Tolerance: Too Little for Clinical Ethics in a Pluralist Society?

"Virtually all Western societies embrace liberalism as a political and moral; it emphasizes individual rights and liberty, democracy, autonomy, limited government, consent, pluralism, and tolerance. Clinical ethics in these societies reflects those priorities. Human migration has made Western societies more diverse and expanded the plurality of values represented within them. As a consequence, clinical ethics consultants (CEC) have encountered cases which reflect a clash between the liberal values of contemporary medical ethics and non-liberal values of patients. Because CECs are steeped in liberalism, their default attitude toward the values outside of that tradition will be tolerance. This paper will argue that because tolerance implicitly contains a judgment of inferiority to other values, it is the wrong attitude for CECs to adopt towards parties whose fundamental values clash with medical ethics. In such cases, this attitude can disrespect to the holders of the values, endorse a consequentialist compromise of values, and leave medical professionals prone to moral distress. Agonism democracy is a political philosophy that accepts that values conflicts are inevitable, and there will be winners and losers from them. It aims to channel this conflict positively by promoting a process marked by openness to questioning fundamental values and genuine consideration of (even contrary) alternate values. As an alternative to tolerance, this paper will explore if cultivating an attitude of agonism can be a better disposition for CECs in such cases. It will use a case study to compare the results of the two approaches in cases of fundamental values clash. "

Provide Access to Information on Assisted Suicide for a Patient with a Diagnosis of Depression?

Assisted suicide (AS) is one of the most controversially discussed topics, both in bioethical academia and in clinical practice. This is especially true for psychiatric patients. In Switzerland, the organization of AS and patient accompaniment in the dying process is practiced by lay right-to-die societies (RTDS). Despite this demedicalization, healthcare professionals are increasingly encountering AS requests in their institutions and experiencing moral uncertainty. This led to a physician’s request for clinical ethics support when confronted with an elderly patient with depression asking for information on AS: When does “assistance” start and what am I supposed and willing to do? The following clinical case report discusses these ethical questions from the perspective of the clinical ethics consultants involved. By recounting and discussing this clinical ethics case, this article aims to illustrate the difficulties that arise in daily practice, the importance of guidance and support in view of controversy, the possibilities of finding pragmatic, acceptable solutions for all parties involved, and what clinical ethics consultation can contribute.

Retrieving the Moral in the Ethics of Maternal-Fetal Surgery

Open-uterine surgery to repair spina bifida, or ‘fetal surgery of open neural tube defects,’ has generated questions throughout its history—and continues to do so in a variety of contexts. As clinical ethics consultants who worked (Mark J. Bliton) and trained (Virginia L. Bartlett) at Vanderbilt University—where the first successful cases of open-uterine repair of spina bifida were carried out—we lived with these questions for nearly two decades. We worked with clinicians as they were developing and offering the procedure, with researchers in refining and studying the procedure, and with pregnant women and their partners as they considered whether to undergo the procedure. From this experience in the early studies at Vanderbilt, we learned that pregnant women and their partners approach the clinical uncertainty of such a risky procedure with a curious and unique combination of practicality, self-reflection, fear, and overwhelming hope. These early experiences were a major contributing factor to the inclusion of an ethics-focused interview in the informed consent process for the Management of Myelomeningocele Study (MOMS) trial study design.