Research

Recent Publications
“Artificial Kidneys and the Emergence of Bioethics: The History of the ‘Outsiders’ in the Allocation of Hemodialysis,” forthcoming in Social History of Medicine.

“Ethics Consultation and Facilitated Consensus,” forthcoming in The Journal of Clinical Ethics.

Review of Meyers, A Practical Guide to Clinical Ethics Consulting (Lanham, MD: Rowman & Littlefield Publishers; 2007) in Cambridge Quarterly of Healthcare Ethics 17 (3) 2008: 347-350.

Work in Progress
Below are summaries of a couple of projects on which I am currently working.

1. I am currently completing a draft of a paper on an aspect of the Supreme Court's death-penalty jurisprudence that raises a number of difficult conceptual and normative problems. The Court has long required that inmates who develop mental illness on death row must be "competent for execution" before the death sentence may be carried out. The competence for execution (CFE) requirement generates wrenching moral dilemmas for prisoners, health care professionals, and the legal system. The prisoner must choose between foregoing anti-psychotic and other medications that would otherwise palliate the devastating symptoms of severe mental illness, thereby rendering him "incompetent" and "unexecutable," or taking medication that will provide relief but bring it about that he is "competent" and thus is killed. The prisoner's psychiatrist must decide whether she should continue to write a prescription where doing so is tantamount to an authorization to kill the patient, or to refuse such a course and deliberately exacerbate mental disease in the prisoner. My draft piece argues that the "competence" requirement is an unworkable conceptual muddle. But I want to expand this argument to consider the problems posed by "synthetically" creating competence by medicating death-row inmates. Do anti-psychotic medications actually effect a "cure," such that inmates who were formerly disordered now no longer are? Or does drug therapy merely "mask" the offender's psychoses? Is the resulting "competence" genuine or "artificial"? And what would such competing descriptions mean?

2. This is an abstract of a paper tentatively titled “Philosophy, Therapy, and Clinical Ethics.”

Philosophers have been engaged in the practice of clinical ethics consultation for several decades. The continued presence of philosophers in a practice increasingly populated by diverse health-care professionals raises fundamental questions about what philosophers are doing still engaged in this kind of work. 

It is my thesis that the distinctive contribution philosophers can make to clinical ethics comes, not in the clinical encounter itself, but in examining widely-held assumptions and beliefs that emerge from those clinical encounters—beliefs and assumptions that commonly lead to problems in the clinic. Thus, while I agree that philosophers can and do participate in clinical consultation, our most useful contributions are not so much in the practice of clinical ethics, but in what might be called its “meta-practice”: critical reflection upon the conceptual issues arising out of particular clinical situations.

The claim has sometimes been made that philosophers are uniquely qualified to be clinical ethicists. But the arguments for this are often not persuasive. Periodically, the claim surfaces that philosopher-ethicists can properly lay claim to a kind of expertise that makes them the best persons to provide clinical ethics consultation.[1] Meyers, for example, has recently argued that philosopher-ethicists qualify in an appropriate sense as moral experts who not only may but in some cases ought to offer specific recommendations as a consequence of their expertise in getting at the “right answer” (or at least closer to the right answer than others).[2] Without re-visiting the debate over whether moral experts exist or what exactly it would mean to be one, it seems unlikely that philosophers will be able to convince others in the clinic that they know better than the rest what outcome should obtain in a given case.  As philosophers, we may be skilled at precisely and cogently constructing a theoretical justification for some claim about what people ought to value or how they should act. But it is difficult to conclude from this that we know better than our interlocutors in the ICU what is best for this patient in these circumstances at this time.

The current widely-endorsed model of clinical ethics consultation calls for ethicists to be engaged as “facilitators” of deliberative reflection and consensus-building, or as a mediators pursuing “assisted negotiation” and conflict resolution.[3] But why think that philosophers (as opposed, e.g., to medical social workers or psychologists) are well positioned, or even adequately qualified by virtue of their training to undertake such tasks? Of course, philosophers trained as mediators, for example, could (and presumably do) perform in that role as well as any other professionals similarly prepared. But they are not so prepared qua philosophers.

What then can a philosopher-ethicist bring to the role of ethics consultant? What, if anything, is distinctively philosophical about what philosopher-ethicists do in the clinic? Can any such work count as “doing philosophy” in any meaningful sense?

The idea that philosophical training is central to the work of clinical ethics is often secured by the claim that philosophy produces mastery of a necessary skill set, consisting in a combination of conceptual discernment, theoretical knowledge, and logical acumen—the incisive marshalling of arguments, deft wielding of distinctions, and so on. It is clear that these abilities can be of great value; though again it is my view that proficiency at careful analysis and conceptual clarification are of greater value outside the clinic that within it. I recently participated in an ethics consultation concerning a conflict between the family members and the physicians of a patient with end-stage renal disease. The consultation meeting revealed that the family members held several beliefs—for example, about meaning of living with suffering—that could profitably be subjected to subsequent philosophical analysis and scrutiny. But such analysis was not the intended goal of the meeting. A philosopher-ethicist could, of course, invite all parties to an ethics consultation to articulate relevant beliefs and value-judgments and gently encourage them to reflect jointly upon them, thereby clarifying those aspects of their thinking. But the goal of such an encounter is not theoretical.

Philosopher-ethicists might be thought to be engaged in a process similar to so-called “philosophical counselors” or “practitioners” who help their clients with “problems of living” by teasing out and subjecting to scrutiny elements of their system of beliefs which are the source of frustration or dissatisfaction. Are these activities analogous? It seems not, for on the most straightforward level the clinical encounter (to use Richard Zaner’s phrase) between an ethics consultant and parties struggling (say) to identify appropriate treatment goals for a deteriorating, bed-bound patient is to simply to help the parties resolve their conflict; the purpose of ethics consultation is neither “therapy” for family members (e.g., helping them develop skills to cope with their suffering and loss), nor philosophical analysis (e.g., articulating and defending a satisfying account of the value of suffering in a fulfilled human life).

Many and deeper questions are raised by these reflections: Can philosophical activity ever be therapeutic? Are philosophers who serve as clinical ethicists philosophical practitioners? When a someone “does philosophy” in the familiar ways, by writing articles and books, presenting papers at conferences, or discussing and debating philosophical theories and positions with students in the classroom, is one “practicing” philosophy? Plainly, much more work remains to be done here. My aim in this paper is primarily to raise the issues.