As a practicing CEC, I appreciate this post. But let me suggest that medicine faces a similar problem. Classically, the goal of medicine are to safeguard and promote health. But "health" -- much like "morality" -- is a troubled and contested topic admitting of multiple concepts from multiple traditions. One only needs to survey the intellectual traditions of Aristotle, David Hume, and Michele Foucault to see how complicated and value laden "health" can be. There are proper functionalist concepts, sentiment-based concepts, statistical concepts, and normative-social concepts that all come up (and sometimes conflict) in internal med, palliative care, psychiatry, and surgery -- really everywhere in medicine. There are intractable disputes about the status of certain interventions. The development of new biotechnologies pushes the boundaries of our health concepts into puzzling territory. AND YET, we are able to meaningfully practice medicine, come to wide agreement on treatment plans, provide actionable, evidence-based outcomes associated with healing and the restoration of health.
I submit the case is similar in CEC. There are wide and deep differences in opinion about the natural and status of morality, the correct normative system, the moral status of subjects at the margins, and the permissibility of certain treatments. AND YET, there is a lot of agreement about how to approach a case, what process to follow, and what principles should govern a certain course of action. One of the things that struck me as a CEC fellow is how 95% of the time I could converge on the same recommendations as my colleagues who came from very different starting points and worldview commitments. I am not naive to the problems that beset CEC and ethics more generally. But I think we can overstate them in ways that make the practice seem dubious when it really is not. We can resolve most of the morally-laden conflicts driven by value uncertainty that come up in the clinic.
And that should not be too surprising. There is a difference between practical and theoretical reasoning, after all.
My challenge to your "and yets" would be: *are* we meaningfully practicing (good) medicine in the USA, where amount spent doesn't track with clinical outcomes, there remains vast disparities in care, and the basics to sustain health (e.g., food, physical activity, healthy pace of life) are consistently overlooked? What is, after all, an "evidence-based" outcome when the evidence is so easily manipulated? e.g., the most recently developed antipsychotic for schizophrenia was FDA approved on the basis of a placebo-controlled trial (https://www.fda.gov/news-events/press-announcements/fda-approves-drug-new-mechanism-action-treatment-schizophrenia). All very well, you might say: placebo controlled trials are good! But that kind of control arm is unethical when "placebo" isn't the standard of care. No one is treating schizophrenia with placebo. The drug should have been compared to a current antipsychotic.
Anyway, I'm not sure agreement should be the standard for either health or good medicine.
I agree with you that there's a lot of alignment re: process in CEC. I wasn't disputing ASBH's process standards (as I mention). What I'm concerned about is that we adopt a subtle form of secularized and utilitarian bias when we think that all we're doing is adhering to these process standards.
How do you think you were able to achieve such high consistency in your fellowship? I can't speak for your experience, obviously, but I do wonder if there's such vast consistency across heterogenous populations (CECs, patients, clinicians, situations), if that doesn't signal some other "story" at play that trumps the other relevant stories that might impact our deliberations about ethical quandaries and conflicts. Perhaps it's adherence to institutional policy and state law, maybe it's an internalized ethic via hidden curriculum - not sure.
The other possibility is that what rises to the level of CEC are often things that are settled by reviewing a law or policy (e.g., who is the legally appropriate surrogate decision-maker here? When can we overrule a patient's expressed preference?), or ironing out terms (He uses this term this way, she uses it that way, but what you both mean is X, which is a shared interest). Other issues may not rise to CEC because they're not seen by frontline staff and other voices are overlooked or silenced (institution dependent of course).
I think it's also worthwhile to consider that there's more to ethics than just the moment of decision: the quandary or the conflict. Ethics is happening all the time, as I wrote. Institutions leaning on CEC for quandaries and conflicts alone might overlook that and, again, subtly use CEC to restore things to status quo - when ethics is no longer really "needed" but we can just return to business as usual. That would be, after all, the state of things when people no longer see a quandary or conflict.
I agree that "agreement should be the standard for either health or good medicine." My point is that if there is such wide divergence on fundamental issues, we should expect there to be little to no agreement about what to do among participants who represent such divergence in medicine or CEC. But we don't find that to be the case. Most (not all!) of the time we can converge, perhaps for reasons internal to our views, on the same set of recommendations. For example, telling a surrogate that we are going to do a capacity assessment on their loved one instead of going behind their back can be justified from utilitarian, Kantian, Aristotelian, or the "internal" ethics of medicine. The norm of truth telling is what is sometimes called a "mid level" norm, meaning its normativity is widely recognized and that mere disagreement with it is not enough to overcome it. That is to say, going ahead with the covert capacity assessment is wrong. What explains its wrongness may be an open question (appeal to consequences, virtues, rights, etc), but settling that question isn't that important for recommending that the team should engage the surrogate and not sneak around their back.
What I mean to say is that there is a lot of *overlapping* justifications for our actions. What I think is lacking in many criticisms of CEC, and medicine in general, is a justification for thinking that we must reach the correct conclusion by the correct method. While that would be ideal, we live in a non-ideal world where decisions have to be made despite deep worldview differences. That has its problems, alright, but this just seems to be a feature of the human condition we have to negotiate as best we can. THAT is what I experienced in my fellowship and continue to experience today.
I know you and I see eye to eye on a lot of things and I sympathize with many of your criticism of medicine and ethics. But I will continue to maintain that we can be more optimistic about what we can do to serve the common good for the reasons stated above.
Fantastic post, thanks Josh. CEC aren’t very common in Australia, especially outside of paediatrics. Through my work as a pharmacist in paediatrics, palliative care and more recently voluntary assisted dying, I’ve encountered so many scenarios like those you describe, many of which I continue to think about now. To be honest, one of the reasons I left assisted dying because I was concerned we didn’t have these types of CEC roles and ethics boards in place. Anyway, thanks again for a super interesting read.
As a practicing CEC, I appreciate this post. But let me suggest that medicine faces a similar problem. Classically, the goal of medicine are to safeguard and promote health. But "health" -- much like "morality" -- is a troubled and contested topic admitting of multiple concepts from multiple traditions. One only needs to survey the intellectual traditions of Aristotle, David Hume, and Michele Foucault to see how complicated and value laden "health" can be. There are proper functionalist concepts, sentiment-based concepts, statistical concepts, and normative-social concepts that all come up (and sometimes conflict) in internal med, palliative care, psychiatry, and surgery -- really everywhere in medicine. There are intractable disputes about the status of certain interventions. The development of new biotechnologies pushes the boundaries of our health concepts into puzzling territory. AND YET, we are able to meaningfully practice medicine, come to wide agreement on treatment plans, provide actionable, evidence-based outcomes associated with healing and the restoration of health.
I submit the case is similar in CEC. There are wide and deep differences in opinion about the natural and status of morality, the correct normative system, the moral status of subjects at the margins, and the permissibility of certain treatments. AND YET, there is a lot of agreement about how to approach a case, what process to follow, and what principles should govern a certain course of action. One of the things that struck me as a CEC fellow is how 95% of the time I could converge on the same recommendations as my colleagues who came from very different starting points and worldview commitments. I am not naive to the problems that beset CEC and ethics more generally. But I think we can overstate them in ways that make the practice seem dubious when it really is not. We can resolve most of the morally-laden conflicts driven by value uncertainty that come up in the clinic.
And that should not be too surprising. There is a difference between practical and theoretical reasoning, after all.
Thanks for sharing these thoughts, Adam.
My challenge to your "and yets" would be: *are* we meaningfully practicing (good) medicine in the USA, where amount spent doesn't track with clinical outcomes, there remains vast disparities in care, and the basics to sustain health (e.g., food, physical activity, healthy pace of life) are consistently overlooked? What is, after all, an "evidence-based" outcome when the evidence is so easily manipulated? e.g., the most recently developed antipsychotic for schizophrenia was FDA approved on the basis of a placebo-controlled trial (https://www.fda.gov/news-events/press-announcements/fda-approves-drug-new-mechanism-action-treatment-schizophrenia). All very well, you might say: placebo controlled trials are good! But that kind of control arm is unethical when "placebo" isn't the standard of care. No one is treating schizophrenia with placebo. The drug should have been compared to a current antipsychotic.
Anyway, I'm not sure agreement should be the standard for either health or good medicine.
I agree with you that there's a lot of alignment re: process in CEC. I wasn't disputing ASBH's process standards (as I mention). What I'm concerned about is that we adopt a subtle form of secularized and utilitarian bias when we think that all we're doing is adhering to these process standards.
How do you think you were able to achieve such high consistency in your fellowship? I can't speak for your experience, obviously, but I do wonder if there's such vast consistency across heterogenous populations (CECs, patients, clinicians, situations), if that doesn't signal some other "story" at play that trumps the other relevant stories that might impact our deliberations about ethical quandaries and conflicts. Perhaps it's adherence to institutional policy and state law, maybe it's an internalized ethic via hidden curriculum - not sure.
The other possibility is that what rises to the level of CEC are often things that are settled by reviewing a law or policy (e.g., who is the legally appropriate surrogate decision-maker here? When can we overrule a patient's expressed preference?), or ironing out terms (He uses this term this way, she uses it that way, but what you both mean is X, which is a shared interest). Other issues may not rise to CEC because they're not seen by frontline staff and other voices are overlooked or silenced (institution dependent of course).
I think it's also worthwhile to consider that there's more to ethics than just the moment of decision: the quandary or the conflict. Ethics is happening all the time, as I wrote. Institutions leaning on CEC for quandaries and conflicts alone might overlook that and, again, subtly use CEC to restore things to status quo - when ethics is no longer really "needed" but we can just return to business as usual. That would be, after all, the state of things when people no longer see a quandary or conflict.
I agree that "agreement should be the standard for either health or good medicine." My point is that if there is such wide divergence on fundamental issues, we should expect there to be little to no agreement about what to do among participants who represent such divergence in medicine or CEC. But we don't find that to be the case. Most (not all!) of the time we can converge, perhaps for reasons internal to our views, on the same set of recommendations. For example, telling a surrogate that we are going to do a capacity assessment on their loved one instead of going behind their back can be justified from utilitarian, Kantian, Aristotelian, or the "internal" ethics of medicine. The norm of truth telling is what is sometimes called a "mid level" norm, meaning its normativity is widely recognized and that mere disagreement with it is not enough to overcome it. That is to say, going ahead with the covert capacity assessment is wrong. What explains its wrongness may be an open question (appeal to consequences, virtues, rights, etc), but settling that question isn't that important for recommending that the team should engage the surrogate and not sneak around their back.
What I mean to say is that there is a lot of *overlapping* justifications for our actions. What I think is lacking in many criticisms of CEC, and medicine in general, is a justification for thinking that we must reach the correct conclusion by the correct method. While that would be ideal, we live in a non-ideal world where decisions have to be made despite deep worldview differences. That has its problems, alright, but this just seems to be a feature of the human condition we have to negotiate as best we can. THAT is what I experienced in my fellowship and continue to experience today.
I know you and I see eye to eye on a lot of things and I sympathize with many of your criticism of medicine and ethics. But I will continue to maintain that we can be more optimistic about what we can do to serve the common good for the reasons stated above.
Fantastic post, thanks Josh. CEC aren’t very common in Australia, especially outside of paediatrics. Through my work as a pharmacist in paediatrics, palliative care and more recently voluntary assisted dying, I’ve encountered so many scenarios like those you describe, many of which I continue to think about now. To be honest, one of the reasons I left assisted dying because I was concerned we didn’t have these types of CEC roles and ethics boards in place. Anyway, thanks again for a super interesting read.