Ethics and Education

ISSN: 1744-9642 (Print) 1744-9650 (Online) Journal homepage: https://www.tandfonline.com/loi/ceae20

Seeing through medical ethics: a request for

professional transparency and accountability

J. T. H. Connor

To cite this article: J. T. H. Connor (2016) Seeing through medical ethics: a request for
professional transparency and accountability, Ethics and Education, 11:1, 104-116, DOI:
10.1080/17449642.2016.1145492

To link to this article: https://doi.org/10.1080/17449642.2016.1145492

Published online: 24 Mar 2016.

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Ethics and Education, 2016
VOL. 11, NO. 1, 104–116
http://dx.doi.org/10.1080/17449642.2016.1145492

Seeing through medical ethics: a request for professional

transparency and accountability
J. T. H. Connor
Faculty of Medicine, Memorial University of Newfoundland, St.John's, Canada

ABSTRACT KEYWORDS
This essay is a critique of medical/clinical ethics from the personal Consulting ethicists; medical
perspective of a medical historian in an academic health science centre history; accountability;
transparency; religion; core
who has interacted with ethicists. It calls for greater transparency
competencies
and accountability of ethicists involved in ‘bedside consulting;’ it
questions the wisdom of the four principles of biomedical ethics (the
‘Georgetown mantra’) and their American cultural origins with respect
to training; challenges the authority of ‘core competencies’ for ethicists
as identified by the American Society for Bioethics and Humanities;
and muses over the apparent reintroduction of religion into clinical
medicine through the medium of bioethics. This essay is designed to
provoke reflection on the putative ‘professionalism’ of the consulting
ethics enterprise for which educational baselines and curricula are not
standardized. By analysing sources such as the professional material
communicated by the Canadian Bioethics Society, it also critiques the
collective ethical shortcomings and confusions of those who style
themselves medical ethics practitioners – the culmination of which,
it is argued, has been the recent decision by the Canadian Institutes
of Health Research not to appoint a medical ethicist in charge of its
ethics portfolio.

During the mid- to late 1990s first the Toronto, then the Canadian, and finally the inter-
national medical research communities were rocked by revelations over the research of a
clinical researcher at Toronto’s Hospital for Sick Children (HSC). As the animosity built and
the allegations escalated, this professional battle became increasingly personal on all sides,
degenerating to the level of poison pen emails between ‘colleagues.’ In time, this imbro-
glio/debacle/fiasco, which centred on the research of Dr Nancy Olivieri and an experimen-
tal treatment for thalassemia, would spawn numerous investigations and inquiries; much
high-profile media exposure; several books; a dedicated symposium and a journal special
issue (CAUT 2001; Thompson et al. 2001; Welch et al. 2004; Shuchman 2005; Olivieri 2006).
And, of course, it almost destroyed several lives and careers. At the time, and also with the
benefit of historical hindsight, this whole sorry saga could have been the ‘poster child’ for
the biomedical ethics community as there was something to interest and involve anyone

CONTACT  J. T. H. Connor  jconnor@mun.ca

© 2016 Informa UK Limited, trading as Taylor & Francis Group
 Ethics and Education   105

who styled him or herself a bioethicist. Almost every biomedical ethical issue conceivable
was present: academic freedom, Big Pharma gag orders, funding conflicts of interest, patient
safety and rights, duty to care, the complicity/duplicity of university and hospital administra-
tors, research protocols, contractual obligations and/or breaches, academic integrity…. Yet,
the community of academic scholars and institutional practitioners employed as ‘consulting
ethicists’ were silent. Indeed, one bioethicist (Bayliss 2004) later asked rhetorically, ‘where
were the heroes of bioethics?’ She continued:
Bioethicists in Canada failed Dr Olivieri and her colleagues at HSC…. I do not know the reason(s)
for the ensuing silence. I do know, however, that by and large Canadian bioethicists failed to
speak up when there was ample time and opportunity. As a responsible community, we must
ask ourselves whether we could and should have done more. (49)
I shall return to the concept of medical ethicists as ‘responsible community’ more fully,
but for the moment my discussion now fast-forwards two decades. In late 2012, the primary
funder of medical and health-related research in Canada, the Canadian Institutes of Health
Research (CIHR), initiated a study of its ethics portfolio; one year later, it released the Final
Report of the Task Force on Ethics Reform at the Canadian Institutes of Health Research (CIHR
2013). The report was highly critical of CIHR for its failure to promote ethics and for apparently
reneging on its obligation to provide ethics leadership; CIHR was also criticized for failing to
integrate ethics within the organization. In the collective opinion of the five senior ethicists
(all from Canada) who authored the report, the primary solution to these perceived failings
was to have a CIHR vice-president of ethics who would report directly to the CIHR governing
council and who would also have a seat at its table; this proposed VP position would also
sit on the CIHR’s science council. The likelihood of such an emperor (or empress) of ethics
for CIHR and, de facto, for health research in Canada buoyed the ‘responsible community’
of bioethicists. Within a couple of months, however, the community cried ‘Mayday, Mayday,
Mayday’ when it learned that no vice-president of ethics was to be appointed (Impact Ethics
2014a). Instead, the CIHR Chief Scientific Officer and Vice President Research and Knowledge
Translation, a biologist, would also now be dubbed the organizational ‘champion’ for ethics;
at the same time, a psychiatrist was appointed Chair of the Standing Committee on Ethics.
Canadian ethicists reacted despondently: ‘What is happening to ethics at the CIHR is not
just about the Canadian Institutes of Health Research; it is the story of Canada,’ said one
(Impact Ethics 2014b); another likened this outcome to the Titanic disaster and the then
recent shipwreck of the Costa Concordia (Impact Ethics 2014c). In spring 2014, a petition on
Memorial University of Newfoundland letterhead – coincidentally, perhaps, the Task Force
on Ethics Reform report was coauthored by a Memorial University ethicist – signed by 50 aca-
demic and clinical ethicists from across Canada was sent to the minsters of health, industry,
and state (science and technology), along with about dozen other parliamentarians and
senators. Predictably, the petition decried the action of CIHR in appointing a scientist as
its ethics champion as well as a psychiatrist in the leading role of the organization’s ethics
committee as, in quoting the Task Force report, neither person had ‘ethics experience and
neither is “recognized nationally and internationally as a leading scholar and researcher in
ethics”’(Impact Ethics 2014d). A few months later at the annual meeting of the Canadian
Bioethics Society (CBS, an academic group with no restrictions on membership), a session
with two of the Task Force report coauthors and the CIHR ‘ethics champion’ (Dr Jane Aubin)
made clear the concerns of the former and the resolve of the latter; in brief, the ethicists
present were disheartened by the proceedings. While the tone and reaction of some ethicists
106    J. T. H. Connor

were of personal rejection, there was still a call for a strong professional and collective stand
concerning the ethics leadership issue at CIHR (Impact Ethics 2014e). At present, CIHR has
not altered its decision, direction or policies.
Despite the chronological gap of twenty years and their significantly different issues and
contexts, the Olivieri and CIHR episodes nonetheless demonstrate the continuing lack of
effectiveness of professional medical ethicists: the silence at the close of one century may
have morphed into indignant outbursts in the new millennium, but it remains that theirs
is a failed professional project. I argue here that a tangly amalgam of history, philosophy,
culture and educational practices are responsible for this lack of traction; in brief, this has
been due to the failure, and probably the intrinsic lack of desire, of ethicists in Canada and
the United States to ‘professionalize.’ At its extreme, this discussion argues that although the
degree to which bioethics and bioethicists have proliferated and insinuated themselves into
the formal undergraduate medical curriculum, graduate programmes, and the health care
system is staggering – no other humanities-oriented field such as the literature of medicine
or medical history has made similar inroads – there is, ironically, no ‘responsible community’
of ethicists to reckon with – a conclusion I suspect CIHR also came to. This critique of ethics
in/and education speaks directly to the concerns of this special issue, such as how students
in health professions should be trained and/or educated in ethical professional practice and
what the conceptual differences and similarities between ‘acting professionally’ and ‘acting
ethically’ actually mean for such practice. My main conclusion is that while ‘professional’
medical ethicists exhort others that come under their gaze to promulgate and abide by codes
of ethics, they, collectively, do not govern themselves in a likewise fashion: professionally
speaking they appear not ethical! It must be understood from the outset that by and large
medical ethicists are not all nestled in university philosophy departments in which they
pursue traditional ‘academic-y’ things and who have an air of being disconnected from ‘real
life’: even those who are, are often engaged in consultancies or formal contracts with health
care facilities, which may augment their professorial salaries; others may be wholly employed
by institutions such as hospitals. There is also a cadre of ‘freelancers.’ As will become clear,
many medical ethicists aspire to be, and purport to be, practitioners. Because of this state
of affairs, issues such as licensing, professionalization, accountability and practice compe-
tencies become important. Indeed, it is asserted in this discussion that as for the most part
medical ethicists are not licensed, accountable, or professionalized, they do not constitute
a ‘responsible community;’ they do not conform to the norms of what would typically be
expected of a professional class.
Here are some historical facts and interpretations to establish the context for my argu-
ment. Clinical, or medical, or health care ethics – bioethics in general – as understood today,
even in its current international practice, is both a recent and an American invention. Noted
philosopher and physician Engelhardt (2009) reminds us that around 1968–1969 the field
was ‘made in America and then exported across the world, something like Coca Cola and
McDonald’s’ (294). Thus by 1970s, when consuming your ‘Big Mac’ and ‘Coke,’ you could also
recite the ‘Georgetown mantra’ with its four apparently self-evident ‘principles’ of patient
autonomy, social justice, beneficence, and non-maleficence as espoused in the canonical
(and best-selling) text book Principles of Biomedical Ethics by Beauchamp and Childress (2012);
or, you could consult one of the many later fast-food-for-the-mind reference books grounded
in principlist ideology and pitched at students and busy clinicians such as the Canadian text
Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians (Hébert 2014). For
 Ethics and Education   107

someone trained in studying change and continuity over time and across cultures, as well
as being an instructor of medical students, there are a few things that bother me about the
consequences arising from the historical background to biomedical ethics.
First, at its broadest interpretation historical thinking around bioethics embraces the
rise of Western biomedicine within the Hippocratic paradigm of ‘good’ medical practices
and conduct. But there is also a much narrower yet more important historical and cultural
window through which medical ethics must be viewed if it is to be understood critically
and thoughtfully: the social, medical, economic and cultural values of late-twentieth twen-
tieth-century America. In effect, the bulk of the literature on medical ethics has emanated
from the United States during the last several decades and has been written by American
practitioners. Accordingly, concerns in these publications include commercialism, litigation,
conflict of interest, beginning/end of life issues, research agendas, and increasing exter-
nal (non-medical) oversight – in sum, the difficulties associated with striving to be a ‘good’
doctor in an apparently hostile social and economic environment. Such issues are real and
immediate for most physicians practicing across the US as they try to navigate and nego-
tiate within their milieu of ‘for profit’ hospitals, private health insurance programmes, state
and federal government agencies, indigent patients, un- or under-insured patients, ever
escalating multi-million dollar malpractice suits, and changing political agendas. Yet, the
practice and delivery of medicine is different on both sides of the 49th parallel – and has
been for centuries – so we might wish to pause and reflect on the direct transferability of
these concerns to the Canadian context. For example, under Canada’s public health pro-
gramme which mandates universal access to care, issues pertaining to social justice, while
they certainly exist, may not be as charged when compared to those in the United States.
Medical ethics literature can also be infused with agendas in support of patient advocacy
and the protection of vulnerable populations, especially with respect to their involvement in
clinical research. Such a concern is of international and cross-cultural significance, but all too
often the examples of the Tuskegee syphilis study (Reverby 2000), Nazi medical ‘experiments’
(Michalczyk 1994), and the Willowbrook hepatitis project (Rothman and Rothman 1984) are
cited explicitly or implicitly. Without diminishing the enormity of these egregious breaches,
such events need to be contextualized historically as has been done recently with another
historico-ethical chestnut about gastric juice experiments (Green 2010) in order that they
do not become overused by ethicists to the point of caricature, misrepresentation or crude
oversimplification.
Second, does simplifying medical ethics into four principles not tend to ‘McNuggetize’
what is a highly complex medico-intellectual smorgasbord? Maybe this approach is practical
for medical trainees and physicians, but is it wise? As students rehearse the catechism of
patient autonomy, social justice, beneficence and non-maleficence might this not generally
stifle intellectual reflection as much as it may occasionally point a way out of an ethical quan-
dary? My experience with medical students is that they are usually up for a good debate;
interrogative dialogue can ventilate the atmosphere of even the most dark and dismal med-
ical school lecture theatre. While doing right and doing good may coincide, occasionally
perhaps, they may collide. We need to ensure that students, along with full-fledged clinicians,
are grounded in more than dogma or doctrinal recitations. Perhaps Aristotle, Hippocrates
and Socrates (maybe along with Hygiea and Panacea to achieve some form of gender equity)
ought to have a night out to get to know each other better.
108    J. T. H. Connor

Third, why were these four principles selected anyway? And who said they were actually
principles? (As a medical historian, they always remind me of the four humours or the four
ancient elements or the four horsemen of the apocalypse each time I refer to them.) I may
be going out on a limb here, but can we not draw some connection between these prin-
ciples and sentiments expressed in the quintessential Americanism of ‘life, liberty and the
pursuit of happiness’ with its assumptions of the rights of independence and freedom to
choose? Perhaps in a general way the concepts of autonomy, social justice, beneficence and
non-maleficence broadly reflect liberal democratic values held by nation-states adhering
to a parliamentary system of government as in Canada, but somehow they just don’t reso-
nate the same with the analogous phrase ‘peace, order, and good government.’ Expressed
differently, the current, prevalent and entrenched field of medical ethics not only originated
from the United States, but one could also argue that because of these roots it is also deeply
imbued with American cultural values. Although purporting to be objective and apparently
non-judgemental, principlist ethics ought to be seen as culturally determined and socially
constructed (Chambers 1994, 2006). So what? My glib answer is that not every culture around
the world is a fan of McDonald’s or Coca Cola (Cowley 2005). These principles were developed
in the United States and, not coincidentally, they echo other American cultural values, such
as a strong emphasis on individual liberty, that are not shared around the world. Many of
the clinical practices of Western biomedicine may be international and generally travel well,
but its social baggage may sometimes reasonably get lost in transit.
Fourth is a series of interrelated questions, and this is where things start to get really
tangled: Who can be a clinical/medical/health care ethicist? What are the requisite quali-
fications? What might their scope of practice be? How might such a practitioner be reg-
ulated, or held accountable? These simple questions are fundamental within the health
care workplace, yet when applied to the ethics community there are nothing but troubling
answers. Answering these questions in order: (1) Lawyer? Nurse? Physician? Priest? Pastor?
Philosopher? Anthropologist? Actually, anyone it seems – indeed, an ethicist at my institution
once stated in public that I, an historian, could easily do clinical ethics work. (2) Maybe a
doctorate; maybe a lesser graduate degree; maybe a certificate or diploma; maybe a quick
undergraduate credit course; or maybe self-tutoring…. The correlations, if any, between
level of training and medical ethical efficacy (however that might be evaluated or measured)
remain elusive (Fox et al. 2007; Scofield 2007). (3) Whatever you are asked to do/comfortable
doing, it appears – beginning/end of life issues, resource allocation … the list is endless. (4)
I cannot think of any paid worker who is directly involved in patient care and outcomes in
a hospital milieu (and beyond) other than a bioethicist, who is not licensed, registered or
regulated by some professional association, some other duly recognized and constituted
body, or College. At the risk of sounding derogatory or demeaning, even Licenced Practical
Nurses (LPN) in the Canadian province of Newfoundland and Labrador who occupy a low
rung on the hierarchal ladder of health care delivery (they are directed in their duties by a
registered nurse) are, as their title indicates, government licensed and are also self-governed
by their own provincial College which dictates standards of practice and administers a strict
code of ethics to which LPNs are held accountable (College of Licensed Practical Nurses of
Newfoundland and Labrador 2013). Thus LPNs, like most health care practitioners, have set
standards of performance and run the risk of being reprimanded, fired or having a formal
complaint lodged against them if things go awry. But I don’t recall any cases of ‘philosophical
malpractice’ or unethical conduct by bioethicists reported in the public press or elsewhere.
 Ethics and Education   109

Textbooks guiding the would-be consultant on how to go about setting up shop act also
as lightning rods within the ethics community. A review of The Health Care Ethics Consultant,
concluded that there:
is no reliable path to achieving a career as health care ethics consultant. No standards apply
and the positions available tend to be informal. … The Canadian research which is published
in this collection has failed to address the real problem of our lack of professional status and
hence independence. … We are in danger of being as functional as the high-kicking can-can
cheer-squad at a ball game. (Tonti-Filippini 1996, 340)
In comparison to Scofield’s (1994) review of the same book, however, Tonti-Filippini pulled
his punches. To Scofield’s mind, this book although scholarly was ‘remarkably parochial and
mainstream.’ He continued:
Several years ago, Daniel Callahan asked whether bioethics would avoid the hazards that often
befall fields of study – arrogance, insulation, neurosis, and narrowness. Evidently not. Ethics is
now a commodity, which makes ethics consultation a cash cow. This book is an effort to straddle
the line that supposedly separates what it means to be a professional from what it means to be
an entrepreneur, so that those who want or need to regard themselves as ‘ethicists’ can believe
that they can consult in the real world without getting their hands dirty. (369)
Almost 25 years later, Scofield’s position on such issues had not changed. As a professor
of bioethics in the University of Toronto (with a background in religious studies and law),
Scofield (2008) all but demolished the credibility of bioethics outside of it as a purely intel-
lectual, academic pursuit. The case he puts forward also buttresses my earlier claim that
my beef with bioethics takes the form of a tangly amalgam of history, philosophy, culture
and educational practices; that the field of bioethics in many ways lacks ethics. At one level,
bioethics is entirely self-serving and self-protective. As Scofield notes, Had the field actually
done what it said it was going to – had to – do a decade ago, then it would have found itself
having to police itself for the sake of others. Now, it can instead police others for the sake of
itself, and simply spin this otherwise inexplicable turn of events as a good faith on its part
to protect the public from harm. (105) Continuing to quote Scofield in extenso is apposite:
… if ethics is the moral limitation placed on power, and medical ethics consultants have not
themselves set any discernible limits whatsoever to their own power, what more does one need
to know in order to demonstrate, if not prove, that the field of ethics consultation is and can only
be what it purports not to be – a moral, if not an ethics, disaster? It has acted unprofessionally,
because and in spite of its failure to do what a profession worthy of the name would do: for-
mally accredit the programs that educate and train its practitioners, formally certify and license
practitioners, and formally establish a meaningful, binding and enforceable code of professional
misconduct. Because professional experts believe that knowing more means knowing better,
if anyone ought to know – and to have known – better than to behave unprofessionally, it is
medical ethics consultants. If the field truly took itself seriously, what it means to seriously be
a professional and to behave professionally, and what it means to be honestly concerned with
the public interest, not only would it bring itself and its members under the rule of law, it would
have done that a decade ago. (110)
Scofield then asked rhetorically: ‘who guards the guardians?’ His answer, not surprisingly,
was not the ethicists as they cannot be trusted.
Underscoring these comments are more by Engelhardt who draws conclusions that reso-
nate with my own thoughts. He rails against the publication in 2011 of the second edition of
Core Competencies for Health Care Ethics Consultation by the American Society for Bioethics
and the Humanities (ASBH). Englehardt (2011)quotes the ASBH that as many as 29,000 per-
sons undertake ethics consultations annually in the United States alone, yet only 1600 of
110    J. T. H. Connor

those are members of this organization; moreover, only 60 of those 1600 responded to the
ASBH’s call for feedback when preparing its document. Thus, he infers that only 0.3% of
those who actually do ethics consultations had input into Core Competencies. Engelhardt
also correctly points out that the ASBH is a collegial and scholarly organization that is not
in any way a regulatory body or licensing board, and asks what authority or force it or its
publications carry. Thus, as anyone who displays an interest can join the ASBH, it is a het-
erogeneous group from ‘disparate occupational backgrounds … [with] no professional or
ideological unity’ (131–132). Despite its name, the ASBH is not encouraging towards other
medical humanities scholars; indeed, in medical circles bioethicists have all but co-opted
the term ‘humanities’ to mean ethics. (Jones and Tansey 2015)
In this critique Englehardt (2011) delivers the coup de grace to the ASBH’s Core Competencies.
Not only was biomedical ethics born in the USA in the early 1970s, it was fathered (and I use
this term advisedly) by:
preponderantly former Christian ministers, seminarians, or Roman Catholics [that] to various
extents shared … a faith in natural law, or at least moral philosophy, that as [sic] held able to
establish the content of canonical morality. This ethics for the most part had a pre-post-modern
faith in morality, justice, and progressive politics supported by a synergy of late Western Christian
and Enlightenment commitments to freedom, equality, and social justice, along with a faith in
the powers of reason to be able to ground these commitments. (143)
That was then; this is now – almost 50  years later, where we exist in a post-colonial,
post-modern, morally secular, socially and culturally pluralistic, globalized world. ‘As a
consequence’ Engelhardt notes, ‘one must radically and honestly reconsider the “moral
reasoning and ethical theory” component of Core Competencies’ (143). Thus, when
‘encouraging ethics consultants to make reference to deontological, consequentialist
and virtue-based concerns in ethical decision-making, this ritual may falsely suggest
that there is a canonical secular ethics with a conclusive justifying intellectual founda-
tion about which health care ethics consultants have expert knowledge and could give
moral guidance’ (143). To be clear, Engelhardt is not claiming that consultants are in his
words ‘engaging in deception,’ but they ought to appreciate that the ‘ethics of health care
consultants is simply the ethics that is established at law and enforceable public policy’
(143). The ethical and/or moral underpinning of consulting ethics itself is apparently
based on an obsolete and/or socially questionable paradigm.
Further shoring up the competencies critique is recent activity of the Canadian coun-
terpart of the ASBH, the CBS. Although in its third decade of operation, the CBS is only
now beginning to seriously address issues of accountability, transparency, and the role and
professional scope of ‘practicing bioethicists.’ It would appear that members of this group
are still at odds with each other over a code of ethics for ethicists, are struggling to create
agreed on standards of practice, and as yet are still unclear about their ‘professional identity.’
At the 2011 CBS national conference, a symposium was held to address such professional
matters with a major outcome being the:
recognition of the need to better understand the lived experience of practicing ethicists in
Canada; the need to know ‘how each other practices’ and ‘why it is that we practice in that way’.
The group found the absence of this empirical body of knowledge to be a potential challenge
to the development of documents like practice standards. (Canadian Bioethics Society 2015)
To put the matter bluntly, it appears that despite the fact these practitioners are involved
in consulting and important clinical decision-making, they appear to be unable to reach
 Ethics and Education   111

consensus over who they are, what they do, and how they operate – again, not confidence
building. The following year, the international journal devoted to biomedical and legal ethical
issues, HEC Forum, published a thematic issue on the topic of professionalization of bioeth-
icists in Canada. According to the guest editor, the nine articles in this issue captured the
many ‘voices’ and ‘vigorous debate’ relating to professionalization but no broad consensus
on the matter emerged. What this series of discussions does reveal is a movement of sorts
towards agreement on terminological labelling connected with occupational titles. Because
almost anyone can become a bioethicist (and apparently has), there is a plethora of job titles
for these people in different institutional contexts leading to confusion and a diminishing
of professional respect that ethicists believe they are entitled to. Accordingly, ‘Practicing
Healthcare Ethicist’ (PHE) is touted as the descriptor to be employed universally (Simpson
2012). Presumably, the initials PHE would insidiously slip into the jargon of hospital life the
same way one might refer to a doctor in a shorthand way as an MD, or a nurse as an RN or
LPN. Underscoring the importance placed on labelling, four recent graduates of University
of Toronto’s graduate programme in bioethics (which grants the MHSc degree) were satisfied
with their education but ‘expressed frustration at the fact that they felt their degree was
unrecognized and underutilized in their workplace settings.’ They further lamented that as
‘there is no designation (other than the MHSc) for graduates who have completed an ethics
degree…. It would be helpful to acknowledge this extensive training by having a specialized
title.’ To this end, they proposed that the designation ‘Ethics Associate’ be conferred (though
they were silent about who or what would do the conferring) (McColeman et al. 2015). I
confess that the designation of ‘Associate’ in an hierarchical work setting such as a hospital
conjures up a Walmart or Home Depot store in my mind, so I am reluctantly becoming more
partial to the PHE moniker. All of this to my way of thinking helps support the contention
implicit in my argument that the medical ethics emperor/empress has no clothes, despite
claims, jargon and trappings to the contrary.
Matters of professional nakedness lead me to dilate briefly on the concept of competency
itself through historical reflection. In 1976, a pilot project began at Montefiore Hospital in
New York City that saw philosophers and clinicians collaborate – a pioneering experiment
in hospital ethics consultation (Ruddick 1980) – although, interestingly at the time, these
invitees to medicine declined using the term ‘bioethicist’ or ‘medical ethicist’ in favour of
‘philosopher-in-residence.’ PhD applicants interviewed had to be deemed ‘philosophically
competent’ but, as the co-director later confessed in an evaluation of the project, no one
at the time really knew what that meant. More problematic, perhaps, was that, notwith-
standing that insight, he also concluded that clinicians acted on the notion of competency
in philosophy the same way they understood it in medicine. ‘They assumed’ he remarked,
‘that any competent philosopher confronting the same set of facts would draw the same
conclusion. Therefore, the conclusions articulated by the “competent” philosopher would
have the authority of Philosophy (capital “P”) behind them’ (77). To a humanities scholar this
assumption is ludicrous, but the account highlights what happens when different academic
cultures do not understand each other and do not do their homework first. I fear that little has
actually changed after 40 years: While the phrase ‘doctors disagree’ may be apt occasionally,
there remains a homogeneity to their training and their way of thinking and their expecta-
tions as to what an acceptable outcome may be in any given clinical situation. While a PhD
in philosophy is meaningful, it does not – nor should it – routinely guarantee ‘homogeneity.’ I
do not believe that practising MDs still really understand that. (I would surmise that this state
112    J. T. H. Connor

of ignorance also applies to some biomedical scientists engaged in certain grant-funded

research that is mandated to have an, that is, any ethicist on the team.)
Fifth. Much of my essay has been peppered overtly and implicitly with the discourse of
religion; this is no accidental literary device. As asserted here, modern medical ethics grew
out of (American) Christian morality; the so-called ‘Georgetown mantra’ and principlism
emanated from the August Washington DC, institution of Georgetown University and its
Jesuit traditions and legacy. That there was a (holy) ghost in the machine of ethics should not
surprise anyone who has reflected thoughtfully on the invention and growth of the enter-
prise, but I suspect that it will be news to many in the health professions; that it still lives on
in the medical milieu might also be news to some clinicians, along with others. There are of
course signs today that are quite explicit about the relationship between religion and ethics,
morality and medicine: At the general hospital serving the academic health sciences centre
of which I’m a part, there is an office designated ‘Pastoral Care & Ethics.’ Similarly, if I visit the
city’s other major teaching hospital the iconography throughout, along with its historical
roots, should make it clear to everyone that religious values will likely determine or affect
some medical protocols. But what happens if the boundaries or overlap between ethics and
medicine and religion are not so clearly delineated? If indeed there are 29,000 people across
the United States undertaking consultations; if the field is as open and heterogeneous as
claimed; if philosophical competency is difficult to gauge, then how do doctors, patients
and families evaluate or discern both the quality and potential bias (intellectual, religious
or otherwise) of consulting ethicists? In my view, this has real implications for medical edu-
cation, too. The undergraduate medical curriculum across North America is grounded in
learning objectives or elements mandated by a joint US-Canada accreditation agency for
medical schools (LCME 2015). Although there is an objective governing medical ethics its
vagueness is unhelpful:
The faculty of a medical school ensure that the medical curriculum includes instruction for med-
ical students in medical ethics and human values both prior to and during their participation in
patient care activities and requires its medical students to behave ethically in caring for patients
and in relating to patients’ families and others involved in patient care. (11)
Much like the field itself, it remains wide open who can teach medical ethics, what may/
ought to be taught, and how content can be delivered. Open-endedness in medical teach-
ing can be a good pedagogical thing (Connor and Farrell 2013), but given the intellectual
minefield that medical ethics is it can also have negative consequences (Cigman 2013).
Again, caveat emptor.
This is not just an academic question; there can be real-life consequences to it. Fox and
Swazey (2008), scholars who were participants in the formative years and subsequent ascent
of the bioethics movement and who now have turned their investigative and analytical
skills on that field, depict a worrisome situation. Owing to their ‘inside knowledge’ supple-
mented by interviews with colleagues, they demonstrate how especially during the last
decade bio/medical ethics has become wholly polarized in the United States into ‘liberal’
and ‘conservative’ viewpoints – another manifestation of ‘the culture wars.’ Issues such as
abortion, euthanasia, stem cell research, cloning or ‘human dignity’ have split not only the
general public, but also those who intervene in clinical contexts as supposedly objective
ethics consultants. The clamour of the ‘public square’ is also now very present in academic
circles. Once genteel debates are now battlegrounds between the Christian right and its
political backers and bosses against old guard ‘lib lefties;’ it would appear that many ethicists
 Ethics and Education   113

caught up in this overarching dispute are not accidental collateral damage but are active
and willing combatants.
Such a situation is troubling to me personally as a self-declared ‘lib lefty,’ but also more
broadly as a student of medical history. I am not a facile positivist or simplistic progressivist
thinker, but I recognize that a key turning point in the history of Western biomedicine was
the abandonment of rote recitation of doxa and doctrine, along with the gradual exclusion
of religion from medical matters. However, I wonder if organized medicine today might not
be slowly slipping back to an earlier religious incarnation of itself through the Trojan horse
of biomedical ethics as practised by a component of its practitioners. As a medical historian
I was fascinated with the appearance of a special issue of the Southern Medical Journal in
2007 that contained no fewer than 11 articles on miracles and medicine; as a citizen of the
21st-century world I am perplexed by this find. These publications were not just historical
and cultural overviews, but considered together they constituted a handbook of sorts for
physicians in order to recognize, categorize and comprehend miracles today. In his lead
editorial, Dr Daniel Sulmasy (2007) of the John J. Conley Department of Ethics in Manhattan’s
Saint Vincent’s Hospital, informs us:
Miracles are signs from God. Miracles transmit messages. Precisely because they are unusual
or unprecedented according to empirical and scientific laws of nature, miracles evoke awe and
wonder. Miracles can shock us out of our complacency. They might even awake us from our
utilitarian slumbers. (1225–1226)
On the one hand I would be a willing advocate for the general role of spirituality when trying
to understand patients’ fears or angst, or to aid in their well-being and recovery, but on the
other hand I would surmise that invoking miracles against ‘empirical and scientific laws of
nature’ in a CIHR grant application would result in automatic triaging. (Might that sort of
reason have played into CIHR not appointing an ethicist in charge of ethics at this institution?)
The confounding role of revelatory ethics, religion and bedside medicine is seen in
another signal example, again from within the practising medical community. The summer
2011 issue of Nucleus, a publication of the Christian Medical Fellowship (founded in the
United Kingdom in 1949 and which currently has a membership of 5000 British doctors and
medical students who ‘obediently’ serve Christ and who ‘promote Christian values, espe-
cially in bioethics’ and who ‘accept the Bible as the supreme authority in matters of faith
and conduct’), argued ironically against the principle of patient autonomy as espoused by
Beauchamp and Childress (McClenaghan 2011). If so, and regardless of the power of the
tenets of the Georgetown mantra, we could be on a particularly slippery slope depending
on what is at stake medically (pregnancy termination, feeding tube removal, DNRs). Lest
my arguments be dismissed as too abstract, or of little relevance to practitioners or medical
students, perhaps a quick read of Medical Ethics and the Faith Factor: A Handbook for Clergy
and Health-Care Professionals (Orr 2009) might be salutary.
Ethicists of whatever stripe must be open and transparent about their personal values and
beliefs and how they might affect reasoning and decision-making. Just as ethicists demand
informed consent in medical encounters between physicians and patients, so too must clini-
cians, patients and family members elicit from ethicists information that will be analogous to
the process of ‘informed consent.’ Everyone must be able to see through medical ethics not
only immediately at the bedside but also at a wider and higher intellectual level. A credible
mechanism must also be in place that will hold consulting medical ethicists (who typically are
compensated financially for their service) accountable for their recommendations not only
114    J. T. H. Connor

to any ‘in-house’ standard of practice established by their proto-professional organizations,

but also publically; or else maybe they should drop the mantle of medicine that has been
assumed by many and revert to the title ‘philosopher-in-residence’ – however semantically
clumsy, it is less opaque and hence more openly transparent.
To reiterate: how students in health professions are trained and/or educated in ethical
professional practice and what the conceptual differences and similarities between ‘acting
professionally’ and ‘acting ethically’ actually mean for such practice are important issues.
My main conclusion is that, while ‘professional’ medical ethicists exhort others that come
under their gaze to promulgate and abide by codes of ethics, they, collectively, do not gov-
ern themselves in a likewise fashion; this conclusion is, in my opinion, both unsettling and
unacceptable. Medical students, physicians (and other health care practitioners) and patients
– that is, you and me – need to know who we are dealing with when entering the medical
ethics arena either by choice or by dint of unavoidable and unfortunate circumstance. As
ought to have become clear, medical ethics is both an academic sub-discipline and a prac-
tical vocation, often with practitioners with feet in both camps. But when ethicists slip off
their academic robes and don metaphoric white coats, all of us who come into contact with
them must be cognizant of who and what we are dealing with. ‘Consulting ethicists,’ because
they have remained seemingly intransigent to calls to become more transparent about their
intellectual beliefs and rationales for ethical decision-making (many of which admirably have
emanated from the ranks of academic ethicists themselves), ought to be subject to scrutiny.
Despite my plea for more transparency I concede that it is easy to see through consulting
medical ethicists as they appear to live in a glass house. Accordingly, these putative paragons
of virtue ought first to get their own professional house in order before throwing stones in
the form of, for example, self-serving reports and self-righteous letter writing.

Acknowledgement
I am grateful to the guest editors of this issue for their thoughtful and constructive comments. Their
direct input has substantially improved this discussion.

Disclosure statement
No potential conflict of interest was reported by the author.

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