Sunday, August 14, 2011

Medical Ethicists as Secular Priests

In Jonathan Moreno's book "Is There an Ethicist in the House?" I came upon these sentences:
...I have been appointed to ad hoc committees on sensitive administrative problems (such as what to do about a resident who was HIV positive but wanted to stay in the program), even though ethical expertise was not much needed. In such cases I have come to see myself as cast into the role of a “secular priest”: even in a pluralistic and multiethnic society someone must sanctify such delicate proceedings. (pages 14-15)
In psychotherapy the phenomenon Moreno is describing would be seen as "transference" - a perception of the therapist that arises from within the patient, not from a realistic perception of the therapist.

In simplest terms, the therapist has two choices to make with regard to transference - use it to advance the goals of treatment, or interpret it as an opportunity for insight.

The ethics consultant must make a similar choice about the "secular priest" transference. If the group the consultant is meeting with has worked hard and reached a thoughtful, well-reasoned conclusion, but then asks - "what do you think?" - the consultant might accept the "secular priest" role and "bless" the group's work, as by responding - "I'm impressed with the thoughtfulness and depth of the discussion - it looks as if we're all comfortable with where we came out."

One reason for accepting the "secular priest" transference this way would be to encourage the participants to see themselves as competent to grapple with challenging ethical questions. Another reason would be to reinforce their commitment to the method(s) of problem solving they had applied.

But suppose the group has reached an overly certain conclusion about an ambiguous question that isn't susceptible to the kind of closure the group settled on. Here the "priest" might choose to "bless" uncertainty: "We all prefer certainty to uncertainty. That's why Harry Truman only wanted advice from one-armed economists - so that he wouldn't hear "on one hand...on the other hand"! But sometimes certainty is an illusion. I suggest that we go back to the drawing board on this..."

I feel squeamish when I'm introduced as an "ethicist." Since questions about what's the right thing to do come up every day of our lives, we're all "ethicists." Sometimes I make that point. But when I feel the situation requires a "secular priest" I bite my tongue and accept the label.

But there's a serious risk in following that path - we might come to believe the attribution ourself!


Jonathan said...

As an ethicist myself, I have come to believe that the "we're all ethicists" misconception is one of the major barriers preventing my colleagues from utilizing my services. I like to draw the distinction here between being an "ethicist" and being a "moralist" - we're all moralists in the sense that we all have opinions about right and wrong. But we're not all ethicists in the sense that we don't all posess the same skills of critical reflection and reasoning, knowledge of relevant ethical principles and concepts, knowledge of established ethical standards, and the level of humility required to admit our opinion isn't necessarily the correct one. These are but some of the many skills and traits required to "do ethics."

Jim Sabin said...

Hi Jonathan -

Thank you for your very thoughtful comment. I'm sorry for the delay in responding - I've been out of the country for a couple of weeks and just got back last night. (I wrote the post before going away to keep the blog "alive" while I was gone.)

I agree with the distinction you make and with your perspective that while we may not all be ethicists, "we're all moralists." For some this involves no more than holding unreflective opinions about right and wrong, but others have developed, not necessarily through study, a good capacity for critical reflection and reasoning.

I think of the distinction you make as analagous to primary care and specialty care. We expect every PCP to have basic skills in all of the areas of medical specialty, but not to have, say, the skills of a seasoned cardiologist. The PCP will handle common, less difficult, cardiac problems, but will consult or refer for more complex clinical issues. Likewise, we should expect a basic level of understanding of concepts like informed consent and a basic capacity to do ethical reasoning for all health professionals. I especially like your point about the need for humility about our own opinions. Like the PCP, we should be prepared to consult with or refer to someone with a greater level of skill and experience when our own skill set isn't enough.

In terms of our services being utilized, I think we need to work harder than other specialists to "sell" ourselves, since as you point out, the humility necessary to see that our opinion might be improved with another perspective isn't reliably present!

Again, thank you for your comment!