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The ASBH code of ethics and the limits of professional healthcare ethics consultations
  1. Abraham Schwab
  1. Correspondence to Professor Abraham Schwab, IPFW, 2101 E Coliseum Blvd, Fort Wayne IN 46805, USA; schwaba{at}ipfw.edu

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ABSTRACT

From the beginning, a code of ethics for bioethicists has been conceived of as part of a movement to professionalise the field. In advocating for such a code, Baker repeatedly identifies ‘having a code of ethics’ with ‘professionalization’. The American Society of Bioethics and Humanities (ASBH) echoes this view in their code of ethics for healthcare ethics consultants (HCECs)1 and the subsequent publication in the American Journal of Bioethics.2

Taking for granted that a code of ethics could be a valuable asset for HCECs, this essay has two aims. First, there are good reasons to doubt that the label ‘profession’ has significant meaning for HCECs. Attempts to accurately conceive of a profession fall into two broad camps: substantive and formal. Substantive conceptions should be rejected. Specifically, substantive conceptions beg the question about what it means to be a profession, which produces devastating problems for practical application. Formal conceptions of profession (eg, Davis’ conception3) avoid begging the question, but do so at the cost of identifying the responsibilities of a profession.

Using the term ‘professional responsibilities’, then, requires additional explication and classifying HCECs as professionals requires the identification of their role-specific responsibilities.i

Second, this essay will critique the ASBH code of ethics for HCECs as a first articulation of these responsibilities. As written, this code of ethics has limited value for HCECs because most of the responsibilities identified in this code do not identify HCEC-specific responsibilities. In closing, some important strategies to improve upon this initial attempt to define the responsibilities of HCECs are identified.

The limits of professionalising HCECs

For at least the last decade, Baker has encouraged bioethicists to adopt a code of ethics. Throughout this effort, Baker intertwines having a code of ethics with becoming a profession: ‘Is it time for bioethics to assert its integrity by developing …

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Footnotes

  • Twitter Follow Abraham Schwab at @abeschwab

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i This analysis has implications for any field that uses the terms ‘professional’ or ‘professional responsibilities’. The problems identified for HCECs and the ASBH code of ethics can serve as a roadmap to identify challenges facing any group of medical practitioners that refer to themselves as ‘professionals’ or as having professional responsibilities.

  • ii Jacob provides an important analysis of professionalism, but this work has limited applicability for this project.6 One reviewer of the Jacob's book describes it as “declining to define ‘professionalism’ or the process of ‘professionalization’.”7 Because the focus of this essay centers on definitions of profession and professionalism, Jacob's thoughtful analysis will be set aside. Additionally, it should be noted that ‘Medical professionalism in the new millennium: a physician charter’ defines a professional in medicine, but that definition is so narrowly constrained that it will have difficulty translating beyond that scope.8

  • iii Though Greenwood's analysis is sociological, this essay focuses on the normative. Specifically, the arguments in this essay will focus on how the code of ethics falls short of what it should be and how the movement to identify HCEC responsibilities should move forward.

  • iv A strategy reflected in other works.10 ,11

  • v While I do not take the indeterminacy of client to be a definitive means of undermining the possibility of HCECs as professionals, it does raise questions about what exactly the responsibilities of the HCECs are, an issue I will return to in the last section of this essay.

  • vi Davis offers this definition at the conclusion of his critiques of standing definitions that have been offered (including sociological ones). His critiques strike me as reasonable, if different from my own and, as my interest is investigating his conception of a profession, I will not evaluate them here.

  • vii It is only fair to note that this question is a bit ambiguous. When we say the ‘AMA Code of Ethics’ are we referring to the code as the set of nine Principles of Medical Ethics or the opinions that clarify the implications of those statements? While this is an important clarification for those endorsing Davis’ criteria of a profession, for our purposes, this distinction is beside the point. Even among the Principles of Medical Ethics, it would not be difficult to find a substantial number of physicians who disagree with Principle IX: ‘A physician shall support access to medical care for all people’. Accordingly, the question of what percentage endorse the code remains, as does the concern about rebels mentioned in the next paragraph.

  • viii I imagine Davis may try to rescue his account from this problem by acknowledging the formal legal requirement but pointing out the content of this licensure is often left to the profession itself. As Cohen notes, the self-regulating structure of medicine has been chipped away and, he fears, may continue to be chipped away.17

  • ix It is also possible, of course, that the criticisms of formal and substantive criteria demonstrate that the category of profession should be abandoned altogether. In the unlikely situation that this turns out to be the case, the remainder of my argument requires only a minor modification. Rather than discussing the responsibilities of HCEC professionals, it is simply a discussion of the responsibilities of HCECs.

  • x I assume in my analysis that the responsibilities described here are meant to be prescriptive regarding actions and outcomes. Others advocate for a richer more virtue-based understanding of responsibility, which would demand a far more radical critique of the code.18

  • xi It is worth noting that we find some broad contours in the discussion of the responsibility to be competent. These include education, peer review of work, and that ‘HCE consultants should meet standards that have achieved fieldwide acceptance, including those in ASBH's Core Competencies for Healthcare Ethics Consultation (2011)’.1 As I return to later in this section, I agree with the need for responsibilities common to all HCECs. What is less clear is that the core competencies should be those standards or that these competencies have achieved ‘fieldwide’ acceptance.

  • xii And it does not have to be this way. The principles in the AMA code, while still quite broad and vague in many senses, are not so easily translatable to other occupations. For a couple of quick examples, here is how principles VI and IX would translate:

    VI. ‘A [Barista] shall, in the provision of [coffee], except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide [coffee]’.

    IX. ‘[Baristas] shall support access to [coffee] for all people’.

  • xiii It is worth noting that this commitment to a public good is the one responsibility that clearly models Davis’ criterion for a profession—it represents a moral commitment to a good beyond what is required by law, market or regulation.

  • xiv Two additional notes about this obligation. First, the view of confidentiality represented is not without its detractors among medical ethicists.19 This, however, does not represent a problem. Indeed, it makes the code even more valuable. There exists disagreement in the literature and the code lays out a clearly defined view. Second, a close reading uncovers a conflation of privacy and confidentiality (‘should divulge confidential information . . .share relevant private information’ emphasis added). As has been explained elsewhere,20 there is a substantive difference between privacy and the obligation to maintain confidentiality. While confidentiality is well defined, privacy is not. So, for example, when the code assigns HCECs the obligation to respect privacy, does it mean that HCECs should not ask questions of patients and their families? By referencing the private, the code produces unnecessary confusion and risks misunderstanding.

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