Clinical Ethics Consultation and the Myth of Secular Space

Some say it is possible, even necessary, to check our values at the door and remain neutral in clinical ethics consultation. For example, Janet Malek argues that clinical ethics consultants’ (CECs’) own religious worldview should never surface in their work: “Appeals to tenets of a CEC’s religious worldview, whether implicit or explicit, have no place in this consultation methodology.”[i] Allowing space for any values outside accepted standardized bioethical concepts (like those defined by Beauchamp and Childress),[ii] which are based on consensus in the field and assumed to be neutral with respect to worldview, “corrupts the consultative process.”[iii] For Malek, compliance with standardized clinical ethics consultation methodology requires stepping outside of one’s own worldview into a no-man’s-land of supposed value-neutrality.

Malek’s argument is grounded in several unfounded assumptions: (1) a religious worldview can be set aside for the purposes of clinical ethics consultation; (2) those without religious worldviews are neutral;[iv] (3) standardized bioethical concepts are neutral with respect to worldview; (4) clinical ethics consultation can be done without appeal to worldview, in what H. Tristram Engelhardt calls a “secular space”;[v] and (5) there exists something like what Engelhardt calls a “secular space.”

I will argue that Malek’s value-neutral clinical ethics consultation is not what it claims to be but is rather just operationalizing another competing worldview in our pluralistic healthcare environment. I will further argue that value neutrality in clinical ethics consultation is not possible, and to pretend the secular space is value neutral actually smuggles a host of quasi-religious values into the consultation encounter. If true, then there is no secular space in the sense that Malek conceives of it, and in fact there is no secular space even as Engelhardt conceives of it. This does not mean that clinical ethicists should give into practices of coercion or that they should enforce their vision of good moral outcomes on others. Rather, it means that clinical ethicists should interrogate and articulate their ethical commitments with the full knowledge of the limits to enforcing them in the public realm. Although I believe Engelhardt is incorrect in his claim that secular space exists, he is right that there are limits to the enforcement of our moral vision on others in a cooperative enterprise. I conclude by exploring what those limits are and what strategies are acceptable for communicating divergent ethical beliefs between moral strangers who must decide on a course of action in the clinic.

A Religious Worldview Cannot be Set Aside for a CEC

One of Malek’s unfounded assumptions is that it is possible for a CEC to set aside his or her religious worldview in the consultation process and thus to achieve neutrality. She writes: “An asymmetry exists where a consultant must be highly attuned to and respectful of the religious worldviews of others but bracket his or her own worldview so that it plays little or no role in their consulting work.”[vi] Her impulse is, I suspect, a concern that ethicists operating within their religious frameworks may overtly or covertly enforce their ethical beliefs on those who do not share them. Given the value-laden nature of clinical ethics consultation and the high value we afford to patient autonomy, this is a serious concern and must be attended to. However, I believe Malek is incorrect in suggesting that the solution is for religious CECs to bracket their religious worldviews in consultation.

The first reason for this is that it is not possible for religious individuals to bracket their religious worldviews. In contrast to the way many nonreligious people view religion, religion is not primarily intellectual, and it does not consist primarily of beliefs, ideas, and doctrines that can be taken up or set aside in intellectual deliberation. In reality, religion is primarily a holistic, embodied practice that shapes the whole person as he or she performs it.[vii] As James K. A. Smith points out, faith is not (primarily) a set of dogmas and doctrines held in the mind, but necessarily involves an array of powerful, identity-forming, embodied practices (or liturgies) that articulate the meaning of human flourishing and form us into certain kinds of people. Smith argues, along with other neo-orthodox theologians, that “secular” paradigms should not be allowed to define religion, but religion should be allowed to define itself on its own terms.[viii]

If religion defined on its own terms is, at bottom, a set of embodied identity-forming practices, might it be the case that there are other practices and institutions that have the same religious function yet are not considered “religious”? I argue, following Smith, that the powerful institution of the hospital, with its procedures, codes, processes, and techniques, inherently contains “secular” liturgies that shape our attention to ultimate concerns. “Insofar as exclusive humanism has its liturgies, it remains religious,” says Smith.[ix] In this sense, “secular” space as Malek conceives of it does not exist; even the non-religious or a-religious space of procedural clinical ethics consultation is a religious space, because it contains liturgies that shape how its performers view ultimate reality.[x] I will return to these ideas in a later section.

This leads to another (related) reason why I do not believe the solution to Malek’s concern is the bracketing of religious worldviews: it will not accomplish what she thinks it will, namely, neutrality. In Malek’s conception, what is left when a religious CEC brackets his or her worldview is a worldview-neutral set of standard bioethics principles that have, more or less, reached the level of professional consensus. I argue in the following sections that there is no professional consensus on what we are doing when we engage in clinical ethics consultation, and standard procedural clinical ethics approaches are in fact hodge-podges of religious and quasi-religious worldviews. Still, since these procedural approaches all contain normative guidelines and judgements, they should not be considered value-neutral.[xi]

Those Without Religious Worldviews Are Not Worldview-Neutral

Malek’s desire for CECs to set aside their worldviews stems from the conviction that the principle of respect for autonomy requires ethicists to be neutral in order to permit patients or their families to make their own choices in accordance with whatever moral-metaphysical commitments they may possess, free from coercion or undue influence.[xii] The idea is that CECs operating within a religious worldview exert undue influence on patients, a type of influence that inhibits the patient’s exercise of free choice. Once such CECs have set aside their religious worldview, however, they are free to engage in ethics consultation as a neutral party. It seems, although she does not say directly, that Malek defines “neutral” as either value-free or those values that do not exert undue influence over a patient such that the exercise of free choice is limited. As Abram Brummett points out, though, even consultation based solely upon non-religiously grounded bioethical values exerts some level of influence on patients.[xiii] The claim of moral-metaphysical neutrality inherent in Malek’s “procedural” approach is not absolute neutrality, but rather a neutrality within the limits established by appeal to mid-level moral-metaphysical-epistemological commitments that have acquired a (supposed) consensus in the field.[xiv] Since these commitments limit the decisions that can be made by patients, sometimes drastically and against their will, even the procedural approach amounts to what we might call a “quasi-religious” worldview complete with values and normative boundaries.[xv]

So both religious and quasi-religious values in clinical ethics consultation exert influence on patient choice. The operative question is whether it is undue influence presenting a barrier to the exercise of legitimate choice. Malek does not deal with this crux of the issue; instead, she seems to assume religious values always exert undue influence over patients, while standard bioethical values do not.

Even if it were possible for CECs to bracket their own worldview and operate exclusively under a “secular” framework, they would not be neutral. They would be operationalizing a whole set of quasi-religious values; in other words, they would be operating within another value-laden worldview. Malek gives no justification for the claim that these “quasi-religious” values and normative boundaries represent an appropriate amount of influence on patients, whereas religious values represent undue influence.

John Milbank, in his highly influential Theology and Social Theory, makes the case that “secular reason” is not what it claims to be—i.e., secular—but rather a heterodoxy of various belief systems, including paganism and nihilism.[xvi] This is not to be understood pejoratively, since for Milbank paganism, heresy, and nihilism are merely a stripped-down version of the Christian message. He thus views them as containing valuable pieces of truth, but missing the core of the Christian gospel. Nonetheless, he argues convincingly that we must acknowledge the religious and quasi-religious undertones to secular reason. There is no view from nowhere. I will return to Milbank’s argument below.

Standardized Bioethical Concepts Are Not Worldview-Neutral

Malek writes that although a clinical ethics consultant ought not influence a patient with his or her own religious values, he or she may influence the patient with non-religious arguments and values without undue imposition. This is because “unlike preferences and commitments that grow out of an individual’s religious worldview, areas of bioethical consensus are derived from beliefs and values that are available to all people regardless of their religious affiliation.”[xvii] But are there beliefs and values that are available to “all people”? Standardized bioethics concepts, such as Beauchamp’s and Childress’ tetrad of respect for autonomy, beneficence, nonmaleficence, and justice, are not worldview-neutral; they arise from particular cultures and historical realities.[xviii] They assume many Western democratic values such as individualism that would seem anathema to certain populations, deeply philosophical ideas about the purpose and nature of medicine and the role of the physician (e.g., to heal the body, reduce pain, tell the truth, and so on), and quasi-religious appeals to justice and equality that resonate with many religious traditions, but of course not all. It is true, of course, that values arising from deeply particular cultures, times, and places can be normatively taken up and applied in other contexts; however, they will not be fully coherent with the metaphysical foundations of those contexts.

One need only to consider cultures in which one of these principles is devalued to realize the truth of this. Autonomy, for instance, is not of particular value in East Asian countries, where important decisions are more likely to be made by close family members than patients themselves. Many Asian families consider it a loving family obligation to withhold fatal diagnoses from their family members and take the responsibility of decision-making on themselves.[xix] The roots of our Western standard bioethical concepts are obviously varied, but it is important to realize that all concepts grow out of worldviews, whether overtly religiously grounded or not. And these cultural worldviews are not any more universally applicable than the ones we think of as classically religious.

Engelhardt asserts that the very existence of CECs and the field of clinical ethics “presupposes a rich set of local cultural expectations,” and is the result of Enlightenment assumptions that a canonical morality, or at least a normative consensus, can be discovered through rational argumentation.[xx] Unfortunately, this has been proven not to be the case. Sound rational argument has not been able to establish normative agreement across moral-metaphysical worldview boundaries, and it is not even clear why consensus would count as morally normative.[xxi]

Malek disagrees, writing: “The focus on secular reasoning . . . does not reflect a prioritization of that approach over religious reasoning but rather the need for shared concepts in a dialogue among individuals with differing worldviews.”[xxii] While she recognizes that moral questions cannot be answered between strangers speaking different moral languages, she stops short of seeing the full scope of the problem.

Engelhardt goes further in addressing this concern. Instead of merely arguing that moral deliberation requires a shared language, he recognizes that a shared moral language requires a shared worldview. For Engelhardt, content-full moral deliberations can occur only between those who share a common moral-metaphysical worldview.[xxiii] Those who do not are “moral strangers” and cannot deliberate on moral problems because reason alone cannot offer substantive guidance. Whereas Malek sees standard bioethical concepts as a universally accessible common language, Engelhardt recognizes this is not the case. When moral positions are argued via “secular” reasoning, all either beg the question, employ circular reasoning, or infinitely regress.[xxiv] To be truly universally accessible, a moral position must completely divest itself of content; conversely, to hold content, a moral position must by nature be coherent only to those within its worldview. Therefore, for Engelhardt, there can be no content-full secular ethics grounded in secular reason, even in medicine, and any attempt to ground a particular normative view in reason merely disguises a subjective measure as an objective tool.[xxv]

Dissensus on the Nature of Clinical Ethics Consultation

So far, I have argued that those with religious worldviews cannot set them aside for clinical ethics consultation, that those without religious worldviews are not value-neutral, and that standard bioethics concepts entail a worldview with “secular” liturgies and normative value-judgements. But I have not yet addressed the question of whether CECs operating within religious worldviews are in some way less effective or less respectful of autonomy than those operating within nonreligious worldviews.

Malek believes consistency among the recommendations delivered by CECs is vitally important in order to ensure the high quality of the delivered “product.” Although she does not directly address the nature of the “product” in her view, she seems to view clinical ethics consultation as primarily a mediation technique that safeguards patients’ autonomous choice and delivers a defendable and reproducible recommendation to the healthcare team. If variation in the substance of recommendations is to be eliminated, she writes, consultation practices based on the CEC’s religious worldview must be eliminated.[xxvi] The belief that consistency ensures quality in ethics consultation is one that ought to be interrogated, but more important for our purposes here is the belief that there is consistency in secular ethical reasoning that is undermined by religious worldviews. As many scholars have demonstrated, even strictly “secular” bioethics contains a multitude of divergent approaches, values, and priorities. This is made abundantly clear by Brummett and Salter in their recent taxonomy of views on clinical ethics expertise.[xxvii]

The diversity of views on clinical ethics expertise arises partly from dissensus on what the professional obligations of CECs are.[xxviii] Professional obligations are determined largely by the ends or goals of that profession. The problem quickly arises, then, that there is no consensus on the ends or goals of the profession of clinical ethics consultation.[xxix] The variety of views on this question are so divergent that Brummett and Salter offer a taxonomy, which they organize around the fundamental question: “Can clinical ethicists offer justified normative recommendations in active patient cases?”[xxx] They call views that affirm ethicists’ ability to offer normative recommendations positive views and those that deny it negative views. Examples of negative views have been prominent in bioethics literature since the establishment of the field, including Churchill, Singer, Beauchamp, Archard, Gesang, and Adams. Among negative views, varied explanations are given as to why ethicists cannot give normative recommendations and what ethicists can offer instead. On the positive side, Brummett and Salter identify varying positions on how ethics recommendations are to be generated, what is the nature of the recommendations, how the recommendations are justified, and how they are communicated.[xxxi] These variables represent a complex debate on the nature of clinical ethics consultation that makes clear there is no consensus in the field even on basic questions regarding the nature of the process. Even the way a CEC approaches his or her work, then, represents value commitments that are not universal among CECs, much less the rest of the constituents in the process.

Engelhardt agrees, claiming that were there an avenue to moral consensus among bioethicists, they would be able to claim their expert role of guiding clinical choice.[xxxii] There is a deep feeling that, without being able to ground this claim to moral expertise in something like consensus, there is no ground on which the profession may stand. Therefore, there is a great “hunger for consensus”[xxxiii] in bioethics, especially among CECs, as the field moves to legitimate itself through certification programs and the like.[xxxiv] However, consensus on the controversial issues of bioethics is not theoretically or practically possible given the diversity of worldviews and moral schools represented by ethicists.[xxxv] “There is agreement neither regarding the moral content of bioethics nor about a conclusive theoretical foundation that would warrant the claims of canonical normativity,” writes Engelhardt.[xxxvi]

Clint Parker further argues that, although there are aspects of the job CECs can engage in without normative appeal to worldview (legal and policy boundary disclosure, mediation, advocacy, arbitration, and promoting patient satisfaction),[xxxvii] making independent ethical judgements in active patient cases can be done only with appeal to “metaphysical, epistemological, meta-ethical, axiological, and political beliefs,”[xxxviii] i.e., one’s worldview. “If we are going to develop internally consistent intellectual lives, this type of reasoning is unavoidable.”[xxxix] Parker correctly identifies that CECs using non-religious worldviews to justify their ethical judgements rely on metaphysical beliefs just as religious CECs do. It seems more reasonable to expect not consistency, but a multitude of recommendations among nonreligious CECs. Additionally, Parker asserts that to consider the religious CEC’s worldview insufficient to ground his or her ethical judgements, one would need to demonstrate an internal incoherence or otherwise non-rationally defensible position. The burden of proof lies with those who would discount the religious CEC’s ethical judgement, because it has not been demonstrated that religious beliefs corrupt the consultative process by appealing to irrational or false premises. Parker writes that “while atheists may hold their beliefs strongly, they have not succeeded in demonstrating that theists are irrational in their beliefs . . . regarding morality. Neither have they demonstrated that theists’ beliefs are false.”[xl] Therefore, it seems to me that when making moral judgements the Christian CEC, like the atheist CEC, is engaged in the same epistemic enterprise—namely, trying to make justified, true moral judgements, in part, by appealing to important background beliefs, using coherence and non-coherence with these background beliefs as a way to assess the degree of justification of these judgements.[xli]

Parker suggests, contra Malek, that CECs can appeal to their background beliefs (as even nonreligious CECs do) as long as they reach the standard of coherence. While in rare limit cases this fairly low standard may still allow for coherent yet harmful beliefs such as racism or sexism to seep into a CEC’s recommendation, CECs have no decision-making power in patient care. If we establish a paradigm of persuasion and reject coercion in clinical ethics consultation, as I argue in the final section, we need not fear differences of belief or work to unify every party under the same beliefs. Recommendations based on harmful yet coherent beliefs cannot be coercively imposed on the patient or healthcare team. Parker’s argument seems to speak to Malek’s concern that religious CECs may end up imposing their unjustified beliefs on others, while avoiding some of the misconceptions of her argument.

There Is No Secular Space

In this section I will return to the idea of “secular” space and make the case, following others, including John Milbank, James K. A. Smith, and Charles Taylor, that it does not exist in the sense that Malek believes it does. First, a clarification of terms. According to Taylor, the term “secular” can have three connotations. First, it can mean the realm of the mundane, as in “secular” as opposed to “sacred.” Second, it can refer to a space where there is a plurality of beliefs and religious options, similar to a pluralistic society. Finally, “secular” can mean neutral and a-religious, a realm divested of the irrationalities and particularities of religious traditions, which I take to capture Malek’s use of the term.[xlii]

Smith argues convincingly that our social-scientific accounts of the world need to drop the idea of “secular” in this sense and instead embrace the post-secular recognition that humans are essentially religious animals. “That claim does not mean that humans inescapably believe in God, gods, or even transcendence,” he writes.

Rather . . . I mean that humans are liturgical animals whose orientation to the world is shaped by rituals of ultimacy: our fundamental commitments are inscribed in us by ritual forces and elicit from us orienting commitments that have the epistemic status of belief. . . . we become believers through ritual formation—and such formative rituals have the status of “liturgies.” This identification of religion with liturgy effects a double displacement: it displaces the site of religiosity from beliefs to practices, and it displaces the identification of religion with only transcendent or “otherworldly” models.[xliii]

When seen this way, it becomes plausible to consider even the clinical space as religious, i.e., full of rituals of ultimacy that shape us as we participate in them. Engelhardt agrees when he writes that ethical norms are not heady static ideas but necessarily live in actual communal practices: social rituals.[xliv] They reflexively shape us by becoming our habitual ways of acting in and seeing the world, which are realized in particular, concrete contexts. When these rituals and corresponding background beliefs are engaged in uncritically, they have the power to shape us without our full knowledge. Just as Malek is concerned that religious CECs may impose their values on patients, I am concerned that CECs who uncritically engage in the rituals of clinical ethics consultation are in even greater danger of imposing their values on patients. To pretend the “secular” space of ethics consultation is value-neutral smuggles in a host of quasi-religious values into the consultation encounter. This encounter does not cut through biased worldviews to a neutral truth, but simply operationalizes another competing worldview in our pluralistic healthcare environment.

Where did we get the idea that a neutral, secular space exists? Milbank argues that the invention of the “secular” occurred at the end of Christendom as an attempt to carve out space where Christianity was not: it had to be invented and instituted both in theory and in practice. Although our common myth is that the “secular” is what was left over when the world was desacralized, in reality it was a positive creation of a different economy of power than that of Christendom, one that privileged the political and the state rather than the Church.[xlv] The creation of the overarching “secular” public domain assured over time that the public political sphere would be primary, and theology, cast as the content of private worldviews, would need to prove its value in order to carve out space in that political sphere. If it succeeded, it would be policed by state power, and limits would be placed upon it.[xlvi] Although some may argue this is necessary in order to preserve a liberal democracy and ensure freedom from coercion, I fear this becomes a self-fulfilling prophecy. Where space is redrawn into two domains, sacred and secular, we become unable to see it any other way.

Consulting Without Coercion

Throughout this paper I have affirmed Malek’s belief that “respect for autonomy requires that a patient (or surrogate on his behalf) be empowered to make decisions based on his own worldview without manipulation or undue influence from others.”[xlvii] I believe this ideal can be realized, however, only when a CEC is consciously aware of the worldview he or she carries and how it influences the consultation encounter. Malek agrees (at least, for religious CECs) when she writes: “An awareness of one’s own religious worldview and its effect on one’s beliefs and practices is necessary for conducting ethics consultation. . . . A consultant therefore has a duty of self-reflection; that is, an obligation to consider the ways in which her beliefs could influence her interactions and analyses.”[xlviii] In the context of developing standards for the professional certification of CECs, The American Society for Bioethics and the Humanities (ASBH) also recognized the importance of self-reflection, stating: “Ethics consultants need to be sensitive to their personal moral values and should take care not to impose their own values on other parties. This requires that consultants be able to identify and articulate their own views and develop self-awareness regarding how their views affect consultation.”[xlix]

However, those who mistakenly believe bracketing religious worldviews is both possible and necessary for “neutrality” miss this opportunity because they unconsciously smuggle in various background moral-metaphysical values into clinical ethics consultation. Instead of attempting to bracket worldviews, CECs should work to ground their ethical recommendations firmly in their respective moral-metaphysical worldviews and constantly work toward greater internal consistency with their basic convictions. In the consultation process, CECs should faithfully articulate their positions on moral questions, giving reasons for their positions that are rationally defensible to other stakeholders.[l] This respects the fact that a CEC is a moral agent who constantly makes moral judgements, whether overtly or not, and is responsible for those judgements.[li] As Parker notes, a CEC’s integrity depends on the ability to express his or her own judgements and make arguments for those judgements that are rationally defensible and grounded in their worldview.

Without the ability to normatively ground ethical judgements in a moral-metaphysical worldview that is rationally defensible, CECs are left with no moral force or claim to moral expertise. Instead, what they possess is ethics that is only legally, not morally, normative. Their function becomes that of quasi-lawyers, a function that would be better carried out by actual lawyers.[lii] “Under the cover of supporting a particular set of moral and bioethical commitments, they function as partisans for a particular legal and public policy vision, as supporters of a particular political vision.”[liii] This point leads Engelhardt to conclude that CECs ought to inform the public that their real role is to offer quasi-legal advice, provide risk management, and mediate conflicts —not to offer ethical expertise.[liv] My conclusion is instead that CECs need to drop the façade of moral neutrality, or of justification based on consensus, and reclaim their normative role qua normative ethicists.

This does not mean, however, that a CEC can enforce his or her ethical judgements on other autonomous persons. Rather, CECs attempt to offer autonomous decision-makers well-reasoned, morally defensible options that are in accord with their examined worldview. It is then up to the autonomous decision-makers to decide whether CECs’ option(s) are persuasive to them. They can accept the option(s) for the same or different reasons than the CEC does; they can reject the option(s) and choose another.[lv] Regardless, beliefs and convictions have been clarified, each party understands more clearly why he or she is making a particular choice or recommendation, and each party grows in mutual understanding of the others’ position.[lvi] Whether the CEC’s worldview is religious, atheist, or otherwise, all he or she can offer is an option or range of options that seem, from the worldview in which he or she lives, to be morally and rationally defensible. Without pretending her opinion is neutral with respect to worldview, the CEC is now free to take ownership of her moral agency and fulfill her professional obligations.[lvii]

For those who are moral strangers, living in different moral-metaphysical worlds, dialogue and debate is likely to rarely bring the two sides together. But in a pluralistic society, we are committed to allowing a plurality of moral beliefs; in this space, those who ground their moral judgements in religious worldviews have just as much of an epistemic right to their beliefs as those who ground their moral judgements in nonreligious worldviews.[lviii] Parker writes: “To respect other persons is not to accept their position or to offer only reasons that one thinks they might accept, but to be authentic, to be serious, to be truthful, to let them make up their own minds, and to try assiduously to avoid using coercive force to get them to act against their moral judgments once they have been made.”[lix]

Avoiding coercive force is no easy task. In fact, Milbank writes that the logic of liberal democracy (i.e., secularism, myth of neutrality) eventually gives way to postmodern skepticism, then to nihilism.[lx] Every version of secular reason ultimately succumbs to the Nietzschean reduction of the will to power, and its political expression is fascism. This is a strong claim, but if Milbank is right, there is violence at the core of secular social theories, and thus a clinical ethics consultation based upon it. How then to avoid violent coercion?

One’s only resort at this juncture, other than despair, is to return to the demonstration that nihilism, as an ontology, is also no more than a mythos. To counter it, one can only try to put forward an alternative mythos, equally fallible, but nonetheless embodying an “ontology of peace,” which conceives differences as analogically related rather than equivocally at variance.[lxi]

This claim deserves more attention than I can afford here, but for Milbank, the only way to an ontology of peace is a theological turn in which difference is dealt with by asserting the fundamental relationality of all things, or in other words, by offering an alternative mythos. This is because the secular, for Milbank, is itself a mythos, just another “religion,” but one of ontological violence.[lxii] If he is right, the only way to avoid using coercive force is, counterintuitively, to step outside the myth/religion of secular space and its ontology of violence, and offer instead a theological ontology of peace. In this ontology of peace, methods of dialogue can center on persuasion instead of coercion.[lxiii]

Following Milbank, I argue the only way to convince someone to follow your ethical recommendation, besides coercion, is to give up on dialectics and embrace narrative persuasion. “The encounter of . . . diverse reasons cannot be contained and mediated by dialectical conversation alone: at the limits of disagreement it will take the form of a clash of rhetorics, of voices addressing diverse assemblies.”[lxiv] By contrast, non-coercive persuasion involves offering up an alternative vision of the moral possibilities, rooted in a metaphysical worldview, which is a narrative and an embodied practice, not a set of propositions.

References

[i] Janet Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work: Nearly None,” HEC Forum 31 (2019): 95, https://doi.org/10.1007/s10730-018-9363-6.

[ii] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York: Oxford University Press, 2019).

[iii] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 95.

[iv] To be more precise, her argument is that those approaching the ethics consultation process without religious worldviews, or those who set theirs aside, operate instead under the concepts that have been accepted by consensus in the field. She believes these concepts are accessible to everyone, as opposed to religious concepts, which are morally esoteric. In this sense, those without religious worldviews are “neutral.”

[v] H. Tristram Engelhardt, Jr, The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996).

[vi] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 97.

[vii] James K. A. Smith, “Secular Liturgies and the Prospects for a ‘Post-Secular’ Sociology of Religion,” in Philip S. Gorski, ed, The Post-Secular in Question: Religion in Contemporary Society (New York: NYU Press, 2012).

[viii] Smith, “Secular Liturgies and the Prospects for a ‘Post-Secular’ Sociology of Religion,” 161–2.

[ix] Smith, “Secular Liturgies and the Prospects for a ‘Post-Secular’ Sociology of Religion,” 162.

[x] This idea is not original; it represents the postmodern and post-liberal critique of rationality and the “secular” by Wolterstorff, Stout, Milbank, and many others, who have cast doubt on the epistemological foundations of secularism itself. For two flagship works in this area, see John Milbank, Theology and Social Theory: Beyond Secular Reason (Malden, MA: Blackwell, 2013) and James K. A. Smith, Desiring the Kingdom (Grand Rapids, MI: Baker, 2009).

[xi] I am not implying that, because they are not neutral, standard clinical ethics consultation approaches and the mid-level principles they operationalize are bad or wrong. They may very well be the best we have. But they are not neutral.

[xii] Notice that this emphasis on patient autonomy is already normative and certainly not value-neutral.

[xiii] Abram Brummett, “The Quasi-religious Nature of Clinical Ethics Consultation,” HEC Forum 32, no. 3 (2020): 199–209, https://doi.org/10.1007/s10730-019-09393-5.

[xiv] Brummett, “Clinical Ethics Consultation as a Quasi-Religious Affair.”

[xv] Wording is Brummett’s, “The Quasi-Religious Nature of Clinical Ethics Consultation.”

[xvi] John Milbank, Theology and Social Theory: Beyond Secular Reason (Malden, MA: Blackwell, 2013), xiv.

[xvii] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 97.

[xviii] Beauchamp and Childress, Principles of Biomedical Ethics.

[xix] Tana Nilchaikovit, James Hill, and Jimmie Holland, “The Effects of Culture on Illness Behavior and Medical Care: Asian and American Differences,” General Hospital Psychiatry 15, no. 1 (1993): 41–50, https://doi.org/10.1016/0163-8343(93)90090-b.

[xx] H Tristram Engelhardt, Jr, “Credentialing Strategically Ambiguous and Heterogeneous Social Skills: The Emperor without Clothes,” HEC Forum 21, no. 3 (2009), 294, https://doi.org/10.1007/s10730-009-9106-9.

[xxi] Engelhardt, “Credentialing Strategically Ambiguous and Heterogeneous Social Skills,” 295.

[xxii] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 100.

[xxiii] Engelhardt, The Foundations of Bioethics, 9.

[xxiv] Abram Brummett and Erica K. Salter, “Taxonomizing Views of Clinical Ethics Expertise,” The American Journal of Bioethics, 19, no. 11(2019): 50–61, https://doi.org/10.1080/15265161.2019.1665729. For more on the failures of secular reasoning, see Engelhardt, The Foundations of Bioethics, and H. Tristram Engelhardt, Jr., Bioethics and Secular Humanism: The Search for a Common Morality (Philadelphia, PA: Trinity Press, 1991).

[xxv] Engelhardt, The Foundations of Bioethics.

[xxvi] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 96.

[xxvii] Brummett and Salter, “Taxonomizing Views of Clinical Ethics Expertise,” 50–61. See also Jeffrey P. Bishop, Joseph B. Fanning, and Mark J. Bliton, “Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultation,” HEC Forum 21, no. 3 (2009): 275–91, https://doi.org/10.1007/s10730-009-9101-1.

[xxviii] J. Clint Parker, “Religion, Authenticity, and Clinical Ethics Consultation,” HEC Forum 31, no. 2 (2019): 103–17, https://doi.org/10.1007/s10730-019-09375-7.

[xxix] Parker, “Religion, Authenticity, and Clinical Ethics Consultation.

[xxx] Brummett and Salter, “Taxonomizing Views of Clinical Ethics Expertise,” 54.

[xxxi] Brummett and Salter, “Taxonomizing Views of Clinical Ethics Expertise,” 54.

[xxxii] H Tristram Engelhardt Jr, “Consensus Formation: The Creation of an Ideology,” Cambridge Quarterly of Healthcare Ethics 11, no. 1 (2002): 7, https://doi.org/10.1017/s0963180102101034.

[xxxiii] Engelhardt, “Consensus Formation,” 7.

[xxxiv] American Society for Bioethics and Humanities (ASBH), Core Competencies for Healthcare Ethics Consultation, 2nd ed. (ASBH, 2011). See also “Healthcare Ethics Certification Program,” ASBH, accessed June 9, 2022, https://asbh.org/certification/hec-c-exam-information.

[xxxv] Engelhardt, “Consensus Formation,” 7.

[xxxvi] H Tristram Engelhardt Jr, “Core Competencies for Health Care Ethics Consultants: In Search of Professional Status in a Post-Modern World,” HEC Forum 23, no. 3 (2011): 130, https://doi.org/10.1007/s10730-011-9167-4.

[xxxvii] Even the engagement of these activities, however, involves normative value judgements. For example, one must decide when and how to appropriately apply legal mandates, who to invite to the mediation table, who to speak to first in mediation, whose voices to advocate for, whose interests are worth protecting, etc.

[xxxviii] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 111.

[xxxix] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 111.

[xl] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 112.

[xli] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 112.

[xlii] Smith, “Secular Liturgies and the Prospects for a ‘Post-Secular’ Sociology of Religion,” 163–64. See also Charles Taylor, A Secular Age (Cambridge, MA: Belknap Press, 2007).

[xliii] Smith, “Secular Liturgies and the Prospects for a ‘Post-Secular’ Sociology of Religion,” 165 (emphasis original).

[xliv] Engelhardt, Ethical Norms and Social Rituals, 11.

[xlv] Milbank, Theology and Social Theory, 9–10.

[xlvi] See Milbank, “Policing the Sublime,” in Theology and Social Theory, 101–44.

[xlvii] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 97.

[xlviii] Malek, “The Appropriate Role of a Clinical Ethics Consultant’s Religious Worldview in Consultative Work,” 97.

[xlix] ASBH, Core Competencies for Healthcare Ethics Consultation, 9.

[l] By “rationally defensible” I do not mean that sound argument grounds the normative force of the CEC’s ethical recommendation. I agree with Engelhardt that secular reason cannot ground normativity. Instead, I mean that the CEC’s ethical recommendation should be internally consistent with her worldview in a way that can be rationally demonstrated and cogently argued, even though the argument itself does not justify her position; the metaphysical worldview does.

[li] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 114.

[lii] Engelhardt, “Core Competencies for Health Care Ethics Consultants,” 129.

[liii] Engelhardt, “Core Competencies for Health Care Ethics Consultants,” 144.

[liv] Engelhardt, “Core Competencies for Health Care Ethics Consultants,” 144.

[lv] There are limits, of course, to what other choices a decision-maker can decide; as stated above, standard bioethics creates a range of acceptable options but does not allow patients or surrogates to request simply anything they want. There are good reasons for this that are not all religious. Secular humanists offer good reasons to limit patient autonomy (see Abram Brummett, “Responding to the Incredulous Brow: Naturalizing the Harm Principle for Ethics Expertise,” [diss., St. Louis University, 2019]). The important thing is to recognize this means bioethics is not neutral.

[lvi] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 114–16.

[lvii] There is more work to be done in parsing out what this means for the employment of CECs. For instance, is it appropriate for hospitals to hire CECs whose moral-metaphysical worldviews align with that of the institution? As professional obligations for CECs are increasingly standardized by ASBH, and as allowance for conscientious objection increases in American society, this range of concerns will continue to grow.

[lviii] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 113.

[lix] Parker, Religion, Authenticity, and Clinical Ethics Consultation, 115.

[lx] Milbank, Theology and Social Theory, 278–326.

[lxi] Milbank, Theology and Social Theory, 279.

[lxii] Milbank, Theology and Social Theory, 380.

[lxiii] Milbank, Theology and Social Theory, 327–442.

[lxiv] Milbank, Theology and Social Theory, 341.

Cite As:

Jordan Mason, “Clinical Ethics Consultation and the Myth of Secular Space,” Dignitas 29 ,no. 1–2 (2022): 4–10.