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 #A Medicine, Health Care and Philosophy 6: 247-254, 2003.
©2003 Kluwer Academic Publishers. Printed in the Netherlands.

Balancing the perspectives. The patient's role in clinical ethics consultation

Stella Reiter-Theil
Institute for Applied Ethics and Medical Ethics, University of Basel, Missions Strasse 21A, CH-4055 Basel, Switzerland (Url:
www.unibas.ch/aeme; E-mail: S.Reiter-Theil@unibas.ch)

Abstract. The debate and implementation of Clinical Ethics Consultation (CEC) is still in its beginnings in
Europe and the issue of the patient's perspective has been neglected so far, especially at the theoretical and
methodological level. At the practical level, recommendations about the involvement of the patient or his/her
relatives are missing, reflecting the general lack of quality and practice standards in CEC. Balance of perspectives
is a challenge in any interpersonal consultation, which has led to great efforts to develop "technical" approaches,
e.g., in psychological counseling or psychotherapeutic treatment. In ethics, unbalance or partiality is a matter of
justice and has provoked significant theoretical work, also relevant for practical medical ethics. A lack of balance
seems to be particularly serious in those situations, where ethical conflict is triggering a consultation and where
the "parties" involved may try to persuade the consultant that their particular opinion is the most convincing; but
to our knowledge the connection between patient/relatives involvement and balance has not yet been discussed
in the context of CEC. Central questions of access and involvement of the patient and his/her relatives will be
analysed and discussed regarding the challenge of balance and the adequate role or attitude of a Clinical Ethics
Consultant. It is argued that the Clinical Ethics Consultant should have a methodological awareness regarding the
concepts of "neutrality" versus "advocacy" in his/her role and try to achieve a balanced procedure that allows for
an optimum of change of perspectives. The argumentation is developed along the narrative of a real case study.
Recommendations concerning the involvement of (the perspectives of) the patient or the relatives are formulated
for the practice of CEC.

Key words: advocacy, balance of perspectives, Clinical Ethics Consultation, family, hospital ethics committee,
patient rights, neutrality, recommendations, role of ethics consultant

1. The problem of unbalance in Clinical Ethics
Consultation
How can Clinical Ethics Consultation cope with the
risk of unbalance related to who is presenting and
discussing the problem? What is the best attitude for
the consultant: advocacy or neutrality? How can we
approach a balanced procedure vis-a-vis the conflicts
of interests where the "veil of ignorance" obviously
cannot be applied? Is multi-directional partiality an
option reconciling the two oppositions?
In Clinical Ethics Consultation (CEC) we often
deal with a patient's known or unknown wishes, with
doctors' obligations, and with various key issues like
"dying with dignity," but mostly we are struggling
with ethical ambiguity and conflict. Conflict is not
the only matter of ethics, but in medical and health
care ethics it is certainly a dominant one.2 Therefore,
it is surprising that the role and attitude of a clinical
ethics consultant have rarely been studied concerning
advocacy or neutrality towards the conflicting interests
of the parties involved. As a first working hypothesis
-
is generally triggered by a conflict, mostly initiated by
health care professionals seeking assistance to solve a
problem. We may as well expect (2) that most ethicists
will be very aware of patient rights as a central ethical
dimension to reflect upon, and that some may tend
to ally with the patient's party (2a), whereas others
will identify more with the colleagues caring for the
patient, doctors or nurses (2b). There is, and this is our
third assumption (3), no "natural neutrality" in the role
of the clinical ethics consultant (CECo); we can rather
assume that unbalance is inherent in CEC, at least in
the beginning of the process, where much information
is missing and a full change of all perspectives is not
present. Therefore, the question has to be answered
how the CECo may handle the various loyalties and on
which theoretical grounds.
2. Which way to go in Europe?
Experiences with "clinical ethics" in Germany seem to
rely much on the organisational challenges of building

lacking sound empirical data - we assume (1) that CEC hospital ethics committees, especially in hospitals
248 STELLA REITER-THEIL
under Protestant or Catholic patronage following a
common directive of the executive boards. 3 It is diffi-
cult to generalise without sound data whether and
how the established HECs in Christian Hospitals as
such are providing clinical ethics consultation. In
both, University Hospitals and Christian Hospitals in
Germany, we have observed that the actual involve-
ment of an HEC in practical clinical ethics consultation
depends on the availability of a professional or quali-
fied person (or team) to develop and direct the support
service competently and will, thus, collaborate with
the HEC as a forum for further debate and activities.
One risk of the emphasis on organisational aspects
of "clinical ethics" and the establishment of commit-
tees in the absence of competent consultants may be
that the HEC is regarded as an alibi institution not
really accepted by those involved in everyday clinical
work. The solution to this problem could be to create
a lively and fruitful combination between the prac-
tice of support service via "consultation on demand"
on the one hand with the institutional-organisational
structure on the other. From the perspective of patient
access, HECs could be the first and official address to
contact; but in order to find confidential and empathic
support a committee will not be the right setting and
will need, again, to rely on competent persons or teams
available for ethics consultation. - Another aspect of
complementarity between HECs and Clinical Ethics
Consultation concerns the ethical expertise as such.
Slowther et al.4 raise the question whether a hospital
ethics committee needs an ethicist when investigating
the HECs and their functions in the UK; they quote
a chairman saying "I think that the idea of having a
committee like this without appropriate expertise all
round is absurd" (p. 16).
It will - hopefully - be a matter of debate whether
European countries have to go the same way along
the implementation of clinical ethics support service
or HECs that have been taken in the U.S. 5 In European
hospitals we would probably be better off avoiding
some of the bureaucracy and structures that may be
difficult to modify once they have been established.
The question rises if it would not be more favourable to
focus the (scarce) health care resources on developing
the quality and reliability of the practice of clinical
ethics consultation first, before institutions are being
created. And should we not try to initiate an approach
to clinical ethics allowing for the development of local
models and their continuous evaluation before they are
"institutionalised?"
In Switzerland, a country with a long standing
tradition of direct democracy and strong federal and
regional particularities, it may be regarded more
helpful to the general development and implementa-
tion of clinical ethics to take a pragmatic approach
accepting local models first instead of a primary
process of broad institutionalisation. Clinical ethics
and medical ethics have been academically institution-
alised only recently at a few universities in Switzer-
land (in Basel since 2001). But the national medical
association, the Swiss Academy of Medical Sciences
(SAMW), 6 has put "ethics" on its agenda, not only
through its well acknowledged Guidelines in sensitive
fields of medical research, but also as an initiative to
further the development of ethical competence within
clinical institutions.
The debate and implementation of CEC is still in
its beginnings in Europe and the issue of the patient's
perspective has been rather neglected, especially at the
theoretical and methodological level. In the following,
the central questions of access and involvement of
the patient and his/her family will be analysed and
discussed. The argumentation will be developed along
the narrative of a real case allowing for a broad change
of perspectives.
Clinical ethics consultation in Europe is, we
believe, not only an imitation of the American
concepts and models, but trying to develop socio-
culturally sensitive answers to ethical issues in clinical
practice. Thus, our challenge is - due to a great variety
of traditional and value patterns in European health
care - to find ethical orientation in universal principles
as well as moral flexibility in different contexts of prac-
tice. Taking the patient perspective seriously in the
consultation process should be regarded as a universal
prerequisite, but the way how this is best achieved
should be a matter of contextualisation. Also, we need
to develop CEC in times of limited economic growth,
where "ethics" has to compete with other services
in the clinic; consequently, CEC has to prove itself
helpful to those who are using it.
3. Physicians' expectations of Clinical Ethics
Consultation
The academic discourse on clinical ethics, and partic-
ularly clinical ethics consultation, is physician-centred
in the sense that the needs and wishes of clinical staff,
especially doctors, who are actually initiating most of
the CECs, are prevailing. A recent survey of internists
in the United States gives revealing data concerning
the motivation of physicians requesting a Clinical
Ethics Consultation.7 DuVal et al. report an empir-
ical ranking of ethical dilemmas and issues leading
to CEC. The most frequent dilemmas mentioned by
the internists are "end-of-life issues," followed by
"patient autonomy" and "conflict" (p. 125). In a further
step of analysis, the authors found two categories
of factors predicting whether CEC was triggered by
 BALANCING THE PERSPECTIVES
"conflict" or "distress" (category 1) or by "more intro-
spective reasons," e.g., "wants help thinking through
ethical issues" (category 2). Looking at the trig-
gers of consultation requests in more detail reveals
the following answers: "resolving conflicts," "inter-
acting with a 'difficult' patient or family member,"
"emotional trigger," "making a clinical decision or
planning care," "legal or regulatory reasons," "thinking
through ethical issues," "fostering communication,"
"fairness and justice," "anticipation of a bad situation,"
"other responses" Obviously, it is not possible to guess
what the contribution of patients (their relatives) may
be to initiate CECs through studies like this. It seems
evident that CEC has to face the risk of unbalance
given the prevailing of conflict as a trigger, given the
strong relation to doctors' wishes, and given the fact
that it does not mirror in what way and amount patients
are contributing to it. It should be added that among
the physicians' characteristics correlating significantly
with triggering CEC is "bioethics rounds attended"
(6 or more), which means that moderate knowledge
and skills to diagnose a significant clinical ethics issue
deserving clinical ethics consultation are instrumental
(p. 128).
What do these data tell us about the role of a clinical
ethics consultant and the chances to avoid unbalance?
Looking at the needs for help in responding to conflicts
the authors of the study suggest that there has been a
shift in emphasis for CEC since the last decade - at
least from their American perspective.
LaPuma and Schiedermayer suggested a decade
ago that the ethics consultant requires the skills of:
identifying and analysing ethical problems; using and
modelling reasonable clinical judgement; communic-
ating with and educating the clinical team, patient and
family; negotiating and facilitating negotiation, and
teaching and assisting in problem resolution. Similar
descriptions of the skills required for ethics consulta-
tion have been offered - among other authors - by the
American Society of Bioethics and Humanities (Core
Competencies for Health Care Ethics Consultation). 8
LaPuma and Schiedermayer conclude while these are
still important, "these findings suggest there should
also be a strong emphasis on the skills of conflict or
even crisis resolution, and on handling emotionally
charged situations" (p. 129). The authors also demand
the "ethicists must be adept at identifying the partic-
ular needs of the clinician. The ethicists must do more
than grasp the clinical situation and analyse it from
an ethical standpoint. (.. .) They conclude "it appears
that such teaching should ideally include proficiency in
dealing with discord in clinical relationships" (p. 129).
The role of the ethicist as a "mediator" is welcomed
by DuVal et al. and discourse ethics is embraced as a
type of ethics theory that would fit with this approach.
249
The initial situation of CEC is, thus, characterised
by conflict and discord; the ethicist (as mediator) is
seen in the role and authority to help find a balanced
approach through the complex conflicts of interests,
needs and obligations. The challenges of unbalance
or partiality, the questions of methodological answers
to the danger of becoming a "partisan" rather than a
mediator, though implicitly, are raised.
4. What happens if Clinical Ethics Consultation
(CEC) is initiated by a patient?
Case, part 1
Imagine you are a clinical ethicist who can be
approached for ethics matters in your university
hospital. You get a phone call. A lady asks your advice
and support concerning her 80-year-old mother who is
seriously ill and being cared for in your hospital. She
is calling you on the advice of the social worker of the
department involved.
You learn that the mother is a cancer patient who had
been operated on the tumor some months ago, but
surgery did not improve her situation. Rather, she feels
it would have been better to have died instead and not to
have had to live through all the pain and suffering that
had come since. Now, the daughter reports, the mother
is not willing to have invasive diagnostic procedures
or surgical interventions suggested by the doctors any
more.
Recently, the doctors planned an invasive diagnostic
procedure because they think the patient is at risk of
an acute ileus, which they argue would make surgery
(anus praeter) necessary.
The patient who is said to be able to articulate her
wishes very clearly has refused the diagnostic pro-
cedure as well as the surgical intervention, even in
the case of an acute situation, and is now afraid her
decision might not be respected.
The daughter asks whether you can help to set up an
advance directive for her mother and to give support in
defending her decision.
Is this a case for clinical ethics consultation (CEC),
or should you just provide the lady with forms for an
advance directive or power of attorney (which may
be more reliable in some countries) or transfer her
to an address where she would get help to set up an
advance directive or power of attorney? Imagine, in
your university hospital you are not only entitled to
offer CEC (alone or with your team), but are also in
charge of developing concepts, models and methods in
this evolving field and to implement them in clinical
practice. In most cases you have been involved with,
it has been the medical/nursing staff or the director
250 STELLA REITER-THEIL
who took the initiative for a CEC; so far, it is done
on demand only - from the side of the clinicians 9
(Reiter-Theil, 2001).10 So, what will happen, if the
initiative comes from the patient's side, and if the ethi-
cist may be regarded as acting in the role of a patient's
"advocate?"
Like in many European hospitals, in this clinic
there has been little experience at the time with patients
and relatives getting directly involved with clinical
ethics consultation on their own initiative. Also, clin-
ical ethics consultation at this institution has been in
a process of getting accepted by the clinical staff,
whereas in many other medical centres there is no such
support service available at all. Obviously, the lady has
already tried to find someone to support the decisions
of her mother "against" the doctors, and she is sent
to the clinical ethics unit by a health care professional
for help. We assume that she has a right to initiate a
clinical ethics "intervention" of some kind, which is
not clear at the beginning of the process.
Agich and Youngner have discussed the issue of
patient access to hospital ethics committees from a
US-perspective as early as 1991.11 They defined a
spectrum between minimum and maximum access. In
our case, there is no institutional policy; this gives the
ethics consultant the privilege to develop a procedure
anew and to take the responsibility about how to handle
an urgent request like this one. 12
The decision was taken to explain to the lady that
it would not be very promising to use an advance
directive combined with a power of attorney as a
"defensive instrument" alone without trying to reach
mutual understanding and consensus with the clinical
team about how the care for the patient could be
improved on a basis of trust and respect. A CEC was
offered for the patient, the family and the clinical staff;
participation of both sides or "parties" was explained
to be essential for the success. Thus, it was agreed
that the lady go back to the attending physician and
ask him to participate in a clinical ethics consultation.
The consent of the patient herself to get into contact
with the ethicist was also clarified and affirmed by the
daughter.
Case, part 2
In the meantime, the ethicist has learned more about the
80-year-old female patient:
* Transitional cell carcinoma / kidney
* 4 months ago tumor nephrectomy (unilateral)
* no stabilization since
* strong suspicion of local recidivism
* suffering from severe, possibly therapy-resistant
pain, nausea, recidivism of subacute ileus con-
nected with opiate therapy (spastic obstipation),
risk of intestinal obstruction
5. Whom to get involved
In all cases where a "party" struggling with another
in conflict initiates Clinical Ethics Consultation, the
question will arise whether and how the other side
will accept the enterprise. "No matter how reluctant
or unenthusiastic their initial reception of the ethics
consultant might be, acceptance by others constitutes
a prima facie basis for the ethics consultant's partici-
pation in the case and confers an operative kind of
authority on the ethics consultant" (Agich, 2000).13
In the patient-initiated case of an ethics consultation
it seems one of the first tasks to contribute to the
development of motivation in all participants, here
especially the clinical colleagues, by building trust in a
fair and non-judgmental procedure, rather than relying
on authority.
Back to our case: Until then, the preconditions
for the involvement of the daughter, the patient,
and possibly the doctors have been prepared. The
daughter immediately accepted the suggestion that the
doctors be involved in order to reach consensus. This
was done on the assumption that the disagreement
between the patient and the doctors had already
created open conflict and threatened confidence in the
patient-physician relationship; thus, it seemed most
important to build a working atmosphere where all
parties could try to make a new start. But it was also
very likely that the patient's / relatives' perspectives
need to be balanced and also informed by those of
the clinical staff. - Apparently, the nurses were not
actively involved in this conflict; due to the patient's
pain and discomfort, much care was offered by the
family members who felt that nursing was not as
helpful as wished. - It was planned to bring together
the physicians with the patient / family and to try to
reach consensus on basic ethical issues such as the
respect for the patient's decisions, but also to share
valuable medical or other information relevant for
decision making.
Case, part 3
According to the agreed procedure, the daughter con-
tacts the doctor in charge to arrange a meeting with the
ethicist on the ward. He agrees with the suggestion to
talk together. The ethicist first meets the doctor alone, a
man of app. 30 years old, who explains his view that the
invasive diagnostics (coloscopy) is necessary in order
to prepare for preventive surgery. He stresses that in his
view it would be a terrible mistake and even unethical
to let the patient die from an acute ileus instead of doing
surgery (anus praeter) to prevent death and suffering.
He also explains that the patient is very "difficult"
- as are the relatives - getting involved with patient
management and discussing the doctor's decisions (3
 BALANCING THE PERSPECTIVES
adult children, the 2 daughters are actively involved in
the care for the mother; the patient is a widow). On the
ward, it becomes clear that the nurses are distant to the
patient and are not motivated to get involved with the
conflict.
In the first talk with the junior doctor we get the
impression that from the perspectives of the physicians
involved the solution to the problem was to achieve
the "compliance of the patient with their sugges-
tions" If the ethics consultation process proceeded
with the clinical staff alone, the family, who had
initiated the contact, would have felt excluded or
marginalised; also, the consultation could well become
unbalanced with the doctors' perspectives prevailing,
without somebody, e.g., the ethicist, taking the role of
a patient's advocate.
After this first clarification of who is willing to
participate in the CEC we learn that the consultant is
not available, but wishes to delegate the whole affair
to the junior doctor. Is it necessary to insist on the
consultant's participation? Does it make sense to get
him involved if he is not motivated at all, given that
there is no policy that would make him collaborate?
Should we try to get the nurses involved? And how to
include the patient? She was actually very weak and
suffering from severe pain; therefore, she explicitly
preferred that the ethicist and her daughter(s) talk
with the physicians in her place. In order not to make
the constellation too complex, we included persons
step-wise: as a first step, an initial talk with the
relatives alone, then, with the junior doctor alone;
as a second step we organised conversations with
all three parties together - always going back to the
patient, reporting, as she had wished. Step by step,
the doctor, the daughters, and the ethicist shared basic
information: medical information about the patient's
status, the risk of ileus and its consequences, but
also about the patient's right to refuse intervention,
the advance directive, the relevant guidelines of the
German Medical Association (1998) concerning
end-of-life care etc. 14 The parties involved did not
yet, however, reach consensus on the evaluation of
the conflicting issues: the patient's refusal to undergo
invasive procedures on the one hand, and the doctors'
understanding of their obligation to prevent ileus by
all means on the other. As to the risk of unbalance, the
ethicist and the process of CEC so far concentrated
on giving each side equal opportunity to formulate
the preferred options and the reasons for them. This
relieved the initial tension and confrontation; rather, it
facilitated mutual understanding and helped to develop
the shared view that everybody had good "ethical"
arguments and nobody was just "paternalistic" (the
251
doctor), "ignorant" or "non-compliant" (patient) or
just "difficult" (the family).
6. Patient's wishes - doctors' obligations - and the
balancing of the clinical ethics consultant
In describing whom to get involved and why, we
have already touched implicitly upon the patient's
wishes. It has already become obvious that the
central negative preference of the patient, to refuse
all invasive interventions, is not accepted by the
physicians involved. They consider this to collide
directly with their own ethical obligation to treat or
prevent deterioration, to alleviate suffering, to avoid
a way of dying (namely from ileus) that they think
is unprofessional or even unethical to tolerate. As
a consequence, the patient's central (negative) wish
creates severe ethical conflict for the doctors: "We
cannot watch the patient die from an ileus. This is
against medical ethics."
Case, part 4
In further conversations with the patient and the daugh-
ters, the ethicist inquired after the patient's wishes and
values. She revealed a strong wish to die, rather, to
be dead already, due to her great suffering. Initially,
she asked for active euthanasia; she and her daugh-
ters understood that this was certainly not available in
Germany. Although she came back to this idea several
times arguing in favour of a lethal dose to terminate
her life, she understood that this was no real option for
her.
She explained that she would welcome dying from an
ileus and that she expected to received terminal seda-
tion to be relieved form pain, in this case. Preventive
surgery providing her with an anus praeter was rejected
by her, because she felt that this was violating her
dignity; she had decided that she had suffered enough,
and she wanted everyone to respect her decision. When
she heard that the physicians would not agree with
terminal sedation in case of an ileus, because they
considered this malpractice, she became almost desper-
ated and considered suicide. This was revealed by
her in private conversation with the daughters and the
ethicist.
A long conversation followed in order to develop a
perspective for her to live the final period of life
without dramatic suicidal actions possibly contributing
to trauma in her relatives. She was very determined
not to be seen by any psychiatrist, because she felt a
diagnose of "depression" would imply that her decision
was seen as being not "valid" or "competent."
252 STELLA REITER-THEIL
During this part of the conversation, the ethics con-
sultant could not but understand the patient's despair
and wishes to die as soon as possible. She explained,
however, several times - as often as necessary - to
the patient that these wishes needed to be recon-
ciled with the existing limitations; also, she tried to
support the patient in understanding that the family
would face great trouble with potential suicidal action,
as the daughters had explained. Thus, the ethicist's
role was clearly not that of a patient's advocate
defending the patient's preferences as such vis-a-vis
the doctors or even family. Rather, she tried to clarify
and communicate the "reasonable" and the "ethically
justifiable" between those involved. Most of the time,
the conversation focused on formulating what was not
"reasonable," not "ethically justifiable" and feasible in
the existing legal framework. It was stated that the
following were no options: 1. violating the respect
for autonomy by overriding the patient's refusal, 2.
assisting in or tolerating suicidal action of the patient
within the hospital, 3. risking ileus without explaining
the medical information about the circumstances of
an acute ileus and the suffering connected with dying
from it. As a positive guideline, competent palliative
care was strongly requested on an interdisciplinary
basis including the explicit dialogue with the patient
about the ethical conflicts involved.
7. What we achieved
Case, part 5, and end
During the ongoing process of CEC, the ethicist
involves another attending consultant (now available
due to shift regulations) to communicate with him
about the following steps.
Initially, the patient does not want to accept any male
professional any more, but then accepts his involve-
ment with the mediation of the ethicist.
The advance directive and the refusal of surgical inter-
vention is officially accepted by the attendant. A less
invasive alternative diagnostic procedure to evaluate the
risk for an acute intestinal obstruction is performed.
He undertakes special efforts to improve pain medic-
ation as well as palliative care and nursing. It is agreed
that no psychiatric consult will be called against the
patient's wishes.
Conflict declines, but the patient's suffering is still
considerable. It takes 4 weeks until the patient can be
dismissed home to comfort care by a newly appointed
family doctor with special instructions from the clinic.
Follow-up shows that the patient died 3 weeks after
dismissal at home in the care of the family, but still
with periods of severe pain and despair.
Later evaluation with the family reveals that they
experienced the CEC to be helpful in finding a way out
of the frightening confrontation and crisis on the ward,
in facilitating communication and consensus seeking
as well as problem solutions. From their perspective,
the balancing of the particular perspectives and inclin-
ations via CEC - on either side - was part of the
solutions brought forward.
As in most cases, this CEC was triggered by one
"party" in a conflict; unusual was at the time that it had
not been the clinical staff, but the patient's relative who
took the initiative and, thus, asked for support. We do
not know of any study providing data about patients' or
families' wishes concerning CEC, whereas we know
that health professionals do have special preferences
about what CEC should do for them. Most ethicists are
very aware of patient rights as a central ethical dimen-
sion to reflect upon; some tend to ally with the patient's
party, others identify with the colleagues caring for the
patient. There is no "natural neutrality" in the role of
the clinical ethics consultant; rather it is one of the
challenges in this work to develop an approach how
to balance the expectations of those involved. The case
study has illustrated how the expectations of the patient
and the family may create alliances and that unbalance
is inherent in CEC, at least in the beginning of the
process, where a multi-perspective overview is not yet
possible.
8. Recommendations
" It is suggested that every institution providing
Clinical Ethics Consultation should develop
a transparent position and communication on
access.
" Relying on experiences with CECs initiated by
the patient or family, these processes and out-
comes seem to be as satisfying as those from
CECs initiated by clinical staff, depending on
the ability of the Ethics Consultant to commu-
nicate with the different "parties" in conflict and
particularly with troubled patients or families
directly.
" As soon as patient / family access is established,
emphasis has to be laid on a rule of good prac-
tice to involve "the other party" systematically,
i.e., the clinical staff. This should help to avoid
that the Ethics Consultation looses the potential
to be considered a helpful resource for the health
professionals as well.
" Transparent and open access to patients or their
relatives should be discussed in continuing ethics
education or grand rounds in order to contribute
 BALANCING THE PERSPECTIVES
to approaches such as a "systematic change of
perspectives" necessary to balance any partiality.
* The patient's wishes and the respect for self-
determination are a landmark in CEC, not only
if patients are actively involved. However, the
patient's wishes should never be taken as an
imperative, but should be included in real coun-
selling and reasoning on the basis of respect
and care. It is important to differentiate between
(a) adopting the content of the wishes and the
procedures, and (b) taking them seriously into
consideration.
* What does this mean to the professional attitude
of the Clinical Ethicist? The spectrum reaches
from neutrality to advocacy - two poles that
can hardly be reconciled. The only chance to
integrate the advantages of the two (distance as
well as engagement) without buying the disad-
vantages as well (negligence, lack of empathy
versus enmeshment, partiality) is to practice the
systematic change of perspectives, to take the
side of everyone involved in turns, the so called
multi-directional partiality. This needs training
and should be part of education in clinical ethics.
* Do Clinical Ethicists need an ethos, and if yes,
which one? One possible tentative answer is
that as they are referring to patient care they
should participate in the ethos of the healing
and helping professions. If an ethos for Clin-
ical Ethics Consultation is developed, it should
formally be oriented at the interaction between
universal principles and contextualisation as well
as individualisation, allowing for a movement
between a meta-level of reflection and a very
concrete, personal and empathic attitude allowing
for a continuing movement between the two
poles.
* Particular attention should be given to the fact
that the clinical colleagues may be experts in
one situation, "clients" in another. At least this
final point should have made it clear that good
clinical ethics practice needs tact, modesty, and
self-critique.
Acknowledgements
In this paper, a case study is reported. The author wants
to thank the patient, the family and the clinical staff for
their trust during the consultation process.
The author is grateful for various grants helping
to set up the research program "Clinical Ethics"
(German Research Council/Bonn, Robert Bosch
Foundation/Stuttgart, German Academic Exchange
253
Council/Bonn, British Council/London, Max Kade
Foundation/New York, Funds of the University of
Basel, Swiss National Fund/Berne.
Notes
1. Reiter-Theil, S.: 1998a, 'Ethical Questions in Genetic
Counselling: How far do Concepts like 'Non-Directivity'
and 'Ethical Neutrality' Help in Solving Problems?'
Concilium, InternationalReview of Theology. March: 23-
34.
2. Reiter-Theil, S.: 2000, 'Ethics Consultation on Demand.
Concepts, Practical Experiences and a Case Study', Journal
of Medical Ethics 26, 198-203.
3. According to data reported by Simon and Gillen 25% of all
(795) members of the German Christian Hospitals Asso-
ciations responded to a questionnaire concerning ethics
activities in the hospital. 30 answers indicated that a HEC
had been established (almost 24%). Another 15% reported
they planned to do so.
Simon, A. and E. Gillen: 2001, 'Klinische Ethik-Komitees
in Deutschland. Feigenblatt oder praktische Hilfestellung
in Konfliktsituationen?', in: D. von Engelhardt, V. von
Loewenich and A. Simon (eds.), Die Heilberufe auf der
Suche nach ihrerIdentitaet. Muenster: Lit.
4. Slowther, A., C. Bunch, B. Woolnough and T. Hope: 2001,
'Clinical Ethics Support Services in the UK: An Investiga-
tion of the Current Provision of Ethics Support to Health
Professionals in the UK', Journal of Medical Ethics 27
(suppl I), 12-18.
5. Kettner, M. and A. May: 2002, 'Organisationsethik - das
nachste Paradigma im Gesundheitswesen?', in: A. Brand,
D. von Engelhardt, A. Simon and K. Wehkamp (eds.),
Individuelle Gesundheit versus Public Health? Muenster:
Lit.
6. www.samw.ch
7. DuVal, G., L. Sartorius, B. Clarridge, G. Gensler and M.
Danis: 2001, 'What Triggers Request for Ethics Consulta-
tions?' Journal of Medical Ethics 27 (suppl I), 124-129.
8. American Society for Bioethics and Humanities: 1998,
Core Competencies for Health Care Ethics Consultation.
4700 W. Lake Avenue, Glenview, IL.
9. The term "clinicians" here may include physicians, nurses,
therapists, but sometimes also psychologists, priests - all
professionals involved in patient care in the hospital.
10. Reiter-Theil, S.: 2001, 'Ethics Consultation in Germany.
The Present Situation', HealthCare Ethics Committee
Forum 13 (3), 265-280.
11. Agich, G.J. and S.J. Youngner: 1991, 'For Experts Only?
Access to Hospital Ethics Committees', Hastings Center
Report, September-October: 17-26.
12. The case happened in Germany. Professional or ethics
guidelines in medicine in Germany do not help regarding
CEC and patient involvement; Clinical Ethics Consultation
is hardly ever mentioned. Just the German Society for
Medical Law (DGMR) has issued a recommendation
about end-of-life care where CEC is suggested as a valu-
able approach for decision-making; patient-involvement,
254 STELLA REITER-THEIL

however, is not discussed here: 'Empfehlungen zum
Arzt-Patient-Verhaltnis am Ende des Lebens', in: A.
Wienke and H.-D. Lippert (eds.): 2001, Der Wille des
Menschen zwischen Leben und Sterben - Patientenverfi-
gung und Vorsorgevollmacht. Ausgewuhlte medizinrecht-
liche Aspekte. Heidelberg: Springer, p. 151.
13. Agich, G.J.: 2000, 'Why Should Anyone Listen to Ethics
Consultants?', in: H.T. Engelhardt, jr (ed.), The Philosophy
of Medicine, pp. 117-137.
14. Bundesarztekammer: 1998, Grundsutze zur drztlichen Ster-
bebegleitung. Deutsches Arzteblatt 95 (Heft 39), 25.9.1998
(19), p. A-2367.