In several splendid essays, John La Puma and others (La Puma 1987; La Puma et al. 1988; La Puma and Toulmin 1989; Schiedermayer et al. 1989) have defended the view that there is a legitimate role for the ethicist working within the clinical context as a consultant. Mentioning several models for this role, they argue that only a clinical model is appropriate. Possessing special knowledge and skills, as these authors see it, the ethicist should be responsible for helping physicians become more sensitive to ethical issues. In this, the clinical ethicist is precisely like any other clinical consultant, bringing special knowledge and skills to bear on special problems flagged by an attending physician as needing that expertise—most often, as these occur as regards some specific patient. I should note here, in passing, that there is hardly a mention of other health professionals, patients with their significant others, or the social nexus of the practice of medicine.

Although they pose the idea that the ethicist could be either physician or non-physician, they in fact argue that the ethicist must be able to interview and do physical examinations of patients—as well as speak with families, discuss cases with members of the health care team, review charts, and document recommendations in patient’s medical records. In short, he/she must be an experienced clinician able to help the attending manage patients—which suggests that the physician is the one who is best able to serve this role, as Siegler argued a long time ago (Siegler 1979). For this view of ethics, the ethicist’s credibility and effectiveness depends not only on knowing ethics but, of equal if not more importance, on possessing a fund of relevant medical knowledge, hands-on clinical patient care skills, and the ability to discern medical distinctions that are technically or morally relevant in caring for patients (i.e. to make clinical judgments, and to be as accountable for them as any other clinician). In fact, therefore, this view of ethics proposes that (a) only a clinically experienced physician can serve as a clinical ethics consultant, and (b) such a consultant serves the attending physician first and foremost, if not exclusively (La Puma and Priest 1992; Edwards and Tolle 1992).

Except for the clear implication that physicians can best serve in this role, George Agich (1990) had already stated and expanded on that proposal some years ago. He delineated four roles inherent to the idea of clinical ethics: teaching, watching, witnessing, and consulting. Moreover, from his comments on my work, it is clear that Agich still endorses his basic view set out in the earlier article (Agich 2005). Clinical ethics is different from more traditional forms of teaching, as it is conducted in the practical settings of clinical medicine. It is, moreover, a form of practice similar to other forms of clinical practice, although it is more involved in role modeling, character building, and skill acquisition than with theoretical, cognitive understanding.

Watching, in Agich’s usage, involves the methodical, disinterested, and objective study of medical practice. Witnessing, by contrast, draws one into the scene of social action as an agent who is accepted by others also involved; the witness is thus a resident expert who is able to provide useful, practical advice to those others. Appealing to an anthropological model derived from the work of Charles Bosk (1985) Agich sees witnessing as most important. As a witness, the ethicist is “more directed to establishing or ratifying a moral community than mere watching…” (Bosk 1985). Somewhat like a priest invited into the private meditation and ceremonies of the group—where inmost secrets, uncertainties, and anxieties are revealed and shared—the witness comes “to symbolize for the group the moral community outside the hospital…” (Bosk 1985). He also insists that this role includes helping to give social definition to clinical realities, and may even provide subjects with a sense of legal protection, although it is unclear in just which sense this “protection” is understood—whether as a form of ‘cover your ass,’ or, more unlikely, I suppose, as giving actual legal information and even advice (in which case, however, the ethics consultant must also then be a licensed attorney).

One natural outgrowth of this unique form of participation is consulting, the fourth activity of clinical ethics. As for any clinical consultation in clinical medicine, this special ethics activity naturally carries expectations of practical help in decision-making. It thus functions strictly under the aegis of the attending physician and within established institutional rules and procedures. The consultant may be an independent professional, but the work of anybody with this role is established and remains under the aegis of the attending physician, whose work is thus directed to problems perceived by the physician and associated with the primary physician-patient relationship. Such a consultant is assumed to have relevant expertise, skill, and training to identify and evaluate the issues involved in caring for an individual patient (Agich 1990, p. 392).

The expectation of practical help is central. The ethicist is expected to possess and utilize the relevant expertise, skills and methods in order accomplish the consultative goal. While not necessarily a physician, as Agich sees it, the ethics consultant is nevertheless a specialized clinical practitioner “who brings an independent expertise to bear on problematic cases or issues in medical practice,” and who functions in clinical situations “as an identified expert…to offer advice or recommendations in specific cases presenting ethical problems” (Agich 1990, p. 393).

But with respect to what is the ethicist a so-called ‘expert’? In an early article focused on just those situations that might reasonably prompt an appeal for a specialist in ethics, Albert Jonsen raised several critical questions that are pertinent to this question: “What sort of knowing…is ethics? Above all, what is its use?” (Jonsen 1980, p. 158). He went on to propose a way of approaching and thinking about these issues within clinical settings. Although it took some time for him to identify just this “way,” a few years later he then more confidently declared, “hospital philosophers or ethicists are, in fact, casuists” (Jonsen 1986).

For Jonsen, the usual approaches to ethics are not helpful, for they miss the main point and focus on decision-making: not conceptual analysis of issues, but direct involvement in the decision making process. Far from a novel proposal, he points out, this is an idea with a long history in western ethical traditions, specifically in casuistry. This approach in general involves considering morally perplexing cases “in the light of certain general ethical norms or rules,” that is, where “a definite view of the nature of the moral life is confronted with a well-described real or fictional situation.” As such discussions call for a specific and practical response, not to abstract concerns but to the particular set of circumstances under consideration, they invoke a clear focus on the question, “What should be done in this situation?” (Jonsen 1980, p. 159)

For Jonsen, then, casuistry is not merely one more way of applying principles already at hand to particular clinical cases, since it is only when a number of such cases are arrayed together that the notion of “principle” itself begins to have significance. In the practice of casuistry, properly understood, a comprehensive ethical theory does not precede but follows the study of particular cases—though it is surely true that moral problems are constructed around “an already perceived but, as yet, inarticulate moral notion” exemplified by particular cases (Jonsen 1980, pp. 169–171).

This focus on the decision process suggests that casuistry and clinical ethics consultation are very much the same activity: both are forms of reasoning directed toward practical resolutions that lead to decisions, and from there to practical actions. In these situations, uncertainty and probability, not “the truth,” are the centering themes. Both have the aim of assurance or, as the casuists said, a “‘certain conscience’;” that is, Jonsen explains, “resolving practical moral doubt” (Jonsen 1980, p. 163). In fact, he insists, casuistry did not presuppose a shared worldview but came about mainly during times of social fragmentation; it “thrived on doubts, uncertainties, and dilemmas, and moved toward the creation of an ethic rather than from one already formed,” and precisely here was the place of “assurance.”

Working in situations where an explicit moral consensus is missing and only probable opinions can be offered, the casuist-consultant methodically follows three steps: typification,¹ use of maxims, and assurance. A ‘case’ of interest to a casuist will present a typical moral dilemma that can be understood only within specific circumstances, which include some moral virtue (justice, charity) or rule (‘Thou shalt not kill,’ for example), and actors with certain social roles (parent, priest, proprietor) who encounter each other within specific social relationships (contracts, promises, requests). The case is a typification or, in Jonsen’s preferred term, paradigm²—a situation that is neither wholly unique nor fully universal, but rather is textured with “roles and relationships that are morally relevant to its interpretation and resolution” (Jonsen 1980, p. 165). As I prefer to say, it is a context.

Built around some virtue that is usually not well-articulated, the case also typically includes a reference to moral maxims called “reflex principles”—statements, the truth of which could not be completely demonstrated but were commonly accepted as having to be weighed in moral deliberations. Not taken for granted in the casuist’s discussions, they had instead to be tested or interpreted for their pertinence to the problem at hand—like “shuttles that move back and forth within the texture of the roles and relationships in order that a pattern can appear” (Jonsen 1980, p. 166).

The search for assurance follows quite naturally. Directly confronting the inherent uncertainty of every case, the casuist mainly sought to provide assurances to the moral agent that an action which provoked some apparently un-resolvable doubts, could nevertheless be performed with practical moral certainty. As Jonsen insists, however, “the ‘new’ casuistry must be more than talking about cases. It must be an articulated art, that is, it must be able to discuss the singular and unique in terms that can be generally understood and appreciated. It must have the quality of moral discourse” (Jonsen 1986, p. 71).

The first two views contend that the ethics consultant should be conceived on the medical model of independent expert brought in by the physician in charge, while Jonsen’s view is that ‘problems’ faced by any agent are the central occasion for the casuist’s thinking, and that the isomorphism between consultation and casuistry apparently holds only for ethics, not medicine; it remains unclear, however, how such an approach is either ‘clinical’ or how it could become involved in clinical encounters. It would seem that such involvement could occur solely at the request of, and mainly for the benefit of, the physician; access, if you will, to the patient could occur only with the physician’s specific permission. And, still, it is worth noting here, as earlier, that there is not a word about the array of other health professionals whose work is clearly highly significant for patient care: nurses, specialist technicians, and the like.

The idea that ethics consultation is different from what the medical model requires is also proposed by others, among them Glover, Ozar, and Thomasma, who specifically wish to differentiate the “individual expert” model that has been an important part of medicine from another which they believe is more appropriate for clinical ethics: the “decision facilitator” (Glover et al. 1986).