Since the inception of our field, clinical ethicists have taken different views on the appropriate methodology for clinical ethics consultation. Lively debates about how to best conduct clinical ethics consultations fill the pages of our academic journals, especially journal issues dating from the 90s and early 2000s. In recent years, however, these debates have slowed as ASBH has recommended a method they term ethics facilitation. This method of ethics facilitation closely mirrors the bioethics mediation method, one of a handful of standardized and well-known methods developed over the years that claims to ensure a responsible and reliable recommendation. Ethics facilitation is a recent but not the only method claiming to have captured the correct way doing of clinical ethics consultation.

The idea that the right method or standardized approach can ensure a reliable ethics recommendation seems to have arisen in the early 90s, which was a time when there was a great variety of educational backgrounds, religious commitments, and core disciplines among clinical ethicists. This background created a crisis of professional identity, which sparked two primary questions. First, amidst diversity, and little to no regulation, how can clinical ethicists as a group properly describe themselves and their work to others? Second, how can the public be sure the results of ethics consultation are consistent and of high quality? These questions were being pondered in the field as ASBH was getting started, and they are certainly still important today.

In a way, moves toward uniform procedures are reactions to the perceived threat of ideological diversity within our ranks. (I say “perceived threat” because there are plenty of people who don’t agree that ideological diversity is a threat to ethics.) Yet because variety and diversity exist, and because professional bodies need to have some standard outcomes to point to, clinical ethics has become increasingly about homogenizing right action. Many assume that following the steps of the right method will reliably lead us to good ethical outcomes.

Certainly, the popular consultation methods, like the Four Boxes, CASES, or Clinical Pragmatism, for example, all have strengths. They each frame moral inquiry in a particular way, which structures the ethicist’s reasoning and imagining so that a decision can emerge. But the strengths of these methods are perhaps also their greatest flaws. Methods frame moral inquiry, limiting the information we see as ethical in nature, potentially blinding us to idiosyncratic and vital aspects of a case. They carry us through a line of inquiry that is expected to result always in a timely answer, regardless of variation and complexity, regardless of context and culture.

My point is not to say methods are bad, or de facto illegitimate, but rather to say that clinical ethics, the search for the good of patients and their caregivers, ought never to be conflated with method deployment. Ethics cannot be circumscribed or captured by a standardized process or method. Ethics, the search for the good, is a way of life, a practice, and an activity that should always be breaking the limits of methodological framing. Ethics is a work of conscience that moves in real time and so ethicists should always be aware of and skeptical of the blinding effects of standardizable reasoning on the vicissitudes of reality. So, I would like to suggest that clinical ethics ought to be seen (especially by Christian ethicists) as liturgical activity.

“Liturgical activity” is a way of approaching the Sacred, the Good, the Other, which is what ethicists are doing when they attempt to discern the right decision in a case. The Eucharistic liturgy, in particular, is a purposeful and ordered approach toward communion with the Sacred, but one that cannot be completed by one’s own power. While it is purposeful and ordered it is also slightly different each time, according to the season, the week, the day, the people gathered, the setting, and so on. Like the Eucharistic liturgy, the “liturgical activity” of clinical ethicists is purposeful and ordered but is not controlling; it flexes to the moment and bends to the shape of the people gathered.

This “liturgical activity” of clinical ethics requires the ethicist to take a certain stance that is similar to that of a worshipper approaching the altar; humble yet bold. We do not learn this stance from methodology, because methodology’s purpose is to put things in order, and as such it seeks to have mastery. Participation in the Eucharistic liturgy teaches us how to properly approach the Sacred, as well as other people and the world around us, as mysterious gifts outside our grasp. Indeed, it teaches us that we must be approached while also approaching, which should take us out of our enchantment with our own ego, a necessary precondition for good ethics consultation. While clinical ethics consultation is not itself the liturgy and is not itself worship, it can be done worshipfully: with the humble stance that the liturgy demands of us.

While space does not permit a thorough defense or examination of the features of clinical ethics consultation in a liturgical stance¹ , I’d like to propose four orienting features:

1. Interruptibility: Keeping moral space and time open. Good ways of doing ethics consultation will create room for being interrupted.
2. Encounter: Attuning to the mysterious and surprising. Ethics consultation is an encounter with people and situations outside our grasp. We should attune ourselves to what we do not expect.
3. Reciprocity and Communication: Mutual participation in the Good. Ethicists participate in the activity of discernment, not as objective all-knowing observers but as human beings with our own perspectives and biases. We must involve ourselves, reflectively and responsibly, as participants in moral discernment.
4. Humility and Reflection: Self-Examination and dealing with our error. We must be willing to look at our own fallibility and the times we get it wrong. We must be professionally accountable for those times and embody the vulnerability necessary to learn from them.

Rather than entering into each consult with a prepackaged form or procedure, a liturgical stance requires us to be spiritually prepared and attuned to the moment. Great jazz artists are classically trained yet they show up on stage ready to improvise in response to their fellow musicians. Those who participate in liturgy do so according to their tradition’s rubrics, only to realize after many years that they can participate without consciously referring to the rubrics, the written pages. Likewise great clinical ethicists are well-versed in the literature, arguments, analyses, and theories that comprise academic ethics, yet they answer a consult call ready to improvise in response to the patient, family, and medical team in each unique situation and context.

Finally, seeing clinical ethics consultation as liturgical activity is not purely theoretical or metaphorical; the nature of the activity offers us practical guidelines for its structure. Rather than following a standardized method, we can engage our work according to the integrity of practical ethics itself. A few (non-exhaustive) practical guidelines that I suggest are in keeping with practical ethics are:

1. Create your own processes in your own contexts. One size does not fit all.
2. Embrace interruption in your processes, as part of the work. Reality rarely conforms to our plans. In contrast to methods which aim directly toward resolution, those in a liturgical stance will be open to inefficient, slow, and repeating parts of the process if they serve ethical inquiry and are best suited to the particular persons gathered.
3. Avoid prematurely limiting consults to “the ethics question” which can overly narrow and constrain engagement with reality and, subsequently, moral imagination.
4. Embrace your role as an active participant in moral decision-making. Standardized methods sometimes serve as ways to distance oneself from the vulnerability intrinsic to prudential judgement, which offers some emotional protection but undermines the process. Ethicists are not called to hide behind procedure for the sake of their conscience.
5. Regularly engage in self-reflection regarding the blind spots in your processes. Every process has blind spots and as we acknowledge our limited understanding of each particular situation, especially with regard to the patient and family who are usually strangers, we must be ready to revise our ethical theories as well as our processes as new features emerge.

I have often found the work of French phenomenologist Jean-Louis Chretien inspirational for my clinical ethics work as liturgical activity. In Under the Gaze of the Bible, he writes:

"For Christian wisdom does not consist in applying rules, nor in confronting what happens with the lessons of a manual, but in making our existence as disengaged, as ductile as possible, so that it tends to be nothing but an Aeolian harp on which the Spirit can improvise, according to the needs of the moment and the exigencies of such an encounter."²

JORDAN MASON, PHD, MDIV, HEC-C

Clinical Ethicist and Theologian

Providence

Santa Rosa, California

ENDNOTES

1.  For such an analysis, see Jordan Mason, Clinical Ethics Consultation and Liturgical Practices of Participation: A Theology of Technique for Practical Ethics, Doctoral Dissertation, Saint Louis University, 2023.
2. Jean-Louis Chretien, Under the Gaze of the Bible, Translated by John Marson Dunaway, Perspectives in Continental Philosophy, Edited by John D. Caputo (New York: Fordham University Press, 2015).