Ethics Committee Core Curriculum

SHHV-SBC Task Force on Standards for Bioethics Consultation

Meeting Two: December 13-14, 1996 Minutes

The Park Ridge Center
 Chicago, Illinois

Prepared by Mark Aulisio, Ph.D.
Executive Director


 
 
The following are the minutes for the second meeting of the SHHV-SBC
Task Force on Standards for Bioethics Consultation (TF).  These  minutes
include abstracts of each of the presentations made at the  meeting and
summaries of major points of discussion.

Some of the  materials referred to in these minutes are attached for
clarity.
 
 December 13, 1996 (Friday)
 
 Working Lunch (12:00 - 1:00)
 
During lunch Stuart Youngner, Bob Arnold, and Mark Aulisio led a
discussion of various business items.  Bob then emphasized the
objectives for the meeting and the means by which these objectives  might
be achieved (see Goals and Methodology attached). 
The  objectives for the meeting were:  
 
1.  To come to a collective position on the core features of health care
ethics consultation (hcec) (what it is and how it differs from other
types of consultation [e.g., traditional medical or legal  consultation,
etc.] and professional activity [e.g.,  risk management, patient
advocacy, etc.]).
 
2.  To reach a consensus on the proper goals of health care ethics
consultation.
 
3.  To come to agreement on the proper scope of health care ethics
consultation (e.g. particular cases, matters of policy, etc.) and
whether, within that scope, ethics consultation should be voluntary or
obligatory.
 
Ellen Fox: Empirical Data Regarding Ethics Consultation (1:00-2:45)
 (prepared by Ellen Fox)
 
Ellen Fox presented a detailed review of the empirical research on
ethics consultation that has been published to date.  After explaining
the methods of her literature search, she summarized 42 empirical
studies, commenting on their research design, methods, and  limitations.
She then discussed what conclusions can be drawn from  the available
empirical data.  She described  in detail what is  currently known about
ethics consultation -- and what is not known.   She also addressed what
the empirical literature says about ethics  consultation's appropriate
purpose, roles, and scope.  Finally, she  shared her personal plans for
future research in this area.  With the  support of the Consortium on
ETHICS (Evaluating Together Healthcare  Institutions' Consultation
Services), she is seeking funding for a  national survey on ethics
consultation, and has begun work on a  follow-up grant.   To read more
about this topic, please see The  Journal of Clinical Ethics (Summer,
1996), in which a special section  on ethics consultation research was
edited by Ellen Fox.  In addition,  Dr. Fox invites anyone with a serious
interest in ethics consultation  evaluation to contact her for further
information.  Her e-mail address  is efox@uic.edu.  
 Discussion:  A brief discussion followed Dr. Fox's presentation.  There
was general agreement that there is a lack of reliable empirical  data
regarding ethics consultation as it is actually done.  This stems  from
the inadequacies of the studies that have been done in this area.   There
was also much agreement regarding the lack of evaluation data  for ethics
consultation.  It was pointed out that one of the reasons  for this is
that before ethics consultation can be evaluated its  proper goals must
be identified (studies might then be constructed to  see how best to
achieve those goals, that is, to set process or  structure standards).
People generally agreed that much more research  needs to be done both in
the gathering of empirical data regarding ethics consultation as it is actually practiced and in the evaluation  of ethics consultation.
 
Mark Aulisio: Nature Ethics Consultation:  Literature Review and Collation
of Essays (3:00-4:30)
 
The purpose of Mark's presentation was to present a lay of the  conceptual
landscape regarding the nature of ethics consultation.  Mark did this by
presenting three broad models for ethics consultation  that can be
elicited from the ethics consultation literature (advisor,  Socratic, and
facilitation consultation; with three versions of the  latter).  In
portraying the various models, Mark underscored a  fundamental dilemma
that will have to be addressed if ethics  consultation is to be
justifiable in our society.  Ultimately, ethics  consultation must be
characterized and justified in a way that is  consistent with the basic
values of a liberal democracy.  The liberal  democratic framework within
which ethics consultation must be  practiced in our society will form
part of the framework within which  an acceptable normative
characterization of ethics consultation must  be situated.  Mark concluded
his presentation of the three broad  models for ethics consultation by
identifying some common themes and disputed questions regarding the
nature of ethics consultation that can be elicited from the literature
review and TF members essays (see  Common Themes and Disputed Questions
attached).
 
Discussion: Much of the discussion following Mark's presentation concerned
the role that an ethicist's personal moral opinions should  have in
consultation.  It was suggested that the advisor model of consultation
is more of a caricature or straw person, but it is the  one that some
critics have in mind when they criticize ethics  consultants.  It was
also pointed out that moral expertise doesn't  imply that one have access
to an "objective moral framework" or "right  answer."  Some argued that
every moral view is substantive so to  require that ethicists not bring
substantive moral views to the  consultation is to require that ethicists
bring no moral views to the  consultation.  This touched off a discussion
of the role of ethicists'  personal moral  views in consultation.  There
was some concern that if  ethicists, unlike any other party to the
consultation, are supposed to  remain completely value neutral then their
helpfulness would be  diminished.  Sometimes patients or care givers are
very interested in  knowing what someone who has spent  a good deal of
time reading, discussing and thinking about moral issues thinks about a
given  question.  It was also pointed out that complete value neutrality
is  not possible.  All seemed to agree that those conducting an ethics
consultation need to be clear about when they are or are not offering
their personal moral views.  There was also concern that those
conducting an ethics consultation be sensitive to the sociological  power
of their authority.  Overall, it seemed to be the sense of the  group
that a facilitation model (rather than advisor or Socratic  models) for
ethics consultation would be most appropriate.  
 
Small Group Discussion of Cases (5:00 - 6:00)
 
This exercise was designed to complement the literature review and  essay 
exercise by showing how an analysis of actual cases might  elucidate the
nature of ethics consultation and its proper goals.  This exercise, in
contrast to the literature review and essay  exercise, was designed to be
more of a bottom-up approach to thinking  about the fundamental
objectives listed above (especially objectives  `1' and `2').  Each TF
member was asked to submit materials from two  or three case consults
she/he had done.  Four of the cases were chosen  by the co-directors to
be distributed to TF members prior to the  second meeting.  At the second
meeting, the TF membership was divided  into three small groups to discuss
the cases.  Each small group was  asked to explain (1) whether the case
is an ethics case and why  (mapping objective `1' above), and, (2) how
the case should be handled  and why (mapping objectives `1' and `2'
above).  The small groups were  not reconvened in large group to discuss
the results of small group  work as originally planned because the
general feeling among the  membership was to conclude for the day
(discussion of the cases is  omitted because it presupposes a rich
description of the cases).
 
December 14, 1996 (Saturday)
 
Group Discussion of the Nature of Ethics Consultation (9:00 - 12:00)
 
This session focused on the nature of ethics consultation.  The Common
Themes and Disputed Questions sheet (see attached) distributed by Mark
the previous day served as a discussion starter.  After approximately an
hour and forty-five minutes of discussion, an informal survey  regarding
the nature of ethics consultation was distributed to TF  members.  After
a brief break, a normative characterization of the  nature of ethics
consultation was distributed to the membership as a  springboard for
discussion (work on this characterization is on-going  so it has not been
included as part of these minutes).  The TF then  divided into two groups
to discuss the characterization, with Bob and  Stuart each leading a group.
 
Discussion of Common Themes (9:00 - 10:30)
 
Most of the discussion centered around three areas: how ethics
consultation should be initiated, terminological issues with the list,
and broad areas of agreement.  Discussion commenced with a TF member
posing a challenge to the number 7 on the Common Themes list.  Item  `7'
reads as follows: "Clinical ethics consultation (regarding  individual
cases) should be at the initiation of a patient, family, or  health care
provider."  The challenge to this involved the question of  what an
ethics consultant should do if she happened upon ethically  questionable
behavior (for example, where the behavior could result in  the loss of
life).  In that event, the consultant might be specially  obliged as an
ethicist to initiate a consultation.  Another TF member  
asked whether anyone had heard of any actual ethics consultation that
was initiated in this way.  The member posing the challenge indicated
that a colleague had recently told her of just such a case.  Other
members questioned whether it was a good idea that ethics consultants
involve themselves in a case without be asked.  Some commented that  this
would not be much different than health care providers involving
themselves in cases without being asked.  In reply to this, it was
suggested that when one is designated as the "ethicist" one has a
special obligation in to initiate a consultation in such a case.  It  was
then suggested that the question of what an ethicist should do in  this
type of case was not much different morally from the question o
f  what any other health care provider should do in similar
circumstances.  Ultimately, the case, it was said, requires that the
individual weigh the reasons involved and act on the basis of his/her
conscience.  The judgment will also have to take into
 consideration  when it is wise to pick battles outside of the normal
course of  consultation.  There was some concern expressed by other
members of  the TF that we not start to think of ethicists as more
virtuous or  holier than other health care providers.   In response to
this, it was  pointed out that we ought to hold ethicists to a higher
standard of  conduct precisely because they are ethicists.  The question
was then  raised as to whether the formulation in number 7 was the norm,
but  that there might be exceptions (such as the type of case under
discussion) to the way ethics consultation should normally get  started.
The second area of discussion concerned the language of  "clinical ethics
consultation."  It was suggested that this  terminology be replaced by
"health care ethics consultation."  The  term "clinical" is far too narrow
and exclusive to capture the area  under discussion.  It was pointed out,
in response, that the  "clinical" here was meant to be much broader and
that the change to  "health care" should be made.  The third area of discussion involved  the other items on the list collectively.  One person felt that the  discussion of this session and of the previous day showed that there  was great deal of agreemen
t with the common th
emes listed.  Other TF  members concurred.  The general sense was that a
facilitator model of ethics consultation was emerging from the
discussion.  
 
Survey (10:30 - 11:00)
 
A brief non-scientific fourteen question (some subdivided; so there  were
twenty items requiring a response) survey was then distributed to  the
group.  The purpose of the informal survey was to get a rough idea  of
whether the group was in broad agreement (as was suggested in the
earlier discussion) with some of the common themes identified in the
literature review.  It was agreed that where the wording "clinical
ethics consultation" appeared on the survey it should be read "health
care ethics consultation."  Although the survey was very informal its
results do suggest that there are broad areas of agreement among the
membership regarding the nature of ethics consultation (these areas
matching closely the common themes identified in the literature review).  

Discussion of Normative Characterization of Clinical Ethics  Consultation
(11:00 - 12:00)
 
The TF is working on the development of a normative characterization of 
ethics consultation.  Once this characterization has been developed  and
given final approval from the TF membership it will be made  available.  
The characterization will probably include a discussion of  the following
questions:  

What is health care ethics consultation [hcec]?
What is the appropriate model for hcec?
Are there limits to the consensus that the involved parties may agree
to?  What if consensus among the involved parties cannot be reached?
May consultants offer their personal moral views? What are the goals
of hcec?
 
 
Discussion of Goals of Clinical Ethics Consultation (1:00 - 2:30)
 
 A list of alternative goals for ethics consultation was then  distributed
to each of the members.  The TF again divided into two  groups to discuss
the proper goals of ethics consultation (see  attached).
 
Bob Arnold's Group:  The group did not think that the Singer et al.
goals best captured the proper goals of hcec.  The statement is too 
physician focused and based heavily on the medical model of
consultation.  The group generally liked the Fletcher-S iegler goals
statement, although there was some serious concern about the language  of
maximizing "benefit" and minimizing "harm."  The wording of the  first
goal was also criticized for its very medical tone.  It was  noted that
the fourth goal of the Fletcher-Siegler statement should  have been
included ("To assist individuals in handling current and  future ethical
problems by providing education in healthcare ethics"  [Fletcher and
Siegler, 1996, 125]).  There was some discussion of the  third and fo
urth goals as being goals that will be served through  successful ethics
consultation.  The group thought that a variation of  the first goal
drawn from the facilitation models of hcec might be a  good overarching
goal or purpose (the following wording was suggested:   "To improve the
provision of health care and its outcome through the  identification,
analysis, and resolution of ethical issues as they  emerge in particular
clinical cases or in the full-range of patient  oriented policy
questions").  The group also liked the first of the  proximate
facilitation model goals, but suggested that it be modified  so that the
focus is on the identifying the nature of the value  uncertainty,
distress, or conflict that underlies the consultation.  Members of the
group indicated again that the wording "health care" is  more apt than
"clinical."
 
Stuart Youngner's Group:  The group did not think that the Singer et  al.
goals were well put.  It was noted that the Singer statement was  too
physician centered.  It was also noted that sometimes improving  process
(which much of hcec is about) does not improve "outcomes" (if  the
measure is strictly medical).  It was also noted that there is a  serious
philosophical problem with the relation between the "right"  and the
"good."  It was pointed out that the first of the  Fletcher-Siegler goals
is very problematic.  Members of the group  wondered about the
compossibility of maximizing benefit and minimizing  harm to "patients,
families, professionals and institutions."  It was  also noted that there
is a deep tension between "fair and inclusive"  proces
ses and maximizing benefit and minimizing harm.  Group members,  for the
most part, liked the rest of the Fletcher-Siegler goals.
 
 
 
Steve Miles:  The Scope of Ethics Consultation (2:45 - 4:00)
 
Steve gave a very brief presentation that he adapted in light of some  of
the discussion at the meeting.  Steve's presentation focused on the
"scope of roles for ethics consultation" within health care institutions.
Steve defined ethics consultation as "Helping to reduce  uncertainty,
mediate conflicting parties, or reconcile competing  values in order to
assist parties engaged in working with a clinical  case that those parties
view as morally complex, difficult or  troubling."  In light of this defi
nition, Steve went on to discuss a  variety of roles for the health care
ethics consultant in health care  institutions.  These roles range from
helping a committee to develop  policy, educate staff in implementing
policy, and offering  consultation regarding the ethical dimensions of
policy.  Steve then  went on to discuss the extended responsibilities of
the ethics  consultant.  These responsibilities can be broadly captured
under the  view of the ethicist as a general purpose ethics expert to
deal with  moral distress anywhere in the clinic (examples include
research on aborted fetuses, anti-dumping policies, and gag rule
policies).  Extended responsibilities of the ethics consultant, according
to  Steve, can be contrasted with nested responsibilities
 which focus on  the relation between policy, education, and ethics
consultation itself  over a limited range of issues (informed consent,
confidentiality,  life-sustaining treatment, etc.).  In these areas, even
post-consultation, ethics consultation can be useful for policy
prospectively to better establish a milieu for the conduct of
consultation and retrospectively to devise more successful means of
handling routine problems identified as causing consultation.  The  same
would be true for education.  Limiting ethics consultants to  nested
areas may have important adverse consequences (for example, it  may
under-utilize the skills of clinical ethics consultants who would  still
be capable of responding as Brody does in the mensch mode to  address m
oral distress by practitioners with regard to institutional
infrastructure or policy aside from clinical ethics consultation), but
it has some Important positive consequences such as more limited set  of
skills, knowledge, etc. for certification.  This 
more limited  definition of problems is a more secure political grounding
for the  survival of the consultant.  Steve concluded his presentation by
raising some concerns about the danger of ethics consultation being
co-opted by the medical-ind strial complex.  To avoid this, it is
important for the ethics consultant incorporate ironic self-criticism  as
part of an ethic for the consultant.
 
Discussion: Much of the time was spent discussing the scope of 
consultant's or ethicist's roles rather than the scope of ethics
consultation.  A consultant's roles might include education, research,
consultation and policy development.  Some suggested that the
consultant's roles might include intervention and informal  consultation
regarding a whole range of issues too broad to specify  (when asked for
informal input while on rounds, etc.).  This led to a  discussion of how
if standards are to be set at all, then they will  have to be very
different for full time ethicists than for members of  ethics committees.
Discussion then was re-focused on the scope of  ethics consultation.  The
question of whether the scope of ethics  consultation should be e
xtended to include education was discussed.  After a lengthy exchange,
members seemed to agree that one of the  effects of good ethics
consultation may be that those involved become  more educated regarding
ethical issues (so ethics consultation is  educative), but that ethics
consultation should not be extended in  scope to cover a broad range of
other ethics services that would  better be captured by the term
"education" (in-services, colloquia,  and so forth).  Discussion then
turned to policy issues for which  ethics consultation might be
appropriate.  There seemed to be general  agreement that the scope of
ethics consultation could extend to the  full range of policy issues that
affect patient care in health care  institutions (including organization
al ethical issues).  Again, this  range of issues is hard to specify in
any exhaustive way (as there is  such a wide variety of policy issues for
which ethics consultation  might be relevant).
 
Close of the Meeting (4:00 - 5:15):
 
 The following is a synthesis of comments made at the concluding session
of the meeting.
 
1.  For future meetings, all documents that the TF will be asked to
consider should be sent to the membership at least one week prior to  the
meeting.
 
2.  The work of this meeting (producing a normative characterization  of
the nature, goals, and scope of ethics consultation) was very  abstract
and difficult.  This work, and the open discussion it  involved, was
important, but future TF meetings will need to be more  product oriented.
 
3.  In the future, small group discussion should be reported back to  the
larger group.
 
4.  The TF needs to be focused on how we can move the field forward.
There is a wealth of experience and talent on the TF.  By drawing on  the
experience and talent of the membership, the TF will best  accomplish its
work.  

5.  TF members would like to have all cases submitted for the case
exercise of this meeting sent out to them.
 
6.  The co-directors and executive director have, in some ways, been
doing too much work.  Small groups of TF members should be asked to  work
on different projects for future meetings so that `4' can be  actualized.
 
7.  The TF should issue a call for education and training materials  for
ethics consultation that have been developed by various  institutions.
These materials would help members of the TF in their  deliberations.
 
8.  Looking at cases in which ethics consultation was done poorly  might
help the TF in its deliberations about standards for ethics
consultation.
 
9.  Overall, considering the size of the TF and the complexity of its
task, the TF is about where it needs to be at this stage.  With two 
meetings in the next five months, the TF is entering a critical phase.
Each TF member needs to be really committed to the project in the  coming
months.
 
10.  The next TF meeting will be held in either New York or Chicago
depending on availability and cost of accommodations.
 
11.  The TF should look into the possibility of a three day retreat  for
either the May or September meetings.
 
12.  There should be a moderator for discussion at each future TF meeting.
The role of the moderator should be clearly defined.  However, if the
moderator is to be successful, then the membership  must grant the 
moderator the authority to focus discussion, move  discussion forward,
and so forth.
 
13.  The TF leadership needs to remember that consensus need not  involve
unanimity on every issue.



Common Themes and Disputed Questions  from the Literature Review and
Essay Exercise  SHHV-SBC Task Force on Standards for Bioethics
Consultation
 
December 13, 1996
 
Mark Aulisio, Ph.D.
 
 
As I mentioned at the outset of this presentation, the differences
among the models that we have just considered are, for the most part,  a
matter of emphasis.  None of the authors that I cited fit neatly  into
the particular model in question.  There are a number of  important
common themes that we can elicit from the models above and  from your
essays.
 
Common Themes:
 
1.  Clinical ethics consultation  (cec) involves helping to resolve
"ethical issues" that emerge in the clinical setting.  "Ethical  issues"
turn out to involve, among other things, value conflict or  uncertainty.
 
2.  Clinical ethics consultation is highly contextual.  Its context
places demands on it that are not normally placed on ethical  theorizing
that may go on in academia.  These contextual demands  include:
 
Value conflict or uncertainty in the clinic generates a practical  need
for resolution, . The clinical context of cec requires the  gathering of
relevant empirical data, . The practical resolution of  such conflicts or
uncertainties must go on in a way that is consistent  with the
fundamental values of society (liberal democracy), law, the  nature of
the clinical institution, and which maximally respects the  values of all
parties to the conflict or uncertainty.
 
3.  Clinical ethics consultation involves facilitating or mediating
among a variety of moral viewpoints (value structures; moral spheres;  conceptions of the good life).
 
4.  Those conducting clinical ethics consultation must have a good  sense
of its limits or boundaries (especially with regard to other
professional domains).
 
5.  Clinical ethics consultation often involves clarifying relevant
concepts and uncovering the implications of various normative issues  for
the case at hand (matters of institutional policy, law and  ethics).
 
6.  Clinical ethics consultation should extend to policy as well as
cases.
 
7.  Clinical ethics consultation (regarding individual cases) should  be
at the initiation of a patient, family, or health care provider.
 
8.  Clinical ethics consultation involves the provision of information
from the relevant bioethics literature.
 
9.  Clinical ethics consultation may involve helping various parties  to
the consultation clarify their values.
 
10.  Ideally, clinical ethics consultation should be conducive to the
building of shared moral commitments among the parties to the
consultation.
 
11.  The "advice" or "recommendation" that results from a cec should  not 
be binding, but rather it should be weighed by those with decision
making authority in their ultimate determination of the course of  action
(or policy) to be adopted.
 
12.  Clinical ethics consultation should not involve the imposition of
the values of those conducting the consultation on other parties to  the
dispute.
 
 Some Disputed Questions:
 
1.  Can clinical ethics consultation be understood and practiced in a
way that is consistent with the fundamental values of a liberal democracy?
 
2.  Who is it that clinical ethics consultation should serve (primary
physician, patient, family, physician/patient relationship, whoever
called the consult, the health care institution, broader society,  etc.)?
 
3.  How should the substantive moral views of those conducting the
consultation influence the consultation (suppose a patient asks,  "Well,
what would you do?")?
 
4.  What weight should a "consensus" view in the bioethics literature
have in the ethics consultation?
 
5.  What are the limits to a "consensus" that emerges in cec and what
should be done in the absence of consensus?


 Goals of Clinical Ethics Consultation: Discussion Starter
 
 SHHV-SBC Task Force on Standards for Bioethics Consultation
 
 December 14, 1996
 
 Mark Aulisio, Ph.D.
 
 From Singer, Pellegrino, and Siegler, "Ethics Committees and
Consultants," The Journal of Clinical Ethics vol. 1, no. 4 (Winter
1990): 264:
 
In our view, the central goal of an ethics consultation is identical  to
the goals of all medical and surgical consultations: to improve  patient
outcomes.  In contrast to technical questions of what can be  done for a
patient (for example, can the patient benefit from this  medication or
operation?), ethical problems often raise the question  of what should be
done and often focus on the process of shared  decision making that
occurs between patients, health professionals,  and families.
Increasingly, in recent years, ethics consultations  also have become an
important mechanism for resolving "ethical"  conflicts and disagreements
within the health-care institution rather  than through recourse to the
courts.  The central goal then of ethics  consultations is to assist the
primary physician, the patient, and the  family to reach a right and good
clinical decision.
 
 From the John C. Fletcher and Mark Siegler, "What are the Goals of
Ethics Consultation?  A Consensus Statement," The Journal of Clinical
Ethics vol. 7, no. 2 (Summer 1996): 125.
 
Ethics consultation is defined as a service provided by an individual
consultant, team, or committee to address the ethical issues involved  in
a specific clinical case.  Its central purpose is to improve the  process
and outcomes of patients' care by helping to identify,  analyze, and
resolve ethical problems.  To guide the evaluation of  ethics
consultation, we propose the following goals:
 
To maximize benefit and minimize harm to patients, families,  healthcare
professionals and institutions by fostering a fair and  inclusive
decision-making process that honors patients'/proxy  preferences and
individual and cultural value differences among all parties to the
consultation.
 
To facilitate resolution of conflicts in a respectful atmosphere with
attention to the interests, rights, and responsibilities of those
involved.
 
To inform institutional efforts at policy development, quality
improvement, and appropriate utilization of resources by identifying  the
causes of ethical problems and to promote practices consistent  with
ethical norms and standards.
 
To assist individuals in handling current and future ethical problems  by
providing education in healthcare ethics.  

Drawing from ethical facilitator and pure facilitator models.  The
following could be offered as an ultimate goal of clinical ethics
consultation:
 
To improve clinical practice through the identification, analysis and
resolution of clinical ethical issues (value conflicts or  uncertainties)
as they emerge in actual clinical cases or in policy  discussion.
 
 More proximate goals:
 
 To properly identify the nature of the value conflict or uncertainty that
gives rise to the need for clinical ethics consultation through  the  
gathering of empirical data, clarifying of relevant concepts, and  
examining the implications of various normative issues for the case or
policy under discussion.
 
To facilitate the development of shared moral commitments among the
various parties to the case or policy in question.
 
To account for the values of relevant parties to the case or policy in 
question so that they are respected in the course of action to be
pursued or the policy to be adopted.
 

 GOALS AND METHODOLOGY
Meeting Two of the SHHV-SBC Task Force on Standards for  Bioethics
Consultation
 
 The Park Ridge Center
 Chicago, Illinois
 
 December 13-14, 1996
 
 Suggested by Mark Aulisio, Ph.D., Bob Arnold, M.D., and Stuart Youngner,
M.D.
 
 As a result of our work at the first meeting (May 24-26, 1996), the
goals and methodology for meeting two have been revised.  The  revisions
correspond to the summary points of Substance, Process, and  Business
articulated in the minutes for meeting one.   A particularly  important
change that resulted from the group discussion at meeting  one is the
shift in focus from an emphasis on the role of the ethics  consultant to
an emphasis on the nature of ethics consultation.  This  shift in focus
is directly reflected in the three fundamental  objectives for meeting
two listed below.  Regarding ethics  consultation, the membership present
at meeting one suggested that the  TF needs to answer questions
concerning its core features, proper  goals, and proper scope.
Furthermore, the membership suggested that  there is a certain
conceptual priority that we need to follow in  trying to answer these
questions.  At the first meeting, TF members  suggested that we need to
define "ethics consultation" before we can talk about what its scope and
goals ought to be.  In other words, it  was suggested that one cannot
rightly talk about the proper goals or  scope of something (e.g., the
activity of ethics consultation) unless  we first know what that
"something" is.
 
The three objectives below are listed in order of conceptual priority.
The objectives are, admittedly, very ambitious.  If we are able to  meet
even the first objective at meeting two, we will have  accomplished much.
 
 
Fundamental Objectives:
 
1. To come to a collective position on the core features of health  care
ethics consultation (what it is and how it differs from other  types of
consultation [e.g., traditional medical or legal  consultation, etc.] and
professional activity [e.g., risk management,  patient advocacy, etc.]).
2. To reach a consensus on the proper goals of health care ethics
consultation.
3. To come to agreement on the proper scope of health care ethics
consultation (e.g. particular cases, matters of policy, etc.) and
whether, within that scope, ethics consultation should be voluntary or
obligatory.
 
 
 Methodology:
 
1. In preparation for meeting two, a review of the literature  concerning
the fundamental objectives listed above will be conducted  by Mark
Aulisio.  This literature review will result in an annotated
bibliography which will be sent to each TF member well in advance of
meeting two.  At meeting two, Mark will present a critical assessment  of
the results of the literature review to the entire TF.  The  presentation
will emphasize fundamental objectives 1 and 2.
 
2.  Prior to meeting two, each TF member will be asked to write a  brief
essay which includes a discussion of each of the three  fundamental
objectives listed above.  In addition to the co-directors  and the
executive director, a number of other TF members will work on  the
formulation of the central questions to be answered in the essay.  Of
particular significance for the essay will be defining what ethics
consultation is and how it might be similar to and different from  other
kinds of consultation (core features of "ethics consultation"  vs. legal,
psychological, medical consultation, etc.) and professional  activities
(e.g., risk management, patient advocacy, etc.).  These  essays will then
be collected and sent out to each of the members  prior to 
meeting two for discussion.  At meeting two, a working  definition of
ethics consultation, formulated, in part, on the basis  of these essays,
will be proposed to the membership for discussion  (the literature review
will also serve as a basis for the working  definition).

3. Each TF member will be asked to submit materials from two or three
case consults she/he has done.  Each TF member will also be asked to
submit the rules governing ethics consultation at his/her institution.
Three or four of the cases will be presented to the TF membership at
meeting two.  Those who have submitted the cases selected for
presentation may be asked to provide either the patient's chart or a
richer discussion of the case in question and to help with the
presentation of the cases to the membership.  The TF membership will  be
divided into small groups to discuss the cases.  Each small group  will
be asked to explain (1) whether the case is an ethics case and  why
(mapping objective `1' above), and, (2) how the case should be  handled
 and why (mapping objective `2' above).  Some of the cases may  consist
only of information that can be gleaned from the patient's  chart.  The
cases will be changed to protect confidentiality.  This  exercise should
complement the literature review and essay exercise by  showing how an
analysis of actual cases might elucidate the nature of  ethics
consultation.

4. Ellen Fox will be invited back to inform TF members of empirical  data
that has been collected which describes what is presently going  on in
clinical ethics consultation (both regarding the types of  backgrounds 
from which clinical ethics consultants come and their  typical roles) and
to review the outcome data on this question. 
 
5. At meeting two, Steve Miles will present a paper on the proper  scope
of ethics consultation in the context of health care  institutions
(fundamental objective 3).  The paper will be followed by  comment and
discussion (please note that this is proposed with the  understanding
that time may not permit the TF to address objective 3  at meeting two).