1. The status of bioethics as a profession is ambiguous, but it at least shares important characteris- tics with established professions. See Freedman, B. Bringing codes to Newcastle. In: Hoffmaster, CB, Freedman, B, Fraser, G, eds. Clinical Ethics: Theory and Practice. Clifton, New Jersey: Humana Press, 1989:125–39.CrossRefGoogle Scholar

2. Some notable articles can be found in Ackerman, TF, Graber, GC, Reynolds, CH et al. , eds. Clinical Medical Ethics: Exploration and Assessment. Lanham, Maryland: University Press of America, 1987Google Scholar; and in Fletcher, JC, Quist, N, Jonsen, AR, eds. Ethics Consultation in Health Care. Ann Arbor: Health Administration Press, 1989.Google ScholarSeveral journal collections have also featured articles on ethics consultation. Two issues of Theoretical Medicine -1991; 12(2)Google Scholar and 1992; 13(1) -contain articles that contribute significantly to this literature. A recent issue of the Quality Review Bulletin, 1992; 18(1)Google Scholar, has as its theme defining quality in ethics consultation. The article it contains by Scofield, G. R. (pp. 26–32), although conceptually imprecise, is the most frank enquiry into the ethics of ethics consultation I have seen.Google Scholar

3. See note 1. Freedman. 1989. A code of ethics has also been proposed for those who do ethics consulting in business. See Masden, P. Toward a code of ethics for business ethicists. Business and Professional Ethics Journal 1988;7(3&4): 147–66.Google Scholar

4. For example, see Hoffmaster, CB. Morality and the social sciences. In: Social Science Perspectives in Medical Ethics. Dordrecht: Kluwer Academic Publishers, 1990:241–60; in the same volume see also Jennings B: 261–71.CrossRefGoogle Scholar

5. Very little work has been done in the sociology of bioethics. For example, Waddington, I. The development of medical ethics – a sociological analysis. Medical History 175; 19:36–51Google Scholar; Fox, R, Swazey, JP. Medical morality is not bioethics: medical ethics in China and the United States. Perspectives in Biology and Medicine 1984;27:337–60CrossRefGoogle Scholar; Fox, R. The evolution of American bioethics: a sociological perspective. In: Social Science Perspectives in Medical Ethics. Dordrecht: Kluwer Academic Publishers, 1990:201–27CrossRefGoogle Scholar; Rothman, DJ. Strangers at the Bedside: A History of How Law and Bioethics Trans-formed Medical Decision-Making. New York: Basic Books, 1991. See especially pp. 241–46Google Scholar; and Marshal, PA. Anthropology and bioethics. Medical Anthropology Quarterly 1992;6(1):49–73CrossRefGoogle Scholar. A survey developed by Fletcher, J. C.is often cited in the literature, but it is very limited in scope and is now somewhat dated. It is reported in Bermel J. Ethics consultants: a self-portrait of decision-makers. Hastings Center Report 1985;15(2):2.Google Scholar For more details on the same study, see Appendix. In: Fletcher, JC, Quist, N, Jonsen, AR, eds. Ethics Consultation in Health Care. Ann Arbor: Health Administration Press, 1989:185–201.Google Scholar A more recent survey, and one much richer in content, was conducted by Self and Skeel. Self, DJ, Skeel, JD. A study of the foundations of ethical decision making of clinical medical ethicists. Theoretical Medicine 1991; 12(2): 117–27.CrossRefGoogle ScholarPubMed

6. It is at least of historical interest that the Constitution of the Canadian Bioethics Society stipulates the following definition of an ethicist: “a professional employed to consult, research, or teach in bioethics, who has a doctorate in theology or philosophy” Canadian Bioethics Society Constitution, 1989 (revised):article 2.7.C.Google Scholar

7. Lynch, A. The ethicist's ethics. Westminster Affairs 1990;4(1):6–7.Google Scholar

8. For an excellent discussion of this issue, see Barnard, D. Reflections of a reluctant clinical ethicist: ethics consultation and the collapse of critical distance. Theoretical Medicine 1992; 13(1): 15–22.CrossRefGoogle Scholar

9. Veatch, RM. Models for ethical medicine in a revolutionary age. Hastings Center Report 1972;2(3):5–7.CrossRefGoogle Scholar

10. See note 9. Veatch. 1972:6.

11. DeGeorge, RT. The Nature and Limits of Authority. Kansas City: The University of Kansas Press, 1985.Google Scholar

12. Plato. The Re-public. Translated by Grube, G. M. A.. Indianapolis: Hackett Publishing Co., 1974.Google Scholar

13. This is what is expressed in the famous motto of the Enlightenment, which Kant articulated in the phrase, “Have courage to use your own understanding!” Kant defines enlightenment as follows:

Enlightenment is man's emergence from his self-incurred immaturity. Immaturity is the inability to use one's own understanding without the guidance of another. This immaturity is self-incurred if its cause is not lack of understanding, but lack of resolution and courage to use it without the guidance of another, (p. 54)

See Kant, I. An answer to the question: “What is enlightenment?” Translated by Nisbet., H. B. In: Reiss, H, ed. Kant's Political Writings. Cambridge, England: Cambridge University Press, 1970:54–60. This essay is an excellent starting point from which to understand the famous quarrel between the Ancients and the Moderns and to understand better why autonomy has come to have the value that it does in contemporary society.Google Scholar

14. Kant, I. Translated by Smith., N. K.Critique of Pure Reason. 2nd ed.New York: St. Martin's Press, 1965. See p. 29.Google Scholar

15. Macklin, R. Mortal Choices. New York: Pantheon Books, 1987. See p. 18.Google Scholar The issue of moral exper- tise has received considerable attention, both in the philosophical and in the applied ethics litera- ture. A good collection of relatively recent articles on the issue can be found in Rosenthal, DM, Shehadi, F, eds. Applied Ethics and Ethical Theory. Salt Lake City: University of Utah Press, 1988. See especially chapters 6–10.Google Scholar

16. Whether clinical ethicists should “give advice,” “make recommendations,” or “state opinions” has been the subject of some debate. The issue depends largely on the status that the ethicist's pronouncement is supposed to have. For example, Ackerman argues that ethicists may make recommendations under the qualification that in doing so they are stating what they believe reflec- tive members of the moral community would endorse. See Ackerman, TF. Conceptualizing the role of the ethics consultant: some theoretical issues. In: Fletcher, JC, Quist, N, Jonsen, AR, eds. Ethics Consultation in Health Care. Ann Arbor: Health Administration Press, 1989:37–52.Google Scholar This view, which has variants in a number of other writings, encounters some fundamental problems. For example, determining what reflective members of the moral community would and would not endorse concerning a particular issue will require a considerable amount of interpretation. In any event, the ethicist who makes a recommendation in Ackerman's sense is not herself making a normative judgment or assuming moral authority. She is, whether accurately or not, reflecting or expressing the normative judgment she believes members of the community would make under ideal conditions. Thomasma offers a bolder and feistier case for making recommendations, but for the most part it can be conceptualized as a variant of Ackerman's consensus view. See Thomasma, DC. Why philosophers should offer ethics consultations. Theoretical Medicine 1991; 12(2): 129–40. However, Thomasma's view exceeds Ackerman's in permitting (or even requiring) the ethicist to state a personal opinion. Even so, although the ethicist who states her “own view, expressed as such” (p. 137) is definitely making a normative judgment, the fact that she moderates her judgment with the qualifications that it is her own signals that she is not claiming or pretending to ground her own view in moral knowledge. Given the likelihood that such qualifications and nuances will be misunderstood in the clinical context, I have doubts whether ethicists should make recom- mendations at all. In any event, to make recommendations in either Ackerman's or Thomasma's sense is a far cry from assuming moral authority or making normative judgments speaking-as-a-bioethicist.CrossRefGoogle ScholarPubMed

17. In Dostoyevsky's classic novel, the Grand Inquisitor is a legendary anti-Christ who takes upon himself the burden of choice and responsibility for a people he supposes to be too weak to live in freedom. Dostoyevsky, F. Translated by Garnett., C.The Brothers Karamazov. New York: Modern Library, 1929.Google Scholar

18. Eric Fromm's classic work Escape from Freedom, in which he analyzes the relinquishment of author- ity and autonomy, would be a good starting point for research along these lines. Fromm, E. Escape from Freedom. New York: Rinehart, 1955.Google Scholar

19. However, I expect that as a matter of sociological fact external demands of this sort –market demands they could be called – will play a greater part in determining how the profession develops than will considerations internal to the profession about what ought and ought not to be. One recent call for greater “moral engagement” (read: assumption of authority) in ethics consultation offers little reason why this ought to be beyond the fact that clinical exigencies in some sense demand or “require” such engagement. See Moreno, JD. Ethics consultation as moral engagement. Bioethics 1991;5(1):41–56. See especially p. 52 and p. 54.CrossRefGoogle ScholarPubMed

20. For an insightful discussion of the public relations dimension of the ethicist's role, see Frader, JE. Political and interpersonal aspects of ethics consultation. Theoretical Medicine 1992; 13(1):31–44. See especially pp. 35–40.CrossRefGoogle ScholarPubMed

21. Harrison, M. Organ procurement for children: the anencephalic organ donor. Lancet 1986; 2(8520): 1383–5. See p. 1385.CrossRefGoogle Scholar

22. Thomasma, DC. Legitimate and illegitimate roles for the medical ethicist. In: Ackerman, TF, Graber, GC, Reynolds, CH et al. , eds. Clinical Medical Ethics: Exploration and Assessment. Lanham, Maryland: University Press of America, 1987:83–94.Google Scholar

23. For a particularly cogent exposition along these lines, see Ackerman, TF. Conceptualizing the role of the ethics consultant: some theoretical issues. In: Fletcher, JC, Quist, N, Jonsen, AR, eds. Ethics Consultation in Health Care. Ann Arbor: Health Administration Press, 1989:37–52.Google Scholar The results of Self and Skeel's recent survey of ethicists may be interpreted as evidence contrary to my sociolog- ical hypothesis. See note 5. Self, DJ, Skeel, JD. 1991; 12(2): 117–27. The majority of respondents to their survey, according to Self and Skeel, could be classed as “moral objectivists.” Whether their data warrant this conclusion, and whether their sample was sufficiently representative, may be questioned. More importantly, however, terms like “moral objectivism” are very abstract and can be defined in a variety of ways. The fact that the authors list Kant (whom I contrast with Plato in this very regard!) as a paradigm example of moral objectivism puts the definition they used in question.Google Scholar