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I refer to the ethics consultant for convenience. My goal is to characterize an operative, but largely neglected, sense of authority in ethics consultation without regard to whether the consultations are provided by individual consultants, consultative teams, or HECs. Evident differences do exist between these three kinds of ethics consultations, and they will affect the application of my points. Although I allude to some of these differences in passing, my main concern is to outline a new way of understanding authority in the process of ethics consultation. The practical and ethical problems associated with this sense of authority will be different for individual consultants, consultative teams, and HECs, but systematically differentiating them is beyond the scope of this paper.Google Scholar

For the best exposition of this view, see Flathman, , supra note 11.Google Scholar

For a description of aspects of the witnessing function of the clinical ethicist, see Agich, George J., “Clinical Ethics: A Role Theoretic Look,” Social Science and Medicine, 30 (1990): 389–99.CrossRefGoogle Scholar

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This belief is due primarily to the way that treatment of ethics consultation has taken as its paradigm the HEC understood in bureaucratic, institutional terms. Such a view stresses the official or formal nature of HECs as committees that wield power or influence within the institution.Google Scholar

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See supra note 3.Google Scholar

The apparent ease with which one can don an insignia of power in some medical centers, simply by wearing a white coat of a certain length and style, suggests that power is diffusely distributed in these settings. No wonder, then, that bioethicists carrying pagers or wearing white coats in the medical center has been the source of innumerable quips. Whether these practices are anything more than convenience or affectation is, however, less important than their function of wittingly or unwittingly appropriating the mantle of power.Google Scholar

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Id. at 37–40.Google Scholar

See supra note 3.Google Scholar

DeGeorge distinguishes epistemic authority from authority based on competence, personal authenticity, or excellence. Although they are closely related, they are dissimilar in important ways. Of these kinds of authority, competence authority is especially important for understanding ethics consultation.Google Scholar

How the ethics consultant is authorized is a complicated process that involves institutional policy or protocol on ethics consultation on the one side, and trust or acceptance of the ethics consultant by the individuals involved in the case, on the other. Who is able to access the ethics consultant is a serious second-generation problem for HECs and ethics consultants, as Agich and Youngner (supra note 10) have pointed out.Google Scholar

See DeGeorge, , supra note 24, at 37.CrossRefGoogle Scholar

The importance of discretion or judgment in the exercise of authority has been well recognized in philosophy. Plato perhaps went further than any other thinker in believing that such functions should be socially delegated to a specific individual, namely, the philosopher-king. Many have rejected his concept of the philosopher-king because his solution minimizes the central practical problem, namely, how to identify individuals who are worthy of being entrusted with so much discretion.Google Scholar

Friedrich, Carl J., “Authority, Reason, and Discretion,” in Friedrich, Carl J., ed., Authority: Nomos I (Cambridge: Harvard University Press, 1958): At 46–47.Google Scholar

This discussion of the etymology of authority is drawn from Friedrich, , id. at 30.Google Scholar

Later, the word auctoritas became a more general notion and acquired a usage similar to the modern word author, meaning a maker or originator. This later meaning seems to be at the basis of modern understandings of power as something that originates with one person and is imposed on another, in contrast to the proper idea [of auctor] as one who adds. Strictly speaking, this must be an adding to what existed before, as a witness adds his testimony about some event in question. From this original usage, the meaning gradually acquired the sense of creation, the creation of something new that can then be subject to further elaboration. An author is thus someone who comes between us and the facts or ideas, and adds to them a ground of belief about them. Authority originally involved adding wisdom to will, adding knowledge of shared values and traditions to whatever the people wanted to do. Even when the stress is placed on the fact that the author adds something, that something is added to what already existed, as a witness does when giving testimony. The author does not create something ex nihilo, but affirms something de novo.Google Scholar

See LaPuma, Schiedermayer, , supra note 3; and Grunfeld, , supra note 3.Google Scholar

Interestingly, when that question is raised about a specific in authority figure, the authority figure is usually well on his way to losing authority. A number of answers might be given to this question, none of which, however, gets at the distinctive phenomenon that reasoning accomplishes by augmenting and confirming the will. One might, for example, appeal to hierarchy and status, interest and advantage, personal attachments and loyalties, or some specific law. None of these considerations in itself really provides a satisfactory explanation of why an authority figure's advice should be followed in a specific context. Augmentation by reasons, however, does provide a basis that can justifiably motivate action.Google Scholar

Beyond that important practical question is one about the implications of this kind of power for the consultant's epistemic authority in clinical ethics. The issue is not whether the ethics consultant's epistemic and competence authority can be transformed into in authority or executive power by means of personal authorization, but whether a different kind of authority is infused that practically and politically complicates the situation. It is inevitable that the dynamics of certain cases will propel the ethics consultant into these uncharted waters. It is an open question to what extent this does occur in the course of ethics consultation.Google Scholar

In such instances, the ethics consultant needs to remember that the individual physician practices within the institution as a matter of privilege, not right. Appealing to the medical staff hierarchy without emotion and guided by clear-headed reasoning is a sure way to bring a recalcitrant physician in line with obvious patient rights. Also, administrative avenues of appeal are usually backed up by legal remedies. A reminder of the law can have a sobering effect on key members of both the medical staff and the administration. Going to such lengths, however, does not make the ethics consultant's authority executive or in authority power. Quite to the contrary, it simply confirms the epistemic authority of clinical ethics, which necessarily includes a detailed knowledge of the relevant common legal requirements, rules, and remedies. Willingness to deploy this knowledge in the service of a patient, however, can require courage and fortitude by the ethics consultant, a fact that underscores the importance of the ethics consultant's character or virtue. This point is important both practically and theoretically, because some contractual and work arrangements for ethics consultants might promote or enhance the expression of this character or virtue, while other arrangements might significantly thwart its expression and stymie its development.Google Scholar

See Friedrich, , supra note 32, at 40–42.Google Scholar