1. For a set of references on the issue of the questionable exercise of ethical expertise by ethics consultants, see Agich, GJ. The question of method in ethics consultation. American Journal of Bioethics 2001;1(4):31. Some critics of ethics consultation see the bogeyman of professional status for clinical ethicists lurking beneath the surface of almost any serious treatment of clinical ethics. For example, Wesley J. Smith (The question of method in ethics consultation: Transforming a career into a profession. American Journal of Bioethics 2001;1(4):42–3) commented on my paper “The Question of Method in Ethics Consultation” and complained that even raising the question of method was a step toward advocating professional status, a point he attributed without warrant and something he assumed to be seriously objectionable without offering supportive argumentation.

2. John Fletcher will be most likely remembered for his unflinching willingness to raise and address difficult ethical questions and to defend positions without regard to their acceptance by others. He specifically challenged the field of clinical bioethics to think critically not only about ethical issues arising in the care of patients but also about the very processes whereby bioethicists become involved in hospitals and healthcare institutions. John not only offered thoughtful reflections, but he addressed questions that many in the field sought to avoid. He was one of the first, and perhaps the leading, proponent of the need to develop standards, and he advocated, at various times, the creation of credentialing or licensing of clinical ethics consultants as a way to press the point about the importance of accountability and the need for quality assessment and improvement in this new field of practice. He minimized concerns about the professionalization of bioethics and related issues such as whether ethics consultants can or do profess ethical expertise and, instead, insisted that accountability is a primary responsibility for an eminently practical field like clinical ethics and consultation. In this spirit, I address the question of why quality is so rarely a theme in the literature on ethics consultation.

3. Agich GJ. What kind of doing is clinical ethics? Theoretical Medicine Bioethics 2005;26(1):7–24.

4. Spielman B. 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 2001;85(1):161–221.

5. This is a descriptive and not a normative point. Of course, clinical ethics should aim to transform the institutional setting of practice, but such change is, in my view, more a by-product of ethics consultation than a direct result, which is why ethics consultation is ideally a component of a clinical ethics program that includes policy formulation and education as well.

6. For a fuller treatment of the complex question of the ethics of quality improvement, see Baily MA, Bottrell M, Lynn J, Jennings B. The ethics of using QI methods to improve health care quality and safety. Hastings Center Report 2006;36:S1–40; Lynn J, Baily MA, Bottrell M, Jennings B, Levine RJ, Davidoff F, et al. The ethics of using quality improvement methods in health care. Annals of Internal Medicine 2007;146(9):666–73; Jennings B, Baily MA, Bottrell M, Lynn J, eds. Health Care Quality Improvement: Ethical and Regulatory Issues. Garrison, New York: The Hastings Center; 2007.

7. Donabedian, A. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press; 1980.