The future of clinical ethics in Switzerland – a plea for further professionalisation

Rouven C. Porz

 

Clinical ethics is an important discipline in our healthcare system, but one that is in need of further professionalisation. In particular, the members of clinical ethics committees in Swiss hospitals need to have opportunities for better training and continuing development in ethics. Let me start briefly with the COVID-19 pandemic as an example; I will then express my concerns in three theses; and conclude with a plea for more training for members of clinical ethics committees.
The COVID-19 pandemic in March/April 2020 in Switzerland has shown very clearly the importance of ethical considerations to our country. The otherwise unquestioned right to individual freedom was subordinated to the interests of the whole population, for example by imposing curfews. This made us all newly conscious of the value of self-determination, which is otherwise taken for granted. Living wills for patients were talked about, the moral distress of healthcare professionals was discussed, criteria for triage situations disclosed; in view of COVID-19, there was a clear spotlight on ethics in all these (and other) issues of values and conflicts of values. At the same time, however, there was a certain lack of clarity, which is very typical of the perception of “ethics” in healthcare: a range of tragic situations, sensationalist journalism, psychological sensitivities and legal issues were often presented as “ethics” as well. In addition, actual ethical value conflicts, such as how to handle domestic violence, or the effect of lockdown on intellectually and/or physically disabled people, received surprisingly little ethical attention.
All this is reason enough to reflect briefly on the role of clinical ethics, not just in relation to the pandemic, but in general: what should the future of clinical ethics in Switzerland look like? There is no doubt – as this journal has shown over the last 10 to 15 years – that ethics has gained enormously in practical significance. It is important to note that I am talking only about clinical ethics here, not about our cantonal research ethics committees, but about the way that many hospitals have established an ethics forum or founded a clinical ethics committee, and the way that numerous ethicists are already working full-time in this clinical-ethics field in universities and hospitals. And yet, in my view, there are still some uncertainties that raise concern, which I would like to present in three theses:

1. “Ethics” is not one’s own personal “morality”

For me “ethics” (as a discipline) means a reflexion of norms and values. In applied ethics, for example, this reflexion is linked to the demand to develop viable and well-reasoned solutions to current and emerging problems and dilemmas. The ethics that takes place in the hospital (“clinical ethics”) performs this task as a kind of support function for healthcare professionals (and so also for patients). Using this definition, I make explicit my personal understanding of clinical ethics. Unfortunately, however, this clarification is often lacking in the debate surrounding clinical ethics. Concrete definitions are rare, and healthcare professionals and members of ethics committees often appear to start from very different conceptualisations of ethics but rarely discuss them in practice. Ethics can variously be understood to be a doctor’s “morality”, a “matter of the heart”, or an opportunity to debrief, often as a case of “it’s good to have been able to talk about it”. I believe this is too imprecise and runs the risk of watering ethics down. If everything is ethics, then nothing is really ethics any more. I would like to see a consensus on a clear definition and also on delineating a clear sphere of activity for our daily work. That should not be difficult, since the Swiss Academy of Medical Sciences (SAMS) has proposed a very helpful definition of ethics as “support for health care professionals” [1] through reflexion on “values and norms” [2]. The definitions are available: they just need to be applied

2. “Ethics” is more than just “the four principles”

The theoretical backbone of Western biomedical ethics (and thus also of applied clinical ethics) is formed by the four principles of Beauchamp and Childress [3]. We all know them, we all use them in daily clinical ethics life, and in teaching and training: respect for patient autonomy, beneficence, non-maleficence, and justice. The pioneering spirit of this ethical paradigm is uncontested, the focus on the patient’s wishes is fundamental. We should nevertheless be confident enough by now – as Beauchamp and Childress themselves are [4] – to include supplementary or alternative concepts in our ethical thinking: care ethics, for example, offers fascinating considerations of the relational dimensions of autonomy; virtue ethics brings moral courage and behaviour back to the centre; feminist approaches to clinical ethics, with their focus on power dynamics and structural dynamics, continue to receive too little attention (e.g., [5]). And the current COVID-19 situation teaches us that we should at all times be ready to switch our perspective from an individual patient focus to that of public health. I would like us to be even more open to fresh insights. This shift would have important ethical implications: for example, a superficial focus on the patient’s wishes can also lead to a dangerous delegation of responsibility (“This is something the patient needs to decide for him/herself”).

3. “Ethics” is applied philosophy

To put it very simply: ethics is concerned with values. Natural sciences are concerned with facts. Of course, from a hermeneutical standpoint, this simplification is by no means absolute, because our facts and values are always interwoven, in both subjective and apparently objective interpretations of the world. Nevertheless, the methodology of ethics is fundamentally distinct from that of natural sciences. “Values” are investigated and weighed up in a different way from presumed facts. Yet the discipline of ethics increasingly submits to the scientific thought pattern of “hypothesis – experiment – result – discussion”, particularly because funding for research, including ethics research, works mainly within a scientific paradigm. Those who seek money for ethics studies realise quite quickly that they have to clothe their ethical ideas in natural scientific approaches in order to acquire funding. We, as representatives of ethics, should show more courage here: we should be ready to make a case to funding bodies that ethics obeys other intellectual imperatives.

These considerations lead me to conclude that the discipline of clinical ethics is nowhere near the level of professionalisation that it could be. Theoretically, we should have the confidence to question our daily activity as ethicists, in terms of experience and scientific theory. We have a responsibility towards the healthcare professionals of the future to prepare the ground for them properly. But what would such professionalisation look like in practice? A crucial step will be to develop a national curriculum for continuing training in clinical ethics. For one thing, it would be interesting for professional ethicists in university hospitals to be able to compare experiences and to network with one another. For another, it would be important for the members of clinical ethics committees in all Swiss hospitals to reach equivalent levels of knowledge and expertise in clinical ethics. And finally, establishing and delivering a national platform for professional training will engage and encourage all of our practitioners committed to the discipline of clinical ethics.

 

Prof. Dr Rouven Christian Porz, Dipl Biol, Medical Ethics and Professional Medical Education, Medical Directorate, Insel Gruppe, Inselspital, Bern University Hospital, Bern, Switzerland

 

References

1. Swiss Academy of Medical Sciences (SAMS). Ethics Support in Medicine. Bern: Swiss Academy of Medical Sciences; 2012. p. 5.
2. Swiss Academy of Medical Sciences (SAMS). Ethics Training for Health Professionals. Bern: Swiss Academy of Medical Sciences; 2019. p. 5.
3. Beauchamp T, Childress J. Principles of Biomedical Ethics. 6th edition [1979]. Oxford/New York: Oxford University Press; 2009.
4. Beauchamp T, Childress J. Principles of Biomedical Ethics: Marking Its Fortieth Anniversary. Am J Bioeth. 2019;19(11):9–12. doi:https://doi.org/10.1080/15265161.2019.1665402. PubMed
5. Scully JL, Baldwin-Ragaven LE, Fitzpatrick P, eds. Feminist Bioethics: At the Center, on the Margins. Baltimore: Johns Hopkins University Press; 2010.