For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the (...) American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, or committees (...) how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

In spite of an intensive discussion of ethical subjects, psychiatric departments rarely request clinical ethics support. However, during regular psychological supervisions subjects with an underlying ethical conflict are increasingly encountered. Based on the case study of a 39-year-old female patient suffering from personality disorder and her newborn child, the role of ethical consultation in psychiatric treatment and the decision making regarding health and welfare of child and mother will be presented. While discussing opportunities and limitations of psychological supervision as a (...) possible vehicle for clinical ethics support, it becomes obvious that during psychological supervision, ethical conflicts can also be reflected and treatment alternatives be evaluated. Psychological supervision finds its limits because of its more intuitive processes when the conflict escalates, when the patient cannot be involved and when institutional interests dominate. In these cases, the more structured and formalised process of clinical ethics consultation clearly offers advantages. (shrink)

There is no doubt that emotions have an important effect on practices of moral reasoning such as clinical ethics consultation. Empathy is not only a basic human emotion but also an important and learnable skill for health care professionals. A basic amount of empathy is essential both in patient care and in clinical ethics consultation. This article debates the “adequate dose” of empathy in ethics consultations in clinical settings and tries to identify possible situations within the process of consultation in (...) which this crucial feeling is at risk. (shrink)

There is little information about the content of ethics consultations in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records at St. Jude Children's Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician's fiduciary responsibility to the patient. Nonpatient consultations provided guidance (...) in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates that the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision making among multiple stakeholders, and further prospective research is need.. (shrink)

A 1999–2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to “best informants” in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The (...) median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC. (shrink)

Over the past few decades, Indigenous communities have successfully campaigned for greater inclusion in decision-making processes that directly affect their lands and livelihoods. As a result, two important participatory rights for Indigenous peoples have now been widely recognized: the right to consultation and the right to free, prior and informed consent (FPIC). Although these participatory rights are meant to empower the speech of these communities—to give them a proper say in the decisions that most affect them—we argue that the way (...) these rights have been implemented and interpreted sometimes has the opposite effect, of denying them a say or ‘silencing’ them. In support of this conclusion we draw on feminist speech act theory to identify practices of locutionary, illocutionary, and perlocutionary group silencing that arise in the context of consultation with Indigenous communities. (shrink)

With the rapid development of genetic research and applications in health care there is some agreement among funding and regulatory bodies that the public(s) need to be equipped to deal with the choices that the new technologies will offer them, although this does not necessarily include a role for the public in influencing their development and regulation. This paper considers the methods and purpose of public consultations in the area of genetics including large-scale surveys of opinion, consensus conferences and focus (...) groups. Consultation has been undertaken to enable the researchers/policy makers to see what the public do not know and plan more public education to make up the deficiency, to check on areas of concern so that public education can be used to address them or to gain a public mandate for a planned policy. An alternative and more recent approach is to find out what the public(s) do know and understand and to see how experts can learn from them in order to get a fuller view of technology in use. (shrink)

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

In this issue, Ellen Fox and colleagues report on their national study on ethics consultation in U.S. hospitals, following up on the previous 1999–2000 landmark study. Th...

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions (...) of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

BackgroundWhile previous research has examined various aspects of ethics consultation (EC) in U.S. hospitals, certain EC practices have never been systematically studied.MethodsTo address this gap, we surveyed a random stratified sample of 600 hospitals about aspects of EC that had not been previously explored.ResultsNew findings include: in 26.0% of hospitals, the EC service performs EC for more than one hospital; 72.4% of hospitals performed at least one non-case consultation; in 56% of hospitals, ECs are never requested by patients or families; (...) 59.0% of case consultations involve conflict; the usual practice is to visit the patient in all formal EC cases in 32.5% of hospitals; 56.6% of hospitals do not include a formal meeting in most EC cases; 61.1% of hospitals do not routinely assess ethics consultants’ competencies; and 31.6% of hospitals belong to a bioethics network. We estimate the total number of non-case consultations performed in U.S. hospitals to be approximately one half the number of case consultations; we estimate the total number of ECs performed in U.S. hospitals, including both case and non-case consultations, to be just over 100,000 per year.ConclusionsThese findings expand our current understanding of EC in U.S. hospitals, and raise several concerns that suggest a need for further research. (shrink)

BackgroundAdherence to widely accepted practice standards is a frequently used measure of healthcare quality. In the U.S., the most widely recognized authoritative source of practice standards for ethics consultation (EC) is the second edition of the American Society for Bioethics and Humanities’ Core Competencies for Healthcare Ethics Consultation report.MethodsTo determine the extent to which EC practices in U.S. hospitals adhere to these practice standards, we developed and analyzed 12 evaluative measures from a national survey.ResultsOnly three of the 12 standards achieved (...) over 75% adherence with reported EC practices: allowing anyone involved in a case to request an EC (100%), not requiring an attending physician’s permission to conduct an EC (97.6%), and having at least one person on the ethics consultation service (ECS) with advanced level EC proficiency (79.3%).ConclusionsImplications are discussed for achieving consensus on EC standards as they continue to evolve. (shrink)

Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons (...) they serve. This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist. (shrink)

The annual volume of ethics consultations (ECs) has been a topic of interest in the bioethics literature, in part because of its presumed relationship to quality. To better understand factors associated with EC volume, we used multiple linear regression to model the number of case consultations performed in the last year based on a national survey. We found that hospital bed size, academic affiliation, and urban/rural location were all associated with EC volume, but were not the primary drivers. Instead, these (...) variables affected EC volume through three other variables, all of which relate to ethics staffing: the percentage of case consultations performed by a single individual; whether the survey respondent’s main role at the hospital contained the word “ethics”; and especially, the number of full-time ethics program staff. We conclude that EC is an example of supply-sensitive care, and further research is needed to determine the optimal level of EC activity. (shrink)

The primary objective of The Health Care Ethics Con sultant is to focus attention on an immediate practical problem: the role and responsibilities, the education and training, and the certification and accreditation of health care ethics consultants. The principal questions addressed in this book include: Who should be considered health care ethics consultants? Whom should they advise? What should be their responsi bilities and what kind of training should they have? Should there be some kind of accreditation or (...) certification program to ensure that those who call themselves ethics consultants are in fact qualified to advise, consult, research, and write in health care ethics? The distinguished authors ofthese articles are persons with diverse backgrounds, interests, presumptions, and val ues. Not surprisingly, therefore, diverse responses have emerged to the questions posed. Though the book's chapters are individually authored, they are informed by the group discussions that went on during active workshop sessions, and by knowledge of the contributions of others. All of the chapters meaningfully represent their consensus. This is not to say that there were no disagreements regarding specific details, but rather that there were no fundamental objections on the book's basic content among a panel of authors who share basic premises regarding the role, responsibilities, education, and certifica tion of health care ethics consultants. (shrink)

This chapter focuses on ethical governance, which speaks to the infrastructure, processes, and practices that decrease the probability of performing ethically wrong actions and ethically bad outcomes resulting from relatively innocent actions. The ethics consultant can help spot gaps or other insufficiencies in ethical infrastructure, process, and practice. Ethics consulting consists in engaging in a due diligence process for ethical risk. The goal is to identify possible sources of ethical risk both in terms of features of the product and the (...) ways it may or may not be used, and to recommend feature changes and best practices for ethical deployment and use of the product. Ethics consulting more generally can be seen as aimed at either doing a bunch of good or avoiding a bunch of bad. Ethical challenges often arise in business because of competing assumptions and commitments that create seemingly irresolvable tensions or obscure the potentially bad consequences of particular decisions. (shrink)

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, thirty-nine (...) (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent, p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families. (shrink)

Genome Canada has funded a research project to evaluate the usefulness of different forms of ethical analysis for assessing the moral weight of public opinion in the governance of genomics. This paper will describe a role of public consultation for ethical analysis and a contribution of ethical analysis to public consultation and the governance of genomics/biotechnology. Public consultation increases the robustness of ethical analysis with a more diverse and rich accounts experiences. Consultation must be carefully and respectfully designed to generate (...) sufficiently diverse and rich accounts of moral experiences. Since dominant groupstend to define ethical or policy issues in a manner that excludes some interests or perspectives, it is important to identify the range of interests that diverse publics hold before defining the issue and scope of a consultation. Similarly, a heavy policy focus and pressures to commercialize products risk oversimplification of the discussion and the premature foreclosure of ethical dialogue. Consequently, a significant contribution of ethical dialogue strengthened by social analysis is to consider the context and non-policy use of power to govern genomics and to sustain social debate on enduring ethical issues. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

Despite their central role in the construction and development of the market for virtues as well as in the design, implementation, and evaluation of corporate sustainability strategies and governmental sustainability policies, sustainability consultants remain at best “hidden” corporate change agents. In this paper, we bring sustainability consultants back to the fore to account for how these actors discreetly regulate and shape contemporary sustainability transformations from the outside-in. We do so first by unpacking various roles of consultants as (...) engineers, market builders, power vehicles, boundary workers, issue translators, and soft regulators; then we conceptualize how, through these roles, they contribute to empowering, legitimizing but also potentially supplanting and undermining the activities of corporate change agents operating inside corporations. We finally propose some research orientations for studying further the role of sustainability consultants in corporate transformations toward sustainability. (shrink)

Background: There is growing interest in credentialing hospital ethicists. Consult volume is being incorporated into credentialing criteria, although few data supporting this approach are available...

With the rapid development of genetic research and applications in health care there is some agreement among funding and regulatory bodies that the public need to be equipped to deal with the choices that the new technologies will offer them, although this does not necessarily include a role for the public in influencing their development and regulation. This paper considers the methods and purpose of public consultations in the area of genetics including large-scale surveys of opinion, consensus conferences and focus (...) groups. Consultation has been undertaken to enable the researchers/policy makers to see what the public do not know and plan more public education to make up the deficiency, to check on areas of concern so that public education can be used to address them or to gain a public mandate for a planned policy. An alternative and more recent approach is to find out what the public do know and understand and to see how experts can learn from them in order to get a fuller view of technology in use. (shrink)

In most U.S. jurisdictions, clinicians providing informal “curbside” consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

In “Ethics Consultation in U.S. Hospitals: Opinions of Ethics Practitioners,” Fox and colleagues note that despite efforts of the American Society for Bioethics and Humanities to impr...

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

Clinical ethicists encounter the most emotionally eviscerating medical cases possible. They struggle to facilitate resolutions founded on good reasoning embedded in compassionate care. This book fills the considerable gap between current texts and the continuing educational needs of those actually facing complex ethics consultations in hospital settings. 28 richly detailed cases explore the ethical reasoning, professional issues, and the emotional aspects of these impossibly difficult consultations. The cases are grouped together by theme to aid teaching, discussion and professional growth. The (...) cases inform any reader who has a keen interest in the choices made in real-life medical dilemmas as well as the emotional cost to those who work to improve the situations. On a more advanced level, this book should be read by ethics committee members who participate in ethics consultations, individual ethics consultants, clinicians who seek education about complex clinical ethics cases, and bioethics students. (shrink)

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (shrink)

_The Consulting Room and Beyond _is not a typical example of clinical writing in the field of psychoanalysis. Therese Ragen, pushing the boundaries of the genre, thoughtfully explores in a very immediate way the intersubjective nature of psychoanalysis, particularly looking at the role of the psychoanalyst’s subjectivity, both how it influences and is influenced by the psychoanalytic relationship. The profound ways in which analyst and patient affect each other are captured as the author moves from a moment with a patient, (...) to one of her own memories, to a dream, to a professional consultation and back to the session with the patient. Ragen’s detailed descriptions of her subjective experiences and clinical skill help to weave the anecdotes into a compelling narrative, worthy of the attention of theorists, academics and clinicians alike. (shrink)

Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (shrink)

BackgroundTo help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners’ opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training.MethodsAs part of a multipart study, we surveyed “best informants” who self-identified (...) as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size.ResultsThe competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours.ConclusionsThese findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees’ preferences and needs. (shrink)

Growing evidence suggests that nurses and other clinicians often feel insufficiently equipped to manage ethical issues that arise in their practice (Truog et al. 2015; Woods 2005; Darmon et al. 201...

In her interesting paper on cross-jurisdictional legal approaches to brain death, Ariane Lewis considers whether informed consent is required for DNC testing in the UK, and proposes that it is not...

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like TIC) is systematically sensitive (...) to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

Laacke et al. investigate the ethical implications of possible artificial intelligence systems that automatically detect signs of depression by analyzing data from social media. The art...

In this paper I attempt to address what appears to be a novel theoretical and practical problem concerning physician-assisted suicide (PAS). This problem arises out of a newly created set of circumstances in which persons are hospitalized in jurisdictions where PAS, though now legally available to patients, remains morally contentious. When moral disagreements over PAS come to divide physicians, patients, and family members, it is quite likely they will today find their way to the hospital’s consulting ethicist, a member of (...) an emerging group of professionals charged with the responsibility (so we are told) of resolving moral conflict in the clinic. What can or should an ethics consultant do to fulfill this mandate in such circumstances? I argue that the now predominant conception of clinical ethics consultation is importantly deficient in that it provides no final guidance to ethicists on how they should respond in such cases. The ethicist may only recommend—or assist others to reach—solutions to moral disagreements falling within the limits of established norms. Since the normative landscape of PAS appears to be changing, whether it falls within these limits is unsettled. I conclude that the accepted goals of ethics consultation require a revised and expanded conception of the ethicist's role in cases involving PAS. I close by outlining what that revised understanding would look like and the further questions it raises. (shrink)