented by those differing standpoints. In that light, and perhaps more urgently, this book is motivated by a mutual recognition that part and parcel with the responsibility of doing clinical ethics is an ongoing and clear need to describe and consider what clinical ethics consultants actually encounter when actively working with physicians, nurses, social workers, and other healthcare providers as well as with patients, families, and others who care about patients. As a contribution to that necessity of being accountable, this Project and the resulting book represent much more than merely collecting together the thoughts and perspectives of a group of colleagues from within a common field: this book is an attempt to display, to model through written text, a set of practices and what is at stake in these practices.

So concluded my first conversation with Samir Zadeh. Our meeting had been purely accidental; as I walked onto the elevator going down from the Surgical ICU, he and one of his sisters (her name, I would learn, was Nadira) were already on, coming down from another one of our hospital’s ICUs, from a floor above. Samir was a man in his early 50s, and his sister, whom I would learn was actually a few years older, appeared younger than he. They were talking quietly when the doors opened, but as is often the case in elevators, especially in a hospital, as soon as I entered, their conversation stopped. We rode down to the bottom floor in silence. As we exited, I let them go first, a courtesy I had been taught by my parents, and they both thanked me, in the usual social way, and walked out into the lobby and then out of the building. I walked the same way.

It was when we were about 25 feet from the building that Mr. Zadeh and his sister stopped, so that I caught up to them. As I did, Mr. Zadeh, a large man, maybe 6 feet tall and 250 pounds, with thinning hair and a well-groomed mustache, turned and said my name aloud, “Dr. Finder, may you be so kind as to talk?”

With “The Zadeh Scenario,” Finder offers us a gift…a rich and thoughtful first-person account of the gradual unfolding of a specific ethics consultation conducted by a specific ethics consultant in a specific context. This is not your average case report, stripped to the bare facts and devoid of the ambiguity of real-time human interactions. It’s also not simply an example of thick description, offering the reader a detailed account of the context out of which an abstract ethical dilemma has emerged, with the ethics consultant describing all from a distance, above the fray. What Finder offers and models for us instead is something entirely new and different. He offers us a case narrative into which he has chosen to place himself squarely and explicitly. And in the spirit of “peer review” he has generously revealed his own inner dialogue in response to twists and turns in the case, sharing his personal reflections as events unfolded, and his musings about various actions he took and choices he made in his role. By inviting us to ponder his story about the story of the case, he generously extends a gift to us: the opportunity to reflect on his—and therefore our own—consultation practice, and the opportunity to try a new kind of peer review.

“The Zadeh Scenario,” a wondrously rich narrative generously shared by Finder, walks the reader through the interactions of an ethics consultant during a case. In this telling, Finder appears deeply cognizant of how memories can be affected by subsequent decisions and experiences. Hence, it is important to note that many key parts of the narrative – if not all of it – were captured concurrently or in close proximity to the actual events, thereby revealing the factual and normative obscurity that unfolds over the course of an ethics consultation. Finder’s polished skills of careful attention and mindful appreciation in recounting the “doing” of an ethics consult thus provide something of an anthropological account – telling us who went where and the content of several weighty conversations – rather than what might traditionally be expected from an ethical analysis of a case presentation. We see that a rich account of the clinical engagement of a consultant is ultimately not enough to provide a holistic account of the consultant’s practice or to discern core moral considerations that emerge among divergent standpoints. Much of the information that is needed to both understand and assess the role of the consultant, the goals of consultation, and the broader societal and legal context in which ethics consultations occur lies outside the parameters of a particular case – no matter how detailed or beautifully told.

My appreciation for in ethics consultation was taken up a notch after experiencing how much thought our neighbors to the North put into procedural elements of professional practice. In 2011, I was privileged to attend a meeting of Canada’s “Practicing Healthcare Ethicists Exploring Professionalization” (PHEEP) group in Saint John, New Brunswick. Much of that meeting was spent attending to how the newly-formed group would work together. While some of the Canadians bemoaned their commitment to things are done as much as to is accomplished, I remember making a “note to self” along the lines of:

The situation described by Finder in “The Zadeh Scenario” is a very familiar one to those of us who work as ethicists in United States hospitals. The outcome he records, however, is unusually benign; indeed, and unfortunately, in many US hospitals the ultimately unresolved/unmediated conflict he describes would almost certainly result in the patient’s being subjected to futile attempts at life-prolongation and resuscitation. In this sense, the outcome of this ethics consultation might be considered “good” insofar as it did not result in such futile attempts. But that sense of “good” is fleeting given other concerns which serve as the focus of this chapter.

We begin with the acknowledgement that with “The Zadeh Scenario,” Finder has provided a rich and thick description of what clearly was a challenging opportunity for end-of-life ethics consultation. As such, his narrative now stands as opportunity for us to engage with him in the even more challenging opportunity of post-mortem moral reflection. We have organized our thoughts on this case mostly in the interrogative mode, as questions or queries, and from perspectives informed by our own interests in clinical ethics and healthcare law.

The peer reviewers of Part Two critically appraise and reflect on the clinical ethicist’s actions in “The Zadeh Scenario.” In what follows, I first outline four prominent methods for “doing” clinical ethics. For each I consider if, and how, the method may have been utilized in the peer reviews of Part Two. Where peer reviewers employ different methods within their analyses, or where they are unclear in their methods, I draw attention to it. Finally, I propose a method that I believe is a common thread in all of the peer reviewers’ assessments; I call this method “proceduralism,” a method that echoes narrative and pragmatism approaches while using procedural standards to orient the method.

At the outset of this chapter, I want to echo the praise offered by all of the contributors to this volume for Finder’s outstanding, thoughtful and self-critical narrative of the case of 83 year old Mrs. Hamadani and her fiercely devoted children. The brocade account is carefully woven, like a fine Persian tapestry, to convey the rich complexity of an actual ethics consultation as it transpires not over hours, but rather over days, weeks, months and even, as in this case, years. Mrs. Hamadani’s narrative so told is replete with questions worthy of critical reflection. What is an appropriate role for ethics consultation in healthcare? How can an autonomy-centric culture accommodate community-centric cultural difference? How can or should the voice of the patient be heard when she cannot speak for herself and the much louder and anguished voices of others demand to be heard? What are the bounds of acceptable medical treatment and how should care teams respond when patient or family demands threaten to push care givers to cross those bounds? What is an appropriate response for ethics consultants when they are asked to take over a case or prevent a colleague from interacting with an unwilling family? Do the motivations of patients, family, or members of the care team in calling ethics consultants necessarily shape the consultant’s role? And so the list goes on, as the variety of commentaries which comprise the majority of this volume, as well as the multitude of discussions that you, the readers, will inevitably have with colleagues, students, and friends make abundantly clear.

Method in ethics consultation has at least three distinguishable components: a canon – that is, the rules that guide actions, cognitions, judgments, and perceptions involved in performing an ethics consultation; a discipline – that is, a mastery, or at least possession, of the specific types of actions and intentions of ethics consultation which are guided by the rules that are embodied in the actions of competent ethics consultants; and a history – that is, the narrative of, and critical reflection on, the actions, including the analyses, assessments, and communications undertaken in the course of the consultation, including the reasoning about the practical issues and the steps toward resolving the ethical question or issues that arose. As a doing, then, ethics consultation consists in actions and intentions that constitute a distinctive set of meanings in the clinical space of patient care in which the meanings brought to patient care through the actions and communications of the ethics consultation help shape, to some extent, the way that the case develops and is understood, which is further reflected in how the case is represented. In this sense, statements about ethics consultation methodology, and theories of ethics consultation, are secondary to the actual practice itself. The analysis and interpretation of actions and communications of those involved in the clinical care of the patient represents a complex process that blends the meaning of ethical concepts, principles, and theories with the constructed and uncovered clinical and value meanings of the case.