Ethics consultants and ethics committees.

To address moral questions in patient care, hospitals and health care systems have enlisted the help of hospital ethicists, ethics committees, and ethics consultation services. Most physicians have not been trained in the concepts, skills, or language of clinical ethics, and few ethicists have been trained in clinical medicine, so neither group can fully identify, analyze, and resolve clinical ethical problems. Some ethics committees have undertaken clinical consultations themselves, but liability concerns and variable standards for membership hinder their efforts. An ethics consultation service comprising both physician-ethicists and nonphysician-ethicists brings complementary viewpoints to the management of particular cases. If they are to be effective consultants, however, nonphysician-ethicists need to be "clinicians": professionals who understand an individual patient's medical condition and personal situation well enough to help in managing the case. Ethics consultants and ethics committees may work together, but they have separate identities and distinct objectives: ethics consultants are responsible for patient care, while ethics committees are administrative bodies whose primary task is to advise in creating institutional policy.

The standard of care: a case report and ethical analysis.

Physicians increasingly allow their perceived legal responsibilities to displace their clinical judgment. Misunderstandings that surround the term "standard of care" have encouraged fears of liability and have led to the practice of defensive medicine. Physicians may consider the standard of care to be a technical or legal obligation, but an optimal standard would be one based on detailed knowledge of a patient's medical history and personal condition. It would include the physician's clinical judgment, which integrates specific technical and legal information with clinical experience in caring for patients. Occasionally, such judgment may conflict with the rulings of a court, which considers technical and legal information without the benefit of clinical judgment. Physicians must be prepared to be advocates for their patients, especially when legal proceedings are flawed or injurious. Systematic processes of examination and analysis, such as those used by ethics consultants, can help resolve questions about the standard of care.

Medical ethics in its American context. An historical survey.

Until the 1950's, moral aspects of clinical practice were handled in the USA within the medical profession. Over the last 30 years, these issues have become subjects for public debate, and have changed the public perception of medicine, in four steps. In the 1950's, moral theologians questioned the implications of medical technology at the edges of life. In the late '60s and '70s, these theologians were joined by political activists, whose zeal provoked a counter-reaction from physicians. In the late '70s and early '80s, the debate became largely theoretical; but in the late '80s it is once again "clinical", though respecting the rights of patients, their families, and other nonphysicians to participate in the relevant moral decisions. In part, these four steps reflect the special feature of American social history in the last 30 years; but in part they also had counterparts in Britain and elsewhere. Either way, the monopoly control over the ethics of medical practice exercised by doctors before the 1950s is unlikely to return.

Divided loyalties and ambiguous relationships.

The author argues that conflicts of obligation may, but need not, give rise to issues of divided loyalties. Given this, the question then becomes under what circumstances and conditions a simple internal conflict may escalate into the problem of divided loyalties or fiduciary ambiguities. After discussing conflicts of obligation, it is asserted that loyalties are divided only when the demands of the various relationships involved are irreconcilable. As this is an extreme, the major problematic issues fall, then, in between, on multiple loyalties and ambiguous loyalties. How and where multiple loyalties arise, and under what conditions they may become ambiguous loyalties lead to the recognition that moral problems are created by leaving in ambiguity things about the relationships involved that would be better sorted out. Finally the author looks at situations in which physicians are systematically exposed to irresoluble ambiguity.

KIE: Using examples from occupational medicine, sports medicine, and clinical trials, Toulmin discusses two of the moral conflicts he believes are common to all professions: conflicts of obligations and divisions of loyalties. Conflicts of obligation are inherent in all medical practice, the author argues, and cannot be resolved by balancing claims, but only by choosing one obligation over another. Conflicts of loyalty result when a physician's relationships "to two or more individuals, or to two or more institutions, become irreconcilable in ways that force him to choose between them." Along the spectrum of loyalties lie multiple loyalties and ambiguous loyalties, and the latter, if unresolved, create moral ambiguities. Toulmin concludes by identifying characteristics of contemporary American medicine that make it likely that the dilemmas of conflicts of obligation, divided loyalties, and ambiguous relationships will persist.