What is Medical Ethics Consultation?

Veterans Health Administration, National Center for Ethics in Health Care, Ethical Boundaries in the Patient-Clinician Relationship: A Report by the National Ethics Committee of the Veterans Health Administration, Veterans Health Administration, Washington, D.C., 2003, at 1 [hereinafter cited as VHA National Ethics Committee].

Starr P. , The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: Basic Books, 1982):15.

Cavell S. , Must We Mean What We Say? (New York: Cambridge University Press, 1976): at 101.

“Technological advances in medicine have greatly enhanced the capacity of health care providers to prevent, detect, diagnose and treat disease; to rehabilitate those with physical or other handicaps, and to promote health….Unfortunately, they have also brought with them unprecedented problems concerning risk and benefit, costs and effectiveness, and ethical and legal implications for patients, clinicians, and society.” Reiser S. J. Anbar M. , “Introduction,” in Reiser S. J. Anbar M. , eds., The Machine at the Bedside (New York: Cambridge University Press, 1984): At xv.

Brint S. , In an Age of Experts: The Changing Roles of Professionals in Politics and Public Life (Princeton: Princeton University Press, 1994).

Kanoti G. A. Youngner S. J. , “Clinical Ethics Consultation,” Encyclopedia of Bioethics (New York: Macmillan, 1995): 404–409; Aulisio M. P. Arnold R. M. Youngner S. J. , “Health Care Ethics Consultation: Nature, Goals, and Competencies,” Annals of Internal Medicine 133, no. 1 (2000): 59–69; see also, Andre J. , Bioethics as Practice (Chapel Hill: University of North Carolina Press, 2002).

Pellegrino E. D. , “Bioethics as an Interdisciplinary Enterprise: Where Does Ethics Fit in the Mosaic of Disciplines?” in Carson R. A. Burns C. R. , eds., Philosophy of Medicine and Bioethics (Dordrecht, NL: Kluwer, 1997): 1–25, at 2.

Yeo M. , “Prolegomena to Any Future Code of Ethics for Bioethicists,” Cambridge Quarterly of Healthcare Ethics 2, no. 4 (1993): 403–415.

Spielman B. J. , Bioethics in Law (Totowa, NJ: Humana Press, 2006): At vii.

Eckenwiler L. A. Cohn F. G. , “Introduction,” in Eckenwiler L. A. Cohn F. A. , eds., The Ethics of Bioethics: Mapping the Moral Landscape (Baltimore: Johns Hopkins University Press, 2007): At xix.

“Instituting…a code [of ethics] has not been much on the ethics industry agenda. This is an incongruous omission in a guild whose bread and butter is the evaluation of codes of ethics. Codes were thought to have a place and in fact are now in place, not just for physicians and attorneys, but for engineers, policemen, businessmen, all kinds of counselors and therapists, and practitioners of some scholarly trades like cultural anthropology….It is anything but obvious why a code [of ethics] for applied ethicists would be less appropriate or functional than for any of these others.” Wertheimer R. , “Socratic Skepticism,” in Winker E. A. Coombs J. R. , eds., Applied Ethics: A Reader (Oxford, U.K.: Blackwell, 1993): 143–163, at 158; see also, Baker R. , “A History of Codes of Ethics for Bioethicists,” in Eckenwiler Cohn , supra note 10, at 24–40; Freedman B. , “Bringing Codes to Newcastle: Ethics for Clinical Ethicists,” in Hoffmaster B. Freedman B. Fraser G. , eds., Clinical Ethics: Theory and Practice (Clifton, NJ: Humana, 1989): At 125–139; Baker R. , “A Draft Model Aggregated Code of Ethics for Ethicists,” American Journal of Bioethics 5, no. 5 (September-October 2005): 33–41; Brody B. Dubler N. Blustein J. , “Bioethics Consultation in the Private Sector,” Hastings Center Report 32, no. 3 (May-June 2002): 14–20.

Writing about this “nascent profession” more than 10 years ago, George Kanoti and Stuart Youngner observed, “Despite growing interest in and practice of ethics consultation, important questions remain….Unlike traditional medical consultants, clinical ethics consultants are not subject to widely accepted standards and procedures for training, credentialing, maintaining accountability, charging fees, obtaining informed consent, or providing liability coverage.” See Kanoti Youngner , supra note 6, at 405; see also, Spielman B. J. , “Has Faith in Health Care Ethics Consultants Gone Too Far? Risks of an Unregulated Practice and a Model Act to Contain Them,” Marquette Law Review 85, no. 1 (2001): 161–221.

The description of medical ethicists used by a medical ethicist 25 years ago still holds true today: “They do not have a license to look and listen to doctors and patients. Their justification is a discipline of some sort that claims its methods and insights will somehow improve the quality of those activities.” Jonsen A. R. , “Watching the Doctor,” New England Journal of Medicine 308, no. 25 (1983): 1531–1535, at 1531–1532. “The people who began to write, teach, speak and otherwise do the work of bioethics were not professionally trained in it. They came from religion, medicine, philosophy, law, nursing, the social sciences and literature….Some stumbled into the territory having never sought it out….Some were professionally homeless. People who had spent five or ten years of their lives earning a doctorate emerged into a fiercely competitive academic world, in which the losers were not simply undistinguished, but unemployed. Some were tourists. A few have come to the field as hustlers. The field offers the opportunity to make a name or, if not quite a fortune, more money than in the usual academic life.” See Andre , supra note 6, at 28. (Emphasis added.)

Fletcher J. C. Hoffman D. E. , “Ethics Committees: Time to Experiment with Standards,” Annals of Internal Medicine 120, no. 4 (1994): 335–338. Portending doom is a technique commonly employed by professionals who wish to cultivate a relationship in which others are made to believe that they are and must remain dependent upon professionals for their expertise, thereby masking the extent to which professionals depend on others for their own livelihood. By pointing to and even describing a potential disaster, the professional…reduce[s] the client to a state of desperation in [response to which] the victim…pay[s] generously, cooperate[s] fully and express[es] undying loyalty to the knowledgeable patron who might save him [or her] from a threatening universe. The culture of professionalism tend to cultivate an atmosphere of constant crisis – emergency – in which practitioners both create…work for themselves and reinforce…their authority by intimidating [others]. Bledstein B. J. , The Culture of Professionalism (New York: W. W. Norton & Co., 1978): at 100.

See Starr , supra note 2, at 9–29.

“Only persons with certain sorts of licenses or roles or duties are allowed to observe the intimacies of the ‘doctor-patient relationship.’” See Jonsen , supra note 13, at 1531; see also, La Puma J. Priest E. R. , “Medical Staff Privileges for Ethics Consultants: An Institutional Model,” Quality Review Bulletin 18, no. 1 (January 1992): 17–20; Siegler M. , “Defining the Goals of Ethics Consultations: A Necessary Step for Improving Quality,” Quality Review Bulletin 18, no. 1 (January 1992): 15–16.

See Aulisio Arnold Youngner , supra note 6, at 66–67.

American Society for Bioethics and the Humanities, Core Competencies for Health Care Ethics Consultation: The Report of the American Society for Bioethics and Humanities (Glenview, IL: American Society for Bioethics Consultation, 1998) [hereinafter cited as ASBH]; see also, SHHV-SBC, Discussion Draft of the Task Force on Standards for Bioethics Consultation (undated document); see also, Post L. F. Blustein J. Dubler N. N. , Handbook for Healthcare Ethics Committees (Baltimore: Johns Hopkins University Press, 2007).

Compare Pellegrino E. D. , “Clinical Ethics Consultation: Some Reflections on the Report of the SHHV-SBC,” Journal of Clinical Ethics 10, no. 1 (1999): 5–12, with Ross J. W. , “The Task Force Report: Comprehensible Forest or Unknown Beetles?” Journal of Clinical Ethics 10, no. 1 (1999): 26–33; King N. M. P. , “Who Ate the Apple? A Commentary on the Core Competencies Report,” Healthcare Ethics Committee Forum 10, no. 2 (1999): 170–175, and Churchill L. R. , “Are We Professionals? A Critical Look at the Social Role of Bioethicists,” Daedalus 128, no. 4 (1999): 253–274. Pellegrino found the report “timely” and “welcome,” but also concluded that “it is long-winded, it sidesteps some of the thornier issues, it sacrifices clarity in the interests of inclusiveness, and it mutes differing opinions [in order] to preserve a conciliatory tone.” Pellegrino, id., at 5. According to King, “[T]he report does not successfully address the central challenge in the long-standing debate about ethics consultation – which is to describe the work of ethics consultation in such a way that only people with the requisite education can and should do it.” King, id., at 171. At the time, the task force said: “[A]t this time, the Task Force recommends that its report be used only for voluntary guidelines. The specification ‘at this time’ is not meant to imply that the Task Force contemplates mandatory guidelines at some later time. Rather, the specification is meant to signal no more than our assessment of the current state of knowledge and our recognition that this state is always evolving.” SHHV-SBC, id., at 5; ASBH , id., at 32.

Fox E. Myers S. Pearlman R. A. , “Ethics Consultation in United States Hospitals: A National Survey,” American Journal of Bioethics 7, no. 2 (February 2007): 13–25; Gordon E. J. , “A Better Way to Evaluate Clinical Ethics Consultations? An Ecological Approach,” American Journal of Bioethics 7, no. 2 (February 2007): 26–29; Zaner R. M. , “A Comment on Community Consultation,” American Journal of Bioethics 7, no. 2 (February 2007): 29–31; Fiester A. , “The Failure of the Consult Model: Why ‘Mediation’ Should Replace ‘Consultation,’” American Journal of Bioethics 7, no. 2 (February 2007): 31–32; Silberman J. Morrison W. Feudtner C. , “Pride and Prejudice: How Might Ethics Consultation Services Minimize Bias?” American Journal of Bioethics 7, no. 2 (February 2007): 32–34; Dubler N. N. Blustein J. , “Credentialing Ethics Consultants: An Invitation to Collaboration,” American Journal of Bioethics 7, no. 2 (February 2007): 35–37; Parsi K. Kuczewski M. G. , “Failure to Thrive: Can Education Save the Life of Ethics Consultation?” American Journal of Bioethics 7, no. 2 (February 2007): 37–39; Dudzinski D. M. , “Education to Dispel the Myth,” American Journal of Bioethics 7, no. 2 (February 2007): 39–40; Jotkowitz A. B. , “Ethics Consultation: Whose Ethics?” American Journal of Bioethics 7, no. 2 (February 2007): 41–42; Smith M. L. Weise K. L. , “The Goal of Ethics Consultation: Rejecting the Role of the ‘Ethics Police,’” American Journal of Bioethics 7, no. 2 (February 2007): 42–44; Scofield G. R. , “The War on Error,” American Journal of Bioethics 7, no. 2 (February 2007): 44–45; Ford P. J. Boissy A. R. , “Different Questions, Different Goals,” American Journal of Bioethics 7, no. 2 (February 2007): 46–47; Klitzman R. , “Additional Implications of a National Survey on Ethics Consultation in United States Hospitals,” American Journal of Bioethics 7, no. 2 (February 2007): 47–48; Spike J. P. , “Who's Guarding the Henhouse? Ramifications of the Fox Study,” American Journal of Bioethics 7, no. 2 (February 2007): 48–50.

“Although the prevalence of [ethics consultation services] in U.S. hospitals is quite high, there appear to be wide variations in practice, a lack of formal training, and few mechanisms for quality control. To ensure the quality and consistency of ethics consultation practices, we believe that there is a need for clear standards for ethics consultation practice, for educational resources to assist [ethics consultation services] in implementing those standards, and for tools to determine whether those standards are being met.” See Fox Myers Pearlman , id., at 19. “[T]he ethics consultation system we have in place in the United States is not working.” See Fiester , id., at 32. “What is to be done? If the field of clinical ethics consultation is to legitimately be considered a ‘profession’ and not merely an assortment of individuals with varying degrees of expertise, knowledge, and supervision, standards have to be developed.” See Dubler Blustein , id., at 35.

“Let us take this sobering study to heart and start to guard the henhouse rather than continue to run around clucking that the sky is falling.” See Spike , supra note 20, at 50; see also, Fox E. Myers S. Pearlman R. A. , “Response to Open Peer Commentaries on Ethics Consultation in U.S. Hospitals: A National Survey,” American Journal of Bioethics 7, no. 2 (February 2007): W1–W3.

“[I]t is more necessary than ever today…to read well…, to read slowly, deeply, looking cautiously before and aft, with doors left open, with delicate eyes and fingers.” Nietzsche F. , Daybreak (New York: Cambridge University Press, 1997): At 5 (emphasis in original); see also, Ricoeur P. , Freud and Philosophy: An Essay on Interpretation (New Haven: Yale University Press, 1970): 20–36; see also, Burt R. A. , “The Uses of Psychoanalysis in Law: The Force of Jay Katz's Example,” Yale Journal of Health Policy, Law, and Ethics 6, no. 2 (2006): 401–413; Bosk C. , “A More Skeptical Bioethics,” Yale Journal of Health Policy, Law, and Ethics 6, no. 2 (2006): 425–429; Meissner W. W. , The Ethical Dimension of Psychoanalysis: A Dialogue (Albany: SUNY Press, 2003).

See VHA National Ethics Committee, supra note 1, at 1.

Aulisio M. , “Minutes” (final version), ShHV-SBC Task Force on Standards for Bioethics Consultation, Meeting One, May 24–26, 1996 (July 18, 1996): At 4. (Emphasis added.)

Burgess M. Bereza E. Campion B. , “Feeder Disciplines: The Education and Training of Health Care Ethics Consultants,” in Baylis F. , ed., The Health Care Ethics Consultant (Totowa, NJ: Humana, 1994): 63–108.

Mizrachi N. Shuval J. T. , “Between Formal and Enacted Policy: Changing the Contours of Boundaries,” Social Science & Medicine 60, no. 7 (2005): 1649–1660; see also, Gieryn T. F. , “Boundary-Work and the Demarcation of Science from Non-science: Strains and Interests in Professional Ideologies of Scientists,” American Sociological Review 48, no. 6 (1983): 781–795; Gieryn T. F. , Cultural Boundaries of Science: Credibility on the Line (Chicago: University of Chicago Press, 1999): 1–35, 336–362; Larson M. S. , The Rise of Professionalism: A Sociological Analysis (Berkeley: University of California, 1977): 41–51; Lamont M. Molnar V. , “The Study of Boundaries in the Social Sciences,” American Review of Sociology 28 (2002): 167–195; Abbott A. , “Things of Boundaries,” Social Research 62, no. 4 (1995): 857–882; Abbott A. , The System of Professions (Chicago: University of Chicago Press, 1988).

Committee on Ethics of the American College of Obstetricians and Gynecologists, “Seeking and Giving Consultation,” Obstetrics and Gynecology 109, no. 5 (2007): 1255–1260; Salerno S. M. Hurst F. P. Halvorson S. , “Principles of Effective Consultation: An Update for the 21st Century Consultant,” Archives of Internal Medicine 167, no. 3 (2007): 271–275; Goldman L. Lee T. Rudd P. , “Ten Commandments for Effective Consultations,” Archives of Internal Medicine 143, no. 9 (1983): 1753–1755; Cohn S. L. , “The Role of the Medical Consultant,” Medical Clinics of North America 87, no. 1 (2003): 1–6; Emanuel L. L. Richter J. , “The Consultant and the Physician-Patient Relationship: A Trilateral Deliberative Model,” Archives of Internal Medicine 154, no. 16 (1994): 1785–1790; Pasnau R. , “Ten Commandments of Medical Etiquette for Psychiatrists,” Psychosomatics 26, no. 2 (1985): 128–132; see also, Frader J. E. , “Political and Interpersonal Aspects of Ethics Consultation,” Theoretical Medicine 13, no. 1 (1992): 31–44.

Cummins D. , “The Professional Status of Bioethics Consultation,” Theoretical Medicine & Bioethics 23, no. 1 (2002): 19–43; see also, Ozar D. T. , “Profession and Professional Ethics,” in Encyclopedia of Bioethics, supra note 6, at 2103–2112; Agich G. J. , “Professionalism and Ethics in Health Care,” Journal of Medicine and Philosophy 5, no. 3 (1980): 186–199; Churchill L. R. , “The Professionalization of Ethics: Some Implications for Accountability in Medicine,” Soundings 60, no. 1 (1977): 40–53.

Miller F. G. Fins J. J. Bachetta M. D. , “Clinical Pragmatism: John Dewey and Clinical Ethics,” Journal of Contemporary Health Law & Policy 13, no. 1 (1996): 27–51, at 28.

See Kanoti Youngner , supra note 6, at 404.

La Puma J. Toulmin S. , “Ethics Committees and Ethics Consultants,” Archives of Internal Medicine 149, no. 5 (1989): 1109–1112, at 1109.

Agich G. J. , “Clinical Ethics: A Role Theoretic Look,” Social Science & Medicine 30, no. 4 (1990): 389–399, at 392; see also, Agich G. J. , “Roles and Responsibilities: Theoretical Issues in the Definition of Consultation-Liaison Psychiatry,” Journal of Medicine & Philosophy 10, no. 4 (1985): 105–126.

Winslade W. J. , “Ethics Consultation: Cases in Context,” Albany Law Review 57, no. 3 (1992): 679–691, at 682. According to Andre, “[B]ioethics is something like a practice[, whose] goals may be thought of as a loose bundle (keeping moral space open, designing solutions, promoting a better public discourse) or. as a mutual engagement in moral growth.” See Andre , supra note 6, at 102.

Capron A. M. Michel V. , “Law and Bioethics,” Loyola of Los Angeles Law Review 27, no. 1 (1993): 25–40, at 30.

Fox M. D. McGee G. Caplan A. , “Paradigms for Clinical Ethics Consultation Practice,” Cambridge Quarterly of Healthcare Ethics 7, no. 3 (1998): 308–314, at 308.

“What is a bioethicist? We might suppose that we can define this role…[but] this keeps changing.” Wikler D. , “Bioethics and Social Responsibility,” Bioethics 11, nos. 3–4 (1997): 185–92, at 185. “People do not know who we are; indeed, we may not know who we are ourselves.” Jonsen A. R. , “Beating Up Bioethics,” Hastings Center Report 31, no. 3 (May 2001): 40–45, at 44; see also, Agich G. J. , “What Kind of Doing Is Clinical Ethics?” Theoretical Medicine 26, no. 1 (2005): 7–24.

See SHHV-SBC, supra note 18, at 3.

See Aulisio Arnold Youngner , supra note 6, at 59.

La Puma J. Schiedermayer D. , Ethics Consultation: A Practical Guide (Boston: Jones & Bartlett, 1994): At 53–55.

Veterans Health Administration National Center for Ethics, Ethics Consultation: Responding to Ethics Concerns in Health Care, VHA National Center for Ethics, Washington, D.C., 2007, at 3.

Id., at 44.

Id., at 45.

Id., at 44.

Agich G. J. , “Authority in Ethics Consultation,” Journal of Law, Medicine & Ethics 23, no. 3 (1995): 273–283.

American Society for Bioethics and the Humanities Clinical Ethics Task Force, Improving Competence in Clinical Ethics Consultation: A Learner's Guide, undated draft, at 1 [hereinafter cited as ASBH Clinical Ethics Task Force].

Id., at 2.

Id., at 1, n. 1.

“Facts are just what there aren't, there are only interpretations. My main proposition: There are no moral phenomena, there is only a moral interpretation of these phenomena.” Nietzsche F. , Writings from the Late Notebooks (New York: Cambridge University Press, 2003): At 139, 94. (Emphasis in original.) “There are no moral facts whatever….Morality is only an interpretation of certain phenomena.” Nietzsche F. , Twilight of the Idols (New York: Penguin Books, 1990): At 66. (Emphasis in original.)

Meyers C. , A Practical Guide to Clinical Ethics Consulting: Expertise, Ethos, and Power (Lanham, MD: Rowman & Littlefield Publishers, Inc., 2007): at 11.

“The clinical ethicist's role has been the subject of extensive debate in the bioethics literature, but one point that everyone accepts is that the specifics of the consultant's role are as varied as are the people engaged in the work.” Meyers C. , “Clinical Ethics Consulting and Conflict of Interest: Structurally Intertwined,” Hastings Center Report 37, no. 2 (March-April 2007): 32–40.

“Trimming the Fat,” The Economist (Special Survey) 3, March 22, 1997.

Hoffmaster B. , “The Form and Limits of Medical Ethics,” Social Science and Medicine 39, no. 9 (1994): 1155–1164, at 1162. Hoffmaster quickly adds, “Much of the time in practical ethics they are objectionable as well, largely because they serve to cloud responsibility.” Id. Indeed, “vagueness may be used as a vehicle for the exercise of control or for the evasion of control.” Schön D. A. , The Reflective Practitioner: How Professionals Think in Action (New York: Basic Books, 1983): At 305. “Rather than comfort…deliberate vagueness creates confusion, anxiety and unrealistic expectations.” See Post Blustein Dubler , supra note 18, at 55. As one medical ethicist has observed, “[I]t is important for professionals to promote their authority and establish their role as indispensable by mystifying their particular knowledge and skills, and by fostering the dependence of others on their services.” Sherwin S. , “Certification of Health Care Ethics Consultants: Advantages and Disadvantages,” in Baylis F. E. , ed., The Health Care Ethics Consultant (Totowa, NJ: Humana Press, 1994): 11–24, at 18; see also, Cummins, supra note 29, at 23–24. Depending on the circumstances, uncertainty and ambiguity, therefore, can be the ethicist's friend or the ethicist's foe, an insight that is sociologically and psychologically significant. See, for example, Nilson L. B. , “An Application of the Occupational ‘Uncertainty Principle’ to the Professions,” Social Problems 26, no. 5 (1979): 570–581; Light D. , “Uncertainty and Control in Professional Training,” Journal of Health and Social Behavior 20, no. 4 (1979): 310–322; Horowitz M. J. , “Sliding Meanings: A Defense against Threat in Narcissistic Personalities,” International Journal of Psychoanalytic Psychotherapy 4 (1975): 167–180; Maldonado J. L. , “On Ambiguity, Confusion and the Ego Ideal,” International Journal of Psycho-Analysis 74, pt. 1 (1993): 93–100; Katz J. , The Silent World of Doctor and Patient (Baltimore: Johns Hopkins University Press, 2002): 165–206; Katz J. , “Why Physicians Don't Disclose Uncertainty,” Hastings Center Report 14, no. 1 (February 1984): 35–44; Scofield G. , “Why Medical Ethicists Don't (and Won't) Share Uncertainty,” in Rubin S. Zoloth L. , eds., Margin of Error: The Ethics of Mistakes in the Practice of Medicine (Hagerstown, MD: University Press Group, 2000): 333–342.

See Cavell , supra note 3, at 126. Not that there's anything wrong with that.

Every profound philosophical vision can have the shape of madness. The world is illusion; I can doubt everything, that

I am awake, that there is an external world; the mind takes isolated bits of experience and associates them into a world; each thing and every person is a metaphysical enclosure, and no two can ever communicate directly, or so much as perceive one another; time, space, relations between things, are unreal….It sometimes looks as if philosophy had designs on us; of as if it alone has gone crazy, and wants company.

Goode W. J. , “Encroachment, Charlatanism, and the Emerging Profession: Psychology, Sociology and Medicine,” American Sociological Review 25, no. 6 (1960): 902–914; Pettigrew A. M. , “Occupational Specialization as an Emergent Process,” Sociology Review 21, no. 2 (1973): 255–278; Baer W. C. , “Expertise and Professional Standards,” Work & Occupations 13, no. 4 (1986): 532–552; see Abbott , supra note 27, at 38–113, 280–314; Reed M. I. , “Expert Power and Control in Late Modernity: An Empirical View and Theoretical Synthesis,” Organization Studies 17, no. 4 (1996): 573–597.

See VHA National Ethics Committee, supra note 1, at 2. “It is incumbent on the individual ethics consultant to recognize her strengths and limitations, and to get help when needed.” See Post Blustein Dubler , Handbook, supra note 18, at 141.

See Aulisio Arnold Youngner , supra note 6, at 61.

Id., at 60–61.

See, for example, McGee G. , “Therapeutic Clinical Ethics,” Health Care Ethics Committee Forum 9, no. 3 (1997): 276–279; Goold S. D. , “Is Distance Critical for Clinical Ethicists? – A Reply to Glenn McGee,” Health Care Ethics Committee Forum 9, no. 3 (1997): 280–283; Churchill L. R. Cross A. W. , “Moralist, Technician, Sophist, Teacher/Learner: Reflections on the Ethicist in the Clinical Setting,” Theoretical Medicine 7, no. 1 (1986): 3–12; Glover J. Ozar D. T. Thomasma D. C. , “Teaching Ethics on Rounds: The Ethicist as Teacher, Consultant, Decisionmaker,” Theoretical Medicine 7, no. 1 (1986): 13–32; Walker M. U. , “Keeping Moral Spaces Open: New Images of Ethics Consultation,” Hastings Center Report 23, no. 2 (March-April 1993): 33–40; Self D. Skeel J. , “Potential Roles of the Medical Ethicist in the Clinical Setting,” Theoretical Medicine 7, no. 1 (1986): 33–39; Aulisio M. P. Arnold R. M. Youngner S. J. , “Can There be Educational and Training Standards for Those Conducting Health Care Ethics Consultation?” in Thomasma D. Monagle J. , eds., Health Care Ethics: Critical Issues for the 21st Century (Gaithersburg, MD: Aspen Publishers, 1998): 484–496.

See SHHV-SBC, supra note 18, at 7–8.

See ASBH, supra note 18, at 5–6; Aulisio Arnold Youngner , supra note 6, at 60–61.

Id. ( Aulisio Arnold Youngner ), at 61.

ASBH, supra note 18, at 5, n. 9. In its entirety, the note reads as follows:

We are not claiming that anyone does ethics consultation in either of these two ways. Rather, we are characterizing two extreme approaches for illustrative purposes. Most approaches fall between these two extremes, but tendencies toward one or the other can be found in the literature. Id. (Reference omitted.) Similarly footnoted explanatory disclaimers are a recurrent feature. See, Aulisio Arnold Youngner , “Educational and Training Standards,” supra note 63, at 489–490, wherein it is stated, first of the “authoritarian” model, then of the “pure” facilitation model:

We again want to emphasize that we are exaggerating features of views that can be found in the literature because the caricatures nake clearer how different models of HCEC [health care ethics consultation] have different implications for skills, knowledge, and so forth.

We want again to underscore that we are intentionally exaggerating the facilitation feature of the model [in order] to emphasize how different models will have different implications for the matter under discussion.

Id., at 496, n. 21 and n. 22. (Emphasis in original.) See also, Aulisio M. P. , “Meeting the Need: Ethics Consultation in Health Care Today,” in Aulisio M. P. Arnold R. M. Youngner S. J. , eds., Ethics Consultation: From Theory to Practice (Baltimore: Johns Hopkins University Press, 2003): 3–22, at 10–13, wherein it is stated of the “authoritarian” and the “pure” facilitation models:

It is important to note that I am deliberately characterizing extreme approaches for the purpose of contrast. I am not offering a description of particular approaches advocated in the literature. (Emphasis added.)

Id., at 21, n. 14. Suffice it to say that using footnotes to control or limit the manner in which readers may misread, misunderstand, or misinterpret a text, especially a text which is likely to be contested and controversial, is a hermeneutically curious way to go about producing a text, especially when these disclaimers and explanations do not appear in the “position paper” that the task force saw fit to have published in the Annals of Internal Medicine. See, Aulisio Arnold Youngner , supra note 6, at 60–61. That some members of the task force repeatedly, if not consistently, telling others how not to read the report means both that the report can and is being read in more ways than one, for which result the task force members themselves are, to a significant extent, responsible. For examples of such problematic readings, see, Banerjee D. Kuschner W. G. , “Principles and Procedures of Medical Ethics Case Consultation,” British Journal of Hospital Medicine 68, no. 3 (2007): 140–144, at 141;

Fox E. Daskal F. C. Stocking C. , “Ethics Consultants' Recommendations for Life-Prolonging Treatment of Patients in a Persistent Vegetative State,” Journal of Clinical Ethics 18, no. 1 (2007): 64–71, at 69–70.

See ASBH, supra note 18, at 5; Aulisio Arnold Youngner , supra note 6, at 60.

Sontag D. N. , “What is Wrong with “Ethics for Sale”? An Analysis of the Many Issues that Complicate the Debate about Conflicts of Interest in Bioethics,” Journal of Law, Medicine & Ethics 35, no. 1 (2007): 175–186, at 175.

Scully J. L. , “Drawing a Line: Situating Moral Boundaries in Genetic Medicine,” Bioethics 15, no. 3 (2001): 189–204, at 190.

See, for example, Nadelson C. Notman M. T. , “Boundaries in the Doctor-Patient Relationship,” Theoretical Medicine 23, no. 3 (2002): 191–201; Frank A. W. , “The Painter and the Cameraman: Boundaries in Clinical Relationships,” Theoretical Medicine 23, no. 3 (2002): 219–232; Coombs G. Freedman J. , “Relationships, Not Boundaries,” Theoretical Medicine 23, no. 3 (2002): 203–217.

Hilliard B. , “The Politics of Palliative Care and the Ethical Boundaries of Medicine: Gonzales v. Oregon as a Cautionary Tale,” Journal of Law, Medicine & Ethics 35, no. 1 (2007): 158–174; Szalados J. F. , “Discontinuation of Mechnical Ventilation at End-of-Life: The Ethical and Legal Boundaries of Physician Conduct in the Termination of Life Support,” Critical Care Clinics 23, no. 2 (2007): 317–337; Bliton M. J. Finder Stuart G. , “Traversing Boundaries: Clinical Ethics, Moral Experience, and the Withdrawal of Life Supports,” Theoretical Medicine 23, no. 3 (2002): 233–258.

“In much advocacy work, the boundary between research and therapy is fuzzy.” Dresser R. , When Science Offers Salvation: Patient Advocacy & Research Ethics (New York: Oxford University Press, 2001): at 9.

Lynn J. Baily M. A. Bottrell M. , “The Ethics of Using Quality Improvement Methods in Health Care,” Annals of Internal Medicine 146, no. 9 (2007): 666–672; Grady C. , “Quality Improvement and Ethical Oversight,” Annals of Internal Medicine 146, no. 9 (2007): 677–678.

Rosenberg C. E. , “Contested Boundaries: Psychiatry, Disease, and Diagnosis,” Perspectives in Biology & Medicine 49, no. 3 (2006): 407–424; Martinez R. , “The Nature of Illness Experience: A Course on Boundaries,” Theoretical Medicine 23, no. 3 (2002): 259–269.

Wainwright S. P. Williams C. , “Ethical Boundary-Work in the Embryonic Stem Cell Laboratory,” Sociology of Health & Illness 28, no. 6 (2006): 732–748. “Medical scientists equivocate on the exact beginning and ending of life (as loved ones, ethicists, religious activists, feminists, prospective organdonor recipients press their cases). See Gieryn (Cultural Boundaries), supra note 27, at 2–3. (Emphasis added).

“Discussions of…boundaries, not surprisingly, comprise a large portion of the bioethics literature (e.g. explorations of informed consent, autonomy, confidentiality, privacy, resource allocation, and conscientious objection).” See ASBH, supra note 18, at 4.

See, for example, Gabbard G. O. Lester E. P. , Boundaries and Boundary Violations in Psychoanalysis (New York: Basic Books, 1995); Peterson M. R. , At Personal Risk: Boundary Violations in Professional-Client Relationships (New York: W. W. Norton & Company, 1992); Epstein R. S. , Keeping Boundaries: Maintaining Safety and Integrity in the Psychotherapeutic Process (Washington, D.C.: American Psychiatric Press, 1994).

Jones J. W. McCullough L. B. , “Ethics of Unprofessional Behavior that Disrupts: Crossing the Line,” Journal of Vascular Surgery 45, no. 2 (2007): 433–455; National Ethics Committee of the Veterans Health Administration, Ethical Boundaries in the Patient-Clinician Relationship , National Center for Ethics in Health Care, Washington, D.C., July 2003; Preisman R. C. Steinberg M. D. Rummans T. A. , “An Annotated Bibliography for Ethics Training in Consultation-Liaison Psychiatry,” Psychosomatics 40, no. 5 (1999): 369–379; Farber N. J. Novack D. H. Silverstein J. , “Physicians with Patients Who Transgress Boundaries,” Journal of General Internal Medicine 15, no. 11 (2000): 770–775; Baylis F. , “Therapist-Patient Sexual Contact: A Nonconsensual, Inherently Harmful Activity,” Canadian Journal of Psychiatry 38, no. 7 (1993): 502–506; Yarborough M. , “The Reluctant Retained Witness: Alleged Sexual Misconduct in the Doctor/Patient Relationship,” Journal of Medicine and Philosophy 22, no. 4 (1997): 345–364; Martinez R. , “Professionalism and Boundaries,” Theoretical Medicine 23, no. 3 (2002): 185–189.

Gutheil T. G. Gabbard G. O. , “Misuses and Misunderstandings of Boundary Theory in Clinical and Regulatory Settings,” American Journal of Psychiatry 155, no. 3 (1998): 409–414, at 410; see also, Gutheil T. G. Gabbard G. O. , “The Concept of Boundaries in Clinical Practice: Theoretical and Risk Management Dimensions,” American Journal of Psychiatry 150, no. 2 (1993): 189–190.

“Role boundaries constitute the essential boundary issue. To conceptualize this entity, one might ask, ‘Is this what a therapist does?’” See id. (“Concept of Boundaries”), supra note 89, at 190. According to Agich George , “The concept of a social role serves an important, though problematic, function in ethics. Roles define not only moral duties for individuals, but also the kinds of action morally permissible for individuals to perform in particular social settings…. In other words, significant social roles define responsibility for the role agent which are qualitatively different from the obligations of moral agents generally.” See Agich (Roles and Responsibilities), supra note 33, at 105. According to Aulisio, Arnold and Youngner: [I]f standards are to be set for a given activity, it will be important to identify what the activity is supposed to be and, further, what it is supposed to achieve….Underlying any intuition one might have regarding the proper goals of an activity is, at the very least, an implicit concept of the nature of that activity. It is the concept of what that activity is supposed to be that allows one to identify certain goals as appropriate to it. To use a humorous example, imagine that your colleague professed that one of his goals in going to the dentist was to have a bunion removed from his foot. With the possible exception of a colleague who was constantly, and quite literally, putting his foot in his mouth, we would be sure that your colleague was confused about the nature of dentistry.

Aulisio Arnold Youngner , (“Educational and Training Standards”), supra note 63, at 487, 488.

See Gutheil Gabbard (“Concept of Boundaries”), supra note 80, at 190.

“Attempts to define the boundaries of the therapeutic relationship yield limited results, because codifying all aspects of human interaction is impossible….This leaves us with the challenge of distinguishing between boundary crossings that further the treatment and those that damage it.” Waldinger R. J. , “Boundary Crossings and Boundary Violations: Thoughts on Navigating a Slippery Slope,” Harvard Review of Psychiatry 2, no. 4 (1994): 225–227, at 225; see also, Glass L. L. , “The Gray Areas of Boundary Crossings and Violations,” American Journal of Psychotherapy 57, no. 4 (2003): 429–444; Radden J. , “Boundary Violation Ethics: Some Conceptual Clarifications,” Journal of the American Academy of Psychiatry & Law 29, no. 3 (2001): 319–326.

See Gutheil Gabbard (“Misuses and Misunderstandings”), supra note 80, at 410; see also, Gutheil T. G. , “Boundary Issues and Personality Disorders,” Journal of Psychiatric Practice 11, no. 2 (2005): 88–96.

Gutheil Gabbard (“Misuses and Misunderstandings”), supra, note 80, at 413; see also, Psychopathology Committee of the Group for the Advancement of Psychiatry, “Reexamination of Therapist Self-Disclosure,” Psychiatric Services 52, no. 11 (2001): 1489–1493, at 1490–1491.

Gruenberg P. B. , “Boundary Violations,” in American Psychiatric Association, Ethics Primer of the American Psychiatric Association (Washington, D.C.: APA, 2001): 1–9, at 5.

See, Katz G. A. , “Where the Action Is: The Enacted Dimension of Analytic Process,” Journal of the American Psychoanalytic Association 46, no. 4 (1998): 1129–1167; Hirsch I. , “The Concept of Enactment and Theoretical Convergence,” Psychoanalytic Quarterly 67, no. 1 (1998): 78–101; Renik O. , “Countertransference Enactment and the Psychoanalytic Process,” in Horowitz M. J. Kernberg O. F. Weinshel E. M. , eds., Psychicstructure and Psychic Change: Essays in Honor of Robert S. Wallerstein (Madison, CT: International University Press, 1993): 137–160.

Gabbard G. O. Nadelson C. , “Professional Boundaries in the Physician-patient Relationship,” JAMA 273, no. 14 (1995): 1445–1449.

Gula R. M. , Ethics in Pastoral Ministry (Mahwah, NJ: Paulist Press, 1996).

Institute of Medicine, Assessing Genetic Risks (Washington, D. C.: National Academies Press, 1994): at 148–184.

Brendel D. H. Chu J. Radden J. , “The Price of a Gift: An Approach to Receiving Gifts from Patients in Psychiatric Practice,” Harvard Review of Psychiatry 15, no. 2 (2007): 43–51.

Gabbard G. O. , ed., Sexual Exploitation in Professional Relationships (Washington, D.C.: American Psychiatric Press, 1989); Celenza A. Gabbard G. O. , “Analysts Who Commit Sexual Boundary Violations: A Lost Cause?” Journal of the American Psychoanalytic Association 51, no. 2 (2003): 617–636; Gabbard G. O. , “Lessons to be Learned from the Study of Sexual Boundary Violations,” American Journal of Psychotherapy 50, no. 3 (1996): 311–322; Norris D. M. Gutheil T. G. Strassburger L. H. , “This Couldn't Happen to Me: Boundary Problems and Sexual Misconduct in the Psychotherapy Relationship,” Psychiatric Services 54, no. 4 (2003): 517–522; Galletly C. A. , “Crossing Professional Boundaries in Medicine: The Slippery Slope to Patient Sexual Exploitation,” Medical Journal of Australia 181, no. 7 (2004): 380–383. As has been observed, Sexual intrusions command attention because of their inherent drama and destructiveness, but they often represent the culmination of a series of mundane but nevertheless insidious distortions of the therapeutic relationship[.]… Although the media have given special emphasis to sexual relations between psychiatrists and their patients, data suggest that such relations occur across all medical specialties and that medical students [as well as others] remain naive about the effects of all manner of nonprofessional contact between doctors and patients. Duckworth K. S. Kahn M. W. Gutheil T. G. , “Roles, Quandaries, and Remedies: Teaching Professional Boundaries to Medical Students,” Harvard Review of Psychiatry 1, no. 5 (1994): 266–270, at 266. (Emphasis in original.)

The defining characteristic of the authoritarian approach to ethics consultation is its emphasis on consultants as the primary moral decision makers….By misplacing moral decision-making authority, this approach fails to recognize the appropriate boundaries of ethics consultation, as [those are] fundamentally established by the rights of individuals in the United States….It fails to open lines of communication between the family and the team in order to work toward a consensus that falls within the boundaries set by societal values, law, and institutional policy.

See Aulisio Arnold Youngner , supra note 6, at 59.

Post S. G. Pulchaski C. M. Larson D. B. , “Physicians and Patient Spirituality: Professional Boundaries, Competency and Ethics,” Annals of Internal Medicine 132, no. 7 (2000): 578–583; Kuczewski M. G. , “Talking about Spirituality in the Clinical Setting: Can Being Professional Require Being Personal?” American Journal of Bioethics 7, no. 7 (July 2007): 4–11; see also, Meisel A. , “A ‘Dignitary Tort’ as a Bridge between the Idea of Informed Consent and the Law of Informed Consent,” Law, Medicine & Health Care 16, nos. 3–4 (1988): 210–218. “While part of the concern for human beings contained in our culture relates to protecting [them] personally, part [of the concern for human beings] also relates to the respect which is deemed proper for the ‘non-physical’ aspects of [humanity], such as [the] power of thought.” Katz J. Capron A. M. , Catastrophic Diseases: Who Decides What? (New Brunswick, NJ: Transaction Books, 1982): 83.

See ASBH, supra note 18, at 4. (Emphasis added.) In the report on the report, it is stated: [I]ndividual persons and communities in our society have the right to pursue different conceptions of the ‘good life’ and to live by their own values. This right does not disappear merely because one becomes a health professional or because one falls ill and becomes a patient. An appropriate approach to ethics consultation must be sensitive to the pluralistic health care setting in which consultation is provided and consistent with the societal value of autonomy.

See Aulisio Arnold Youngner , supra note 6, at 60.

“The sole goal of the pure facilitation approach is to forge consensus among involved parties….By placing too much emphasis on facilitating consensus, consultants risk forging a consensus that falls outside acceptable boundaries.” Id. Edmund G. Howe noted that there was something inherently problematic about the ethics facilitation approach, in that it might not end up differing all that much from the authoritarian approach. Howe E. G. , “Ethics Consultants: Could They Do Better?” Journal of Clinical Ethics 10, no. 1 (1999): 13–25, at 15–21. Although three members of the task force believed that “Howe's caveats should serve as a wise caution to ethics consultants to take steps to guard against the dangers of subtle, unintended, or merely perceived abuses of power,” they concluded that, if one took his critique to its logical conclusion, then almost anything would be disqualified from being what the ethics facilitation model aspires and claims to be. Aulisio M. Arnold R. M. Youngner S. J. , “Moving the Conversation Forward,” Journal of Clinical Ethics 10, no. 1 (1999): 49–56, at 51.

Dr. William Nelson presentation at the National Ethics Teleconference, Core Competencies for Ethics Consultation, National Center for Ethics in Health Care, May 22, 2002, at 2–3

“To understand fully the business of drawing moral lines, we need to know both where the lines have been placed…and what forces have put them there. Bioethicists have so far been rather good at answering the first question, but less skilled at even noticing that the second question exists.” See Scully , supra note 70, at 199.

G. O. Gabbard, M. L. Peltz, and COPE Study Group on Boundary Violations, “Speaking the Unspeakable: Institutional Reactions to Boundary Violations by Training Analysts,” Journal of the American Psychoanalytic Association 49, no. 2 (2001): 659–673; Blos P. , “Silence: A Clinical Exploration,” Psychoanalytic Quarterly 41, no. 3 (1972): 348–363; Kurtz S. A. , “On Silence,” Psychoanalytic Review 71, no. 2 (1984): 227–245; Meissner W. W. , “On Analytic Listening,” Psychoanalytic Quarterly 69, no. 2 (2000): 317–367, at 347–351; Gans J. S. Counselman E. F. , “Silence in Group Psychotherapy: A Powerful Communication,” International Journal of Group Psychotherapy 50, no. 1 (2000): 71–86; Millenson M. L. , “The Silence,” Health Affairs 22, no. 2 (2003): 103–112; Henriksen K. Dayton E. , “Organizational Silence and Hidden Threats to Patient Safety,” Health Services Research 41, no. 4 (2006): 1539–1554; Jones T. R. , “Speak No Evil: Physician Silence in the Face of Professional Impropriety,” Journal of the American Medical Association 276, no. 9 (1996): 753–754; see also, Baylis F. , “The Olivieri Debacle: Where Were the Heroes of Bioethics?” Journal of Medical Ethics 30, no. 1 (2004): 44–49 (arguing that silence can be morally significant). According to Gans and Counselman, “Silence, like speaking, is the result of a decision. People decide whether or not to talk.” Gans and Counselman, id., at 72. Thus, silence can be a form of resistance that must be worked through, be the result of “narcissistic mortification,” or the signifier of a topic that a group would rather avoid. Id., at 73, 77, 82. To the same effect, silence can denote the absence of a thorough discussion of what happens if one does not respond appropriately to a matter that needs to be addressed, in which case “awkward facts swallowed up by the ‘memory hole’ become as if they had never existed at all.” Id. (Millenson), at 104. Just as there are and can be times when a cigar is just a cigar, there are and can be times when silence is simply silence. But because “silence can be as expressive and as defensive, as meaningful and as meaningless, as generous and as begrudging as the spoken word.” Id. (Gans and Counselman), at 85, one must understand the phenomenon in order to make sense of it. Hence, while silence can and often does denote resistance, one should never forget that “assessing the quality of silence is slippery business.” Id. (Meissner), at 348; see also, Katz (The Silent World), supra note 57, at 28–29, 199.

Gifford F. , “So-Called ‘Clinical Equipoise’ and the Argument from Design,'” Journal of Medicine & Philosophy 32, no. 2 (2007): 135–150, at 137.

Jordan C. H. Spencer S. P. Zanna M. P. , “Secure and Defensive High Self-Esteem,” Journal of Personality and Social Psychology 85, no. 5 (2003): 969–978; Stucke T. S. Sporer S. L. , “When a Grandiose Self-Image Is Threatened: Narcissism and Self-Concept Clarity as Predictors of Negative Emotions and Aggression Following Ego-Threat,” Journal of Personality 70, no. 4 (2002): 509–632; Maldonado J. L. , “Narcissistic Resistances in the Analytic Experience,” International Journal of Psychoanalysis 80, pt. 6 (1999): 1131–1146.

See VHA National Ethics Committee, supra note 1, at 3 (citing Roberts L.W. Battaglia J. Epstein R. S. , “Frontier Ethics: Mental Health Care Needs and Ethical Dilemmas in Rural Communities,” Psychiatric Services 50, no. 4 [1999]: 497–503).

See Howe , supra note 96, at 21.

Smith H. F. , “Countertransference, Conflictual Listening, and the Analytic Object Relationship,” Journal of the American Psychoanalytic Association 48, no. 1 (2000): 95–127; Sandler J. , “Countertransference and Role-Responsiveness,” International Review of Psychoanalysis 3, no. 1 (1976): 43–47; Parsons M. , “The Analyst's Countertransference to the Psychoanalytic Process,” International Journal of Psychoanalysis 87, pt. 6 (2006): 1183–1198; Gabbard G. O. , “Countertransference: The Emerging Common Ground,” International Journal of Psychoanalysis 76, pt. 3 (1995): 475–486; Gabbard G. O. , “A Contemporary Psychoanalytic Model of Countertransference,” Journal of Clinical Psychology 57, no. 8 (2001): 983–991; see also, Katz (The Silent World), supra note 57, at 142–150; Katz J. , “Disclosure and Consent in Psychiatric Practice: Mission Impossible?” in Hofling C. K. , ed., Law and Ethics in the Practice of Psychiatry (New York: Brunner/Mazel, 1981): 91–117, at 109–111.

Levinson E. A. , “Aspects of Self-revelation and Self-disclosure,” Contemporary Psychoanalysis 32, no. 2 (1996): 237–248; Levine S. S. , “Nothing but the Truth: Self-disclosure, Self-revelation, and the Persona of the Analyst,” Journal of the American Psychoanalytic Association 55, no. 1 (2007): 81–104; Jacobs T. , “On the Question of Self-disclosure by the Analyst: Error or Advance in Technique?” Psychoanalytic Quarterly 68, no. 2 (1999): 159–183; Renik O. , “The Ideal of the Anonymous Analyst and the Problem of Self-disclosure,” Psychoanalytic Quarterly 64, no. 3 (1995): 466–495; Meissner W. W. , “The Problem of Self-disclosure in Psychoanalysis,” Journal of the American Psychoanalytic Association 50, no. 3 (2002): 827–867; Dixon L. Adler D. Braun D. , “Reexamination of Therapist Self-disclosure,” Psychiatric Services 52, no. 11 (2001): 1489–1493.

Shill M. A. , “Analytic Neutrality, Anonymity, Abstinence, and Elective Self-disclosure,” Journal of the American Psychoanalytic Association 52, no. 1 (2004): 151–187.

Baker R. , “Finding the Neutral Position: Patient and Analyst Perspectives,” Journal of the American Psychoanalytic Association 48, no. 1 (2000): 129–153; Renik O. , “The Perils of Neutrality,” Psychoanalytic Quarterly 65, no. 3 (1996): 495–517; Franklin G. , “The Multiple Meanings of Neutrality,” Journal of the American Psychoanalytic Association 38, no. 1 (1990): 195–220; Shapiro T. , “On Neutrality,” Journal of the American Psychoanalytic Association 32, no. 2 (1984): 269–282; Poland W. S. , “On the Analyst's Neutrality,” Journal of the American Psychoanalytic Association 32, no. 2 (1984): 283–299; Hoffer A. , “Toward a Definition of Psychoanalytic Neutrality,” Journal of the American Psychoanalytic Association 33, no. 4 (1985): 771–795; Apfelbaum B. , “Interpretive Neutrality,” Journal of the American Psychoanalytic Association 53, no. 3 (2005): 917–943.

Kernberg O. F. , “The Analyst's Authority in the Psychoanalytic Situation,” Psychoanalytic Quarterly 65, no. 1 (1996): 137–157; Tuch R. H. , “Questioning the Psychoanalyst's Authority,” Journal of the American Psychoanalytic Association 49, no. 2 (2001): 491–513; Havens L. , “The Risks of Knowing and Not Knowing,” Journal of Social & Biological Structures 5, no. 3 (1982): 213–222.

Wallerstein R. S. , The Talking Cures: The Psychoanalyses and the Psychotherapies (New Haven: Yale University Press, 1995); Stone L. , The Psychoanalytic Situation: An Examination of Its Development and Essential Nature (New York: International Universities Press, Inc., 1961); Aron L. , A Meeting of Minds: Mutuality in Psychoanalysis (Hillsdale, NJ: The Analytic Press, 1996); see also, Kelly K. V. , “Psychoanalysis and Dynamic Therapies,” in Encyclopedia of Bioethics, supra note 6, at 2132–2138.

Klugman C. M. , “As Advisors, Nondirectional Consultation Is Best,” American Journal of Bioethics 5, no. 5 (September-October 2005): 56–57; Kessler S. , “The Genetic Counselor as Psychotherapist,” Birth Defects Original Article Series 15, no. 2 (1979): 187–200; see also, Kenen R. H. , “Genetic Counseling: The Development of a New Interdisciplinary Occupational Field,” Social Science and Medicine 18, no. 7 (1984): 541–549; Biesecker B. B. , “Future Directions in Genetic Counseling: Practical and Ethical Considerations,” Kennedy Institute of Ethics Journal 8, no. 2 (1998): 145–160.

Poland W. S. , “The Interpretive Attitude,” Journal of the American Psychoanalytic Association 50, no. 3 (2002): 807–826; Cooper S. H. , “Interpretive Fallibility and the Psychoanalytic Dialogue,” Journal of the American Psychoanalytic Association 41, no. 1 (1993): 95–126; Kantrowitz J. L. , “The Analyst's Style and Its Impact on the Analytic Process: Overcoming a Patient-analyst Stalemate,” Journal of the American Psychoanalytic Association 40, no. 1 (1992): 169–194; Hoffman I. Z. , “The Intimate and Ironic Authority of the Psychoanalyst's Presence,” Psychoanalytic Quarterly 65, no. 1 (1996): 102–136; Kernberg O. F. , “The Analyst's Authority in the Psychoanalytic Situation,” Psychoanalytic Quarterly 65, no. 1 (1996): 137–157.

Meissner W. W. , The Therapeutic Alliance. (New Haven: Yale University Press, 1996): At 131–134, 180–185.

In all the analyst's interpretive efforts, an overriding aim is expansion of the analysand's ego autonomy from id, super-ego, and reality, including the reality of the analyst's influence. While such autonomy is always relative, the analyst attends especially to the patient's capacity for independent (autonomous) self-observation….Psychoanalysis promotes autonomy by virtue of its expansion of the analysand's ability to recognize…intrapsychic conflicts and to utilize the signal function generated by dysphoric affect to activate self-observing capacities rather than automatically resort to regression and defence. The aim of such self-observation of conflict is better adaptation to inner and outer realities. The analyst's neutrality ensures that conflict and compromise occupy center stage throughout the analytic work.

For the above, see Levy S. T. Inderbitzin L. B. , “Neutrality, Interpretation, and Therapeutic Intent,” Journal of the American Psychoanalytic Association 40, no. 4 (1992): 989–1011, at 1010.

See, Gruenberg P. B. , “Boundary Violations,” in the American Psychiatric Association, Ethics Primer (Washington, D.C.: American Psychiatric Association, 2001): 1–9; Gabbard G. O. , “Boundary Violations,” in Bloch S. Chodoff P. Green S. A. , eds., Psychiatric Ethics (New York: Oxford University Press, 1999): 141–160; Hundert E. M. Appelbaum P. S. , “Boundaries in Psychotherapy: Model Guidelines,” Psychiatry 58, no. 4 (1995): 345–356; Radden J. , “Notes towards a Professional Ethics for Psychiatry,” Australia-New Zealand Journal of Psychiatry 36, no. 1 (2002): 52–59; Malone S. B. Reed M. R. Norbeck J. , “Development of a Training Module on Therapeutic Boundaries for Mental Health Clinicians and Case Managers,” Lippincott's Case Management 9, no. 4 (2004): 197–202; Mohamed M. Punwani M. Clay M. , “Protecting the Residency Training Environment: A Resident's Perspective on Ethical Boundaries in the Faculty-Resident Relationship,” Academic Psychiatry 29, no. 4 (2005): 368–373.

Aulisio M. , “Common Themes and Disputed Questions from the Literature Review and Essay Exercise,” speech presented at the SHHV-SBC Task Force on Standards for Bioethics Consultation, December 13, 1996, at 1.

Aulisio M. , “Minutes of Meeting Three,” SHHV-SBC Task Force on Standards for Bioethics Consultation, February 28- March 1, 1997, at 4.

Id.; see also, Baylis F. Brody H. , “The Importance of Character for Ethics Consultants,” in Aulisio Arnold Youngner , Ethics Consultation, supra note 67, 37–44, at 40–42.

Aulisio M. , “Minutes of Meeting Four,” SHHV-SBC Task Force on Standards for Bioethics Consultation, May 30–31, 1997, at 5.

See Aulisio , supra, note 25, at 5.

Id., at 6.

“Psychiatrists Expel ‘Captain Ethics,’” Washington Post , December 23, 1992, at A4; “‘Capt. Ethics’ Thrown out by Psychiatrists,” Cleveland Plain Dealer , December 23, 1992, at A6; “Medical Ethicist Dr. Charles Culver Expelled by Psychiatric Association,” Union Leader , December 22, 1992, at 4; “Psychiatrist Disciplined for Alleged Affair,” Las Vegas ReviewJournal , December 23, 1992, at 5A; “Culver Calls Expulsion ‘Totally Absurd,’” Union Leader, December 26, 1992, at 5; see also, Culver C. M. , “Should We Research Doctor-Patient Sex?” IRB 3, no. 5 (May 1981): 7–8; Riskin L. L. , “IRB Review of Psychotherapist-Patient Sexual Relations,” IRB 3, no. 10 (December 1981): 7–8; Otten A. L. , “Medical Aid: Ethics Experts Help More Doctors Handle Hard Moral Decisions,” The Wall Street Journal, March 6, 1987, at section 1, page 1. There are no names for the expulsion stories, as it was picked up by the AP Wire Service on December 22,.

See Aulisio , supra note 25, at 2–3.

Goode W. J. , “The Protection of the Inept,” American Sociological Review 32, no. 1 (1967): 5–19; Thompson J. B. , Political Scandal: Power and Visibility in the Media Age (Malden, MA: Blackwell Publishers, Inc., 2000): At 11–30.

See Dubler Blustein , supra note 20, at 35.

Id. (Emphasis added.)

In the draft and the final report, the task force “highlighted” some of the ways in which a person might acquire “competence.” “Some of these involve formal education or training while others involve less traditional means such as self-study or first-hand experience.” See SHHV-SBC, supra note 18 at 11; ASBH, supra, note 18, at 11. “Basic skills” could be acquired through “bioethics intensive courses; conferences and seminars in bioethics; bioethics presentations or inservices at one's local institution; traditional academic courses in bioethics, ethics, or moral theology; structured mentoring processes or independent studies; self-education; or educational programs offered by regional bioethics networks.” Id. (ASBH), at 13. “To acquire advanced ethical assessment skills, one normally needs a longer period of education and training.” Id. In the Learner's Guide, which is supposed to respond, in part, to both the “lack of formal education and training on the part of many involved in ethics consultation, [and also to the] lack of educational and training programs specific to clinical ethics programs,” the task force decided to help “those currently involved in clinical ethics consultation to take up a self-education program specific to it,” in the belief that a “self-education program…will help to develop and improve basic knowledge and skills in ethics consultation.” See ASBH Clinical Ethics Task Force, supra note 48, at 1–2. Insofar as this self-education program is concerned, it is, not surprisingly, easier to know what it is not than what it is.

By ‘self-education’, we do not mean solitary, unguided, or undirected education. Indeed, many of the strategies for achieving the learning objectives laid out in the different content areas of this Guide are strategies that involved the participation of others. We also include learning strategies that entail traditional education means such as ‘taking a course’, ‘doing a supervised practicum’, or even inviting outside experts for continuing ethics education, while acknowledging that these traditional educational means may not be equally accessible to many within our intended audience. Id., at 2. As for “universities and academic medical centers with strong [but not accredited or otherwise formally certified] clinical ethics programs,” the task force hopes “that this Guide will speak to” them, “so that they might develop specific ethics education and training programs that are widely accessible to those who might benefit from them.” Id.

Shalit R. , “When We Were Philosopher Kings,” New Republic, April 28, 1997, 24–28, at 26.

Jonsen A. R. , “Ethicist's Heyday,” American Review of Respiratory Diseases 113, no. 1 (1976): 5–6. Although medical ethicists like to wonder what can and will “save the life of ethics,” see Beresford E. B. , “Can Phronesis Save the Life of Medical Ethics?” Theoretical Medicine 17, no. 3 (1996): 209–224; Toulmin S. , “How Medicine Saved the Life of Ethics,” Perspectives in Biology and Medicine 25, no. 4 (1982): 736–750; Hoffmaster B. , “Can Ethnography Save the Life of Medical Ethics,” Social Science and Medicine 35, no. 12 (1992): 1421–1431; Guinan P. , “Can Principalism Save Medical Ethics?” National Catholic Bioethics Quarterly 2, no. 2 (2002): 229–234; Moreno J. , “Can Ethics Consultation Be Saved? Ethics Consultation and Moral Consensus in a Democratic Society,” in Aulisio M. P. Arnold R. M. Youngner S. J. , eds., Ethics Consultation: From Theory to Practice (Baltimore: Johns Hopkins University Press, 2003): At 23–35. This begs the question: from what? One answer is the “good ”that come of working as an ethics consultant.

Bioethics offers some significant external goods. When Ron Carson and Chester Burns asked whether twenty-five years of bioethics had made the sick better off, my instinctive response was, 'I don't know. But we certainly are. The ways in which bioethicists benefit from doing bioethics deserves attention. All professions offer some external goods, typically status, security, and a reasonable income….Bioethics offers higher salaries and larger stipends than do the standard academic liberal arts…. In addition, bioethics can offer a certain degree of celebrity, if one is quoted in the media or does much public speaking. We can also have a certain amount of power, about specific cases or about policy.

See Andre , supra note 6, at 72–73. As Andre goes on to say, “[T]he chance to gain money, security, prominence, or influence could distort what one chooses to say or do.” Id., at 73.

See, for example, McCullough L. B. , “Preventive Ethics, Professional Integrity, and Boundary Setting: The Clinical Management of Moral Uncertainty,” Journal of Medicine and Philosophy 20, no. 1 (1995): 1–11; Furrow L. Arnold R. M. Parker L. S. , “Preventive Ethics: Expanding the Horizions of Clinical Ethics,” Journal of Clinical Ethics 4, no. 4 (1993): 287–294.

See Dubler Blustein , supra note 20, at 35.

See King , supra note 19, at 171.

Moreno J. , “Ethics Committees: Beyond Benign Neglect,” Healthcare Ethics Committee Forum 18, no. 4 (2006): 368–369.

Hoffmann D. Tarzian A. O'Neil J. A. , “Are Ethics Committee Members Competent to Consult?” Journal of Law, Medicine & Ethics 28, no. 1 (2000): 30–40.

See Thornton B. C. Callahan D. Nelson J. L. , “Bioethics Education: Expanding the Circle of Participants,” Hastings Center Report 23, no. 1 (January-February 1993): 25–29.

See ASBH Clinical Ethics Task Force, supra note 48, passim. From the sociological perspective, this development is significant because, as Starr notes, “Standardization of training and licensing [are] the means for realizing both the search for authority and control of the market.” See Starr , supra note 2, at 22. According to George Agich:

Leaders of aspiring health occupations often argue that their groups provide requisite training in an abstract body of knowledge and therefore conclude that they should be regarded as professions. But this “evidence” is often part of a deliberate attempt to show that their occupation is a profession and so should be given professional status (i.e., autonomy) instead of accurately reflecting the content of their education. Where no systematic body of theory or knowledge exists, it can (and often is) created for the purpose of saying that it constitutes part of the training requisite for professional status. Hence, the training or education requirement can be interpreted, at least in part, as functioning within the political process of lobbying and public persuasion to attain the desired end, namely,…. autonomy.

See Agich , supra note 29, at 188. According to Aulisio, Arnold, and Youngner:

An…important background question is the extent to which standard setting amounts to being merely a political exercise by which some groups carve out domains of power at the expense of other groups. In this view, far from being a call for quality assurance, the push for standards is really a push for economic and social privilege. Those who win the battle over the content of educational and training standards take the spoils….On this view, standard setting ultimately serves only to promote the social and economic interests of those who set and then satisfy the standards. See Aulisio Arnold Youngner , (“Educational and Training Standards”), supra note 63, at 487.

Baker R. Pearlman R. Taylor H. Kipnis K. , Report and Recommendations of the ASBH Advisory Committee on Ethics Standards, undated, at 13. (Emphasis added)

Youngner S. J. Arnold R. , “Who Will Watch the Watchers?” Hastings Center Report 32, no. 3 (May-June 2002): 21–22; Epstein R. A. , “Conflicts of Interest in Health Care: Who Guards the Guardians?” Perspectives in Biology & Medicine 50, no. 1 (2007): 72–88; see Jonsen , supra note 13. Don't expect sociology or sociologists to assume the role. According to Raymond De Vries:

“Although all agree on watching the watchers, the phrase itself indicates the difficulty of the task: Watching the watchers creates the problem of infinite regression. We sociologists of bioethics – whose work it is to describe the emergence, organization and influence, or lack thereof, of a profession whose work it is to watch and to assess the work of doctors and life scientists – find ourselves in an awkward position. If we are watching the bioethicists who are watching the doctors, who is watching us? Good question. The goal of a sociology of bioethics….is to understand better the organization of moral life. It is not the goal to hoist bioethicists by their own petard, to write an expose or to otherwise undermine their work. De Vries R. , “Who Will Guard the Guardians of Neuroscience?”EMBO Reports 8, Special Issue (2007): S65–S69, at S65–S66.

Schudson M. , “The Trouble with Experts – and Why Democracies Need Them,” Theory and Society 35, nos. 5–6 (2006): 491–506, at 500. On the debate itself, see, for example, Rasmussen L. , ed., Ethics Expertise: History, Contemporary Perspectives and Applications (Dordrecht, NL: Springer, 2006); Yoder S. D. , “The Nature of Ethical Expertise,” Hastings Center Report 28, no. 6 (November-December 1998): 11–19; Agich G. J. , “Ethics Expert Testimony: Against the Skeptics,” Journal of Medicine and Philosophy 22, no. 4 (1997): 381–403; Noble C. N. , “Ethics and Experts,” Hastings Center Report 12, no. 3 (May-June, 1982): 7–9; Nielsen K. , “On Being Skeptical about Applied Ethics,” in Ackerman T. F. Graber G. C. Reynolds C. H. , eds., Clinical Medical Ethics: Exploration and Assessment (Lanham, MD: University Press of America, 1987): 95–115.

See VHA National Ethics Committee, supra note 1, at 3, 9.

Scofield G. R. , “Ethics Consultation: The Least Dangerous Profession?” Cambridge Quarterly of Healthcare Ethics 2, no. 4 (1993): 417–426, at 417.

Callahan D. , “Bioethics as a Discipline,” Studies of the Hastings Center 1, no. 1 (1973): 66–73, at 66.