Transfusion and Apheresis Science 42 (2010) 209–214

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Transfusion and Apheresis Science

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Applying Applied Ethics through ethics consulting

W. Moore *

University of Namibia, P.O. Box 828, Windhoek, Namibia

a r t i c l e i n f o a b s t r a c t

Article history:

1473-0502/$ - see front matter � 2010 Published bdoi:10.1016/j.transci.2010.01.020

* Tel.: +264 81 277 2565; fax: +264 61 251093.E-mail address: wmoore@therapinfo.com.na

Applied Ethics is frequently described as a discipline of philosophy that concerns itself withthe application of moral theories such as deontology and utilitarianism to real worlddilemmas. However, these applications often remain restricted to the academic world.The focus of new versions ethics consulting has since the mid-1980s shifted from whatthe ethicist knows to what the ethicist does or enables. This shift remodelled the ethicist’srole to that of a facilitator in an inherently social process of moral inquiry. Applying thesedevelopments in the Namibian context has already proved to be of great value to the localhealth care industry.

� 2010 Published by Elsevier Ltd.

1. Introduction

Although the concept of Applied Ethics has proved dif-ficult to define, it is widely accepted to denote the applica-tion of general ethical theories to moral problems with theobjective of solving these problems [1]. Among the meth-ods used for achieving this goal, a version of the CoherenceTheory, called reflective equilibrium connected to the so-called Common-Morality Theory, today enjoys consider-able prominence in the field of bio-ethical thought [11, p.397–408].

The concept of reflective equilibrium is inextricablylinked to the name of Rawls who used the term to referto his influential statement of this method [2]. Rawls viewsjustification in ethical deliberations as a reflective testingof our moral beliefs, principles and theoretical postulatesin order to make them as coherent as possible [4, p. 398].According to Rawls, method in ethics properly begins withour considered judgements, or the moral convictions inwhich we have the highest confidence and believe to havethe lowest level of bias and may include judgements aboutthe wrongness of racial discrimination, religious intoler-ance and political repression. These considered judge-ments occur at all levels of generality in moral thinkingand whenever some feature of a moral theory conflicts

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with one or more of these judgements, one or the othershould be revised to again achieve equilibrium [3].

Even these considered judgements are thus liable to revi-sion and it remains the goal of reflective equilibrium tomatch, prune and adjust our considered judgements in or-der to render them coherent with the premises of our mostgeneral moral commitments. This process normally startswith paradigm judgements of moral rightness and wrong-ness and then proceeds to the construction of more generaland more specific accounts that are as consistent andcoherent with these paradigm judgements as possible.These results then have to be evaluated for incoherenciesand readjusted if necessary [4].

A completely stable equilibrium can therefore never beassumed, but is dependant on a continuous harmonising ofdiverse moral commitments and of an evaluation of theseresults against all other moral commitments. Rawlsemphasises the ideal, though not utopian, character of thisprocedure by stating that no matter how wide the pool ofbeliefs, there can be no reason to anticipate that the pro-cess of pruning, adjusting and rendering coherent of moralbeliefs will ever come to an end or be perfected. A moralframework is henceforth to be regarded as more of a pro-cess than a finished product and moral problems as consid-ered projects in need of continual adjustment by reflectiveequilibrium [5].

All organised sets of moral belief thus remain some-what indeterminate and unable to eliminate contingent

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conflicts among principles and rules and might even re-quire so-called wide reflective equilibrium in order to eval-uate the strengths and weaknesses of all plausible moraljudgements, principles and relevant background theories[4, p. 399]. Moral views that may come under scrutiny inwide reflective evaluations might therefore include beliefsabout particular cases, rules and principles, virtue andcharacter, the moral standing of foetuses and animalsand the role of moral sentiments [6].

From this perspective, moral thinking is analogous tohypotheses in science that are tested, modified and even re-jected through experience and experimental thinking.Though we start in ethics with a set of considered judge-ments that are initially accepted without augmentativesupport and these judgements may have a history rich inmoral experience, any moral certitude associated withthese norms should derive from beliefs that are acquired,tested and modified over time [7].

In applying general ethical theories to everyday moraldilemmas, the key role of considered judgements in reflec-tive equilibrium also has important connections to theCommon-Morality Theory. While there exist more thanone theory of common morality [8], Common-MoralityTheories share several features, such as being pluralistic,relying on ordinary, shared moral beliefs as points ofdeparture, making no appeals to pure reason, rationality,natural law or a special moral sense as well as a suspicionabout any ethical theory that cannot be made coherent bymeans of pre-theoretical commonsense moral judgements.Common morality thus represents a pre-theoretical pointof view that transcends local customs and attitudes andfor this reason makes it more suitable to play a founda-tional role in bioethics than code-like ethical theories suchas utilitarianism, and Kantianism [9]. This is due to the factthat far more social consensus exist about principles andrules obtained from the common morality than from ethi-cal theories, that the common morality is capable of pro-viding both the starting point and the constrainingframework for innovation in ethics and that morality isto be regarded as the anchor of theory and not the otherway round [10].

Considered judgements thus have their origin in thecommon morality and no more basic moral data exist thanprinciples requiring that we respect persons, take note oftheir wellbeing and treat them fairly. This means that themore general (principles, rules and theories) and the moreparticular (case judgements, feelings, perceptions, prac-tices, parables, etc.) moral categories are integrally linkedin our moral thinking and that neither should have priorityover the other. It is also because of the fact that in everydaymoral reasoning, we effortlessly blend appeals to princi-ples, rules, rights, virtues, passions, analogies, paradigms,narratives and parables, that, according to Beauchampand Chilldress, we should be able to do the same in bio-medical ethics [11].

2. The development of ethics consulting

The current field of bioethics arose in the mid-1960s asa response to wrongdoings and potential wrongdoings by

doctors and biomedical scientists [12]. The Harvard spe-cialist Beecher blew the whistle in 1966 on doctors andbiomedical scientists who were experimenting with pa-tients without their consent [13] and this was followedby among others the exposure of the injection of cancercells into elderly patients of the Jewish Chronic DiseaseHospital in Brooklyn in 1963 and of the Tuskegee Syphilisstudy in 1972. Around the same time medicine’s growingtechnical abilities started triggering the public’s anxietythat doctors might be in a position to decide who will liveand who will die and this made ethicists assume the role ofprotecting patients from the doctor/scientist and interven-ing on the side of the patient in an adversarial relationshipbetween doctor and patient. Hence, many of the early con-cerns of bioethics, like informed consent and patientautonomy, were powered by the suspicion that doctors,left on their own, could exploit and even harm patients[14].

The accompanying assumption that the doctor–patientrelationship is of an adversarial nature, therefore alsoseems to have governed the bioethics agenda over the pastdecades [14, p. 205]. The current bio-ethical focus on pa-tient autonomy can only be understood if the doctor isseen as poised to take advantage of a patient and as a re-sult, doctors and patients found themselves at oppositepoles of interest. The middlemen and women who cameto populate the bio-ethical field between doctor and pa-tient have until recently therefore also tended to be trainedin either law or juridical moral philosophy and even physi-cians and scientists who worked as ethicists came to beseen as ‘‘strangers at the bedside” which posed a funda-mental challenge to the until then uncontested authorityof doctors [15].

Once the doctor–patient dyad was conceived as anadversarial one, contractual safeguards emerged to protectthe one party from the other. Ethics therefore became gov-erned by negotiated instruments like advance directives,informed consent processes and conflict of interest disclo-sures. Ethicists now joined licensing boards, policy makers,insurance company functionaries and hospital admissionprivilege overseers in building a tort-based, law-enshriningenterprise of controlling doctors and protecting patients.Bioethics thus suffered a restriction of its vision and influ-ence when it often implicitly and seemingly unconsciouslyaccepted the assumption that patients had to be protectedfrom their doctors. The example of autonomy is again mosttelling, for in their zeal to protect patients autonomy, someethicists designated as paternalism any expression of per-sonal opinion on the side of health professionals [16].

Against this background, discussions in ethics consult-ing were from the mid-1970s to the mid-1980s largelyoccupied with what the ethicist knows [17]. It portrayedthe ethicist as a logical superintendent who sharpens con-cepts, upholds standards of rigorous argument and policesfallacious thinking and regarded ethicists as the moral engi-neers needed to service the engines of ethics through purelyconceptual maintenance routines [31, p. 354]. This concep-tion of ethics therefore also became known as the engineer-ing model [18] and not only remained the prevailingdefinition of philosophical ethics for most of the twentiethcentury, but also became thoroughly embedded in medical

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ethics. It viewed moral theory as not merely a comprehen-sive, reasoned and reflective account of morality, but as ahighly specific one of where moral judgements come fromand as a compact code of very general (law like) principlesand procedures which, when applied to cases appropri-ately described, would yield completely impersonal justi-fied judgements about what any moral agent under suchcircumstances should do [31, p. 348].

However, since the mid-1980s concerns about what theethicist does moved to the fore [19]. The importance of thisshift is reflected in the prominence now allocated to mat-ters such as the different institutional functions of ethi-cists, the differing kinds of responsibility, authority andaccountability that should accompany them, where theethicist fits into the relationships with health care provid-ers, patients, families and caretakers and how moral delib-eration within health care institutions connects to largersocial arenas of moral consensus and conflict [20].

This shift also coincided with a growing awareness of theprinciples of the European Ethical and Legal Culture which,apart from autonomy, also emphasise the importance ofthe principles of dignity, integrity and vulnerability in the pro-tection of the private sphere of human beings [21].

The Stoics already pointed to the dignitas of man as anessential contribution to the human being and the conceptundergone further development in the Renaissance in thethought of Della Mirandola [22]. It became an importantelement in Kant’s categorical imperative [23] and throughthe work of philosophers such as Sartre [24], Marcel [25]and De Beauvoir [26] developed into an essential elementof the foundation of the development of human rights asa legal instrument for the protection of the human person.Integrity is a philosophical concept that, according to theDanish philosopher Logstrup, concerns that untouchablecore of the human personality that should never be subjectto external intervention [27] and it was the French philos-opher Levinas that regarded the human vulnerability as thefoundation for morality, as morality is a compensation forman’s vulnerability [28].

Reasons for this shift in ethics consulting included thequestioning of the assumption that morality is best repre-sented by code like theories and that moral competenceequals an intellectual mastery of code-like theories andlaw-like principles [29]. It furthermore included suspicionsabout a lack of skills of attention and appreciation, of thewisdom of a broad life experience and of the role of feel-ings in guiding one’s views among ethicists. Doubts alsoemerged about the ability of philosophers to bring theirabstract constructions into a sensitive and useful contactwith the problems of often extremely busy clinics, and thiswas accompanied by a growing awareness of the socialembeddedness of all moral understandings [31, p. 348].

Efforts were also made to bring morality to bear uponparticular instead of general occasions [31, p. 349] andthese were linked to an acknowledgement of the often con-structive nature of moral deliberation as is evident from thefact that communities, relationships and moral ideas areoften renewed and revised as the process of interpersonalnegotiation and interpretation in moral terms goes on[30]. The period after the mid-1980s also saw the emer-gence of the idea that deductively modelled theories and

applications in ethics should give way to a narrative under-standing of moral problems and moral deliberation.

3. A narrative approach in moral deliberations

Emphasis on narrative as the pattern of moral thinking isfirst of all an acknowledgement that morally relevantinformation is always set in particular episodes of deliber-ation – that history is the basic form of representation formoral problems and that an ethicist needs to know whothe parties are, how they understand themselves and eachother, what terms of relationship have brought them to theparticular morally problematic point and by which socialand institutional frames their options are shaped. A narra-tive approach does not spurn general rules or broad ideals,but treat them as markers of moral relevance, as guidelinesto the typical moral weight of certain acts or outcomes, asnecessary shared points of departure and as continuingshareable points of reference and reinterpretation [31].

Narratives in moral thinking therefore come before,during and after moral generalities and permit and invitefull exploration of what is often neglected or devaluatedin the engineering model, viz. specific histories of individ-ual commitment, of relationship and responsibility and ofinstitutional practices and evolving moral traditions. Whilethe need to apply principles in code-like moral theoriestends to dispose of complicating and possibly irrelevant de-tail, narrative is focussed on the enrichment of contextand detail. Specific personal, religious, professional or cul-tural values and commitments may be of crucial impor-tance to the maintaining of individuals’ maintaining ofintegrity and coherent moral self understanding and couldnecessitate a grasp of the history of trust, expectation andagreement that constitute particular relationships [32].

A narrative approach furthermore rather regards moralgeneralities as ingredients to a process than axioms tosteer by and as ingredients to stories that reveal how prob-lems have become the problems they are, that imaginepossible solutions or outcomes and that contemplate themoral influence on the people involved as well as the val-ues at stake. In addition to this, narrative also highlights asituation’s dynamic potential. Narratives are furthermorebuilt or constructed and remain open to further additionsof information through elaboration, continuation and revi-sion [31, p. 352].

Narrative approaches in the resolution of a moral prob-lem are therefore often more like the outcome of a negotia-tion than the solution to a puzzle and address the question ofhow values and obligations can guide people in findingmorally justifiable solutions to complex problems. More-over it keeps people involved in moral deliberation morallyaccountable to one another and is followed in order to actjustifiably to the other and to acknowledge the fact thatimperfect understandings, conflict and incomprehensionoften provide opportunities for critical and constructivemoral reasoning. For these reasons, moral narratives areideally authored and judged by those whose stories theyreflect and invoke shared moral resources not only toachieve solutions, but to achieve solutions that at the sametime protect refine and extend those very moral resourcesthemselves [31, p. 353].

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4. The reframing of bioethics through narrative

Due to the fact that principle governed bioethics aroseto deal with oppositional clinical relationships, it has beenargued that over the past decade conventional bioethicshas struggled to find its way among its chosen principlesand has been found inadequate to address the actual valueconflicts that arise in illness [33]. It for example becameclear that, although a principle governed bioethics mightbe equipped to adjudicate appropriate surrogacy for theincapacitated terminally ill patient, it is ill-equipped tohelp a paediatrician to talk with parents about the mean-ing of their child’s autism [14, p. 208].

A number of alternative approaches in addressing thecurrent ethical problems in health care, like feminist,communitarian, liberation and care ethics have since allstarted to alter the conceptual geography of bioethics[34]. With their foundations not in law and principlegoverned moral philosophy, but in the particularities ofindividuals and the singularity of beliefs, all these ap-proaches share a commitment to narrative truth andthe power of telling and listening. They share a realisa-tion that meaning in human life emerges not from rulesgiven, but from lived thick experience and that determi-nations of right and good by necessity arise from con-text, perspective, culture and time [35].

These approaches are furthermore all grounded in nar-rative orientated theory and practice ranging from literarystudies and liberation theology to human phenomenology.They also do not assume that patients must be protectedfrom their doctors, but locate them and their loved onesclose to those who care for them. Rather than emphasizingthe divides between doctors and patients, these ap-proaches are aimed at congress between human beingsall identified by culture, revealed in language, but alsomarked by suffering and limited by mortality [14, p.209]. While it is not a case that some are sick while othersare well, but that all will die, it is argued that to at leastprovisionally address the ethical conflicts of our day, theethicist will need the means to probe, honour, representand live in the face of temporality, singularity, subjectivityand contingency [36].

These developments remodelled the ethicist’s role tothat of a facilitator in an inherently social process of moralinquiry by which norms and problem solving plans of ac-tion that evoke shared and stable social commitments couldbe identified [37]. It also added the responsibility to createand keep moral reflective spaces in institutional life open,accessible and active where sound and shared processesof ethical deliberations and negotiation can take place.Expectations were especially high for the establishmentand maintaining of these moral reflective spaces in busy,bureaucratised acute care settings where ethics consulting,whether by committee or individual, should serve the endsof clarifying the responsibility and accountability of pa-tients, proxies and professionals without pre-empting,erasing or diluting that responsibility and accountability[31, p. 354–355].

The new approach also witnessed the enlivening of aprocess in which the ethicist is no longer regarded as avirtuoso of moral theory, but one among other partici-

pants in a process in which common moral concerns stayin focus, while differences are recognised and, ideally,mediated [31, p. 355]. With the concept current in thereflective social dialogue embodied in a myriad of aca-demic journals, books, newsletters, government publica-tions and public discussions, this development wasfurthermore accompanied by an urgent need for a histor-ically and sociologically informed understanding of thecommunity’s moral resources and the current state ofdiscussions within institutions and outside them, as wellas the employment of a narrative approach as the keyelement in all moral deliberations [38].

The reframing of bioethics through narrative thereforefocus attention on the process of interpretation, negotiation,construction and resolution required by any complex delib-eration, as well as on the roles of the deliberators. It fur-thermore typifies the ethicist within a moral space as akind of mediator, actively participating in a situation of po-tential conflict with the primary commitment to a fruitfulresolution. Walker also compares this profile with that ofan architect who does have technical expertise, but mustalso involve social, psychological and aesthetic elementsin order to relate structure and function in a workableand satisfying way [39].

5. Applications in the Southern African context

Southern Africa is facing various ethical challenges inhealth care. At patient care level, professional–patient rela-tionships and issues like confidentiality and trust, respectfor autonomy and informed consent are still regarded asethical dilemmas. At institutional level, issues like thesearch for equity, resource allocation and priority settingand the withholding and withdrawal of treatment are stillbeing debated. At national level decisions regarding theHIV/AIDS pandemic and the health budget remain highon the agenda. However, it is envisaged that a nationalcapacity to deal with these social and ethical dilemmascould among others be created by an interdisciplinary ap-proach in health care and by promoting a global healthethics [40].

In addressing these challenges, ethics consulting, in-spired by the Coherence and Common-Morality Theories,as well as by a narrative approach in bioethics and thework of philosophers such as Husserl [41], Sartre [42],Merleau-Ponty [43], Ricoeur [44], Levinas [45] and Hab-ermas [46], has already proved to be of great value topatients and Medical Aid Schemes in the Namibian con-text and also holds great potential for the official creationof moral reflective spaces for addressing the ethical de-mands faced by medical practitioners and medicalclinics.

With regard to the bio-ethical support of patients andMedical Aid Schemes and by utilising the therapeutic valueof information [47], substantial progress have already beenmade in the establishment of an engaged, contextual andcompassionate approach to health care in Namibia. Thiswas largely achieved by honouring the care ethics principleof attachment and by establishing and maintaining per-sonal contact with the patient, employment of a contextual

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approach in health care and by approaching the patientwithin his/her personal situation and through the imple-mentation of traits valued in intimate personal relationshipssuch as empathy, compassion, fidelity, discernment andlove [48].

It is also envisaged to extend these bio-ethical supportservices to more specialised services rendered not only topatients and Medical Aid Schemes, but also to health careprofessionals and medical clinics. With the aim of officiallycreating moral reflective spaces to address moral dilemmasas they present themselves from day to day and with re-spect to for instance the bio-ethical principle of respectfor patient autonomy, such services could include theacknowledgement of people’s rights to hold views, makechoices and take actions based on personal values and be-liefs, the pursuit of the bio-ethical obligation to build up ormaintain others’ capacities for autonomous choice andassistance to allay fears and other conditions that disruptautonomous actions, as well as the enhancement of under-standing and the capacity for autonomous choice and in-formed consent and assistance in the disclosure of healthcare information.

Concerning the concepts of beneficence and nonmalef-icence, bio-ethical support services could for instance in-clude the facilitation through consultation of conflictsbetween beneficence and autonomy, consultations onthe balancing of benefits, costs and risks in health care,deliberations on the value and quality of life, delibera-tions on end-of-life care and the protecting of incompe-tent patients by means of the facilitation throughconsultation of advanced directives and surrogate deci-sion making. Even the bio-ethical principle of justicecould be addressed through deliberations on the conceptof fair opportunities, consultations on the allocation ofhealth care resources and the rationing of scarce treat-ments to patients and support of all those harmed inthe execution of health care.

Also with regard to the ethical duties of doctors, den-tists and medical scientists according to the guidelines ofthe Health Professions Council of South Africa [49] whichinclude duties towards patients, colleagues and other pro-fessionals, health care professionals themselves, society,the medical profession and the environment, ethics con-sulting might be of assistance in addressing some of theseduties. While the ethical duties of doctors, dentists andmedical scientists to patients include aspects such as thepatient’s wellbeing, respect for patients, informed consent,patient confidentiality and patient participation in ownhealth care, the guidelines of the Health Professions Coun-cil of South Africa regards the effective communication ofinformation as the key to the fulfilling of this obligation.It furthermore states that appropriate steps should be ta-ken to determine what patients want and ought to knowconcerning their condition and treatment, that patientshave the right to information, that the amount of informa-tion might vary according to factors such as the nature ofthe condition, the complexity of the treatment, as well asthe wishes of the patient and that care should be takenin the provision of information to determine the influenceof a patient’s beliefs, culture, occupation, and other factorson reaching a decision.

The performance of these ethical duties implies adaunting and almost humanly impossible task to healthcare professionals due to time and economical con-straints, insufficient training and no existing codes forthe claiming of payment for ethical consultations in thecurrent health care remuneration systems. However, theguidelines of the Health Professions Council of South Afri-ca make provision for ethical tasks of health care profes-sionals to be delegated, provided that the person towhom it is delegated is suitably educated, trained andqualified, has sufficient knowledge of the proposed inves-tigation or treatment and understands the risks involvedand acts in accordance with the guidance in this part. Pro-posed solutions to these dilemmas are the creation of acompletely new ethics orientated discipline in clinicalcare aimed at supporting doctors, dentists and medicalscientists in performing their ethical duties towards pa-tients, the proper training of representatives of this newdiscipline to fulfil the task of supporting doctors, dentistsand medical scientists in performing their ethical dutiestowards patients and the introduction of representativesof this new discipline into the current health care teamto serve as delegates of doctors, dentists and medical sci-entists in performing their ethical duties towardspatients.

These proposed solutions are currently being re-searched at the Universities of Namibia and Stellenbosch.

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