Revitalizing Health Care Ethics: The Clinician’s Voice (2025), by Stephen Scher of Harvard Medical School and Kasia Kozlowska of the University of Sydney Medical School, begins with a puzzle. Two senior physicians mention that in their daily clinical work, they inescapably address many ethical problems, large and small, on the spot, in the course of providing patient care. They note, however, that the resident bioethicist, when presented with one of their typical problems, cautioned that it would take him days or even weeks to reach a proper solution.
This new open-access book is, in effect, an extended attempt to understand this puzzle, this difference in perspectives. How does a clinician, without the trained capacity to engage in what Rawls referred to as formal ethical discourse in A Theory of Justice, decide matters of clinical ethics in a matter of moments, right then and there, using the informal ethical discourse embedded in their clinical thinking?
The strength of philosophers and bioethicists is in their capacity to identify and isolate the specifically ethical issues involved in any particular clinical situation, examine each issue separately using the intellectual tools of philosophy or bioethics, and then reach a conclusion that brings some sense of balance and closure to potentially competing considerations. That takes time.
By contrast, clinicians’ understanding of clinical problems, both those involving ethics and those not, builds incrementally over time—indeed, over decades—via the fact-laden challenges of addressing the needs of individual patients. Experienced clinicians may have encountered variants of common ethical problems, such as those involving informed consent, confidentiality, or determinations of appropriate treatment, dozens or even hundreds of times in their clinical careers. This ever-growing body of ethical knowledge is typically both extensive and sophisticated, and its sensitivity to subtle variations in the facts enables quick decisions in the here and now. Experienced clinicians eyeball the situation, identify salient factors, assess potentially countervailing considerations, and make a decision.
The differences between the perspectives of philosophers and bioethicists versus those of health care clinicians have important implications for bioethical interventions into clinical health care. Perhaps most importantly, in any particular clinical situation, the problems identified by a philosopher or bioethicist do not necessarily map onto what clinicians would consider “the problem” or the question to be decided. For a clinician, a clinical problem is not likely to be conceptualized, experienced, or expressed in terms of principles, rights, obligations, or other ethical notions. The questions for the clinician are much more concrete. For example:
- How much information does Mr. Smith need? How much information is he capable of integrating and assessing?
- What care can we reasonably provide in this situation? Is it time for everyone to let go?
- Given the potential consequences, how can we justify taking that sort of risk?
- We all know that our colleague Dr. X is not doing well. What do we need to do [now] to support him? When do we step in [later] to head off further missteps or otherwise unfortunate consequences?
The fundamental discontinuity here is that many, even most, clinical situations that raise what an ethicist might consider ethical questions are identified, understood, and addressed by clinicians without even using explicitly ethical language. Within a clinical setting, problems are typically interpreted and analyzed in instrumental terms related to that particular setting—that is, they are problems relating to particular patients, colleagues, institutional demands, and such matters.
In most cases, and with good fortune, all goes well: appropriate care is provided; goals are achieved; and everyone involved is happy with a job well done. But if something goes wrong with the care of a patient, or if the goals are not achieved, then the questions are “Why has that happened?” and “What went wrong?” Likewise, in considering prospective actions, the questions are typically related to clinical goals and how to achieve them. These questions are largely instrumental—concerning means and ends—and they are typically both conceptualized and answered in those terms. For clinicians, adding a layer of explicitly ethical language and concepts typically achieves nothing and may actually draw attention away from the clinical issues to be addressed.
Just this past week, I gave a talk to a group of psychotherapists. The first question following my presentation concerned the ethical consultation that a therapist and his colleagues had requested in their effort to address an especially thorny clinical situation. The therapist mentioned that the bioethicist never actually addressed their concerns. The question, then, to me was what they might have done differently. I suggested that, rather than presenting the clinical situation to the ethicist and waiting for him to respond, they could have determined in advance exactly what questions they had about the clinical situation and then asked the ethicist to respond to those particular questions. In addition, I suggested that they frame those questions in their own language or terminology, and that they then insist that the ethicist respond to those questions in that clinically based language.
The concern here is not who is right or wrong or even about how problems in clinical ethics should be conceptualized, understood, and analyzed. The concern, instead, is that philosophers and bioethicists who are aiming to help clinicians are potentially undercutting their own efforts insofar as they use formal ethical discourse—the language they have been trained to use—rather than the language that clinicians use daily in their work and in their communication with patients, families, and colleagues. And, even if a bioethical intervention serves to provide a solution to the clinical situation at hand, the use of formal ethical language—if that is what the bioethicist uses—more or less guarantees that the clinicians will have learned next to nothing that they will be able to use or apply in the future. In a clinical setting, the language of bioethics is inescapably foreign.
That said, every problem presents, in turn, an opportunity. The way to escape the foreignness of formal ethical discourse is to enter the world of the clinician. How do they perceive the problem? What are their concerns? How do they articulate their difficulties in trying to address a difficult clinical situation? But then comes the real challenge. Rather than retreating to the language of formal ethical discourse (the easiest thing to do) in framing a response to the situation at hand—and finding a path forward—the bioethicist should embrace the language of the clinic. It is a world of needs, wants, risks, trade-offs, compromises, possibilities, impossibilities, and unknowns, not to mention strong feelings, egos, power, denial, and acceptance. It is these phenomena that a bioethicist needs to understand and to talk about. One’s formal ethical or bioethical training may be helpful in understanding the problem, but the challenge of communicating with clinicians, patients, and families is one that needs to be understood as fundamentally tied to the world and language of the clinic.
Stephen Scher, PhD, JD is Senior Consulting Editor of the Harvard Review of Psychiatry.