Introduction

Clinical ethics consultation is amid a theoretical crisis. Clinical ethicists come from a variety of backgrounds, but those who practice as clinical ethicists have not had to meet any particular standards to do so. Lisa Rasmussen has articulated the crisis of clinical ethics consultation as resting on the horns of a dilemma: “One horn skewers the field for its lack of standards, while the other horn skewers it for proposing arbitrary or deeply contested foundations” (Rasmussen 2011a). It is easy enough to outline standards of knowledge regarding law, landmark medical cases, moral theory, mediation skills, etc. However, the particular standard Rasmussen is referring to as “deeply contested” is whether ethicists have “moral expertise.” After all, what does “moral expertise” mean, and what standards can be used to determine whether one is qualified to offer it better than another?

We adopt the definition of ethics expertise used by Ana Iltis and Mark Sheehan who write, “To be an ethics expert […] is to be an expert in knowing what ought to be done” (Iltis and Sheehan 2016).Footnote 1 Those familiar with moral theory know that such normative claims immediately trespass on contested theoretical ground.Footnote 2 As such, critics have sought to delegitimize the field of clinical ethics by challenging the notion that one can actually possess something like “moral insight” or “ethics expertise” (Cowley 2005, 2012; Scofield 1993; Archard 2011). These critics argue that because there is no consensus within moral theory about what makes one action right or wrong, there can be no such thing as ethics expertise, and therefore, no one can claim to be better at resolving moral questions than anyone else (Ho 2016).

Recognizing the threat this dilemma poses to the discipline of clinical ethics consultation, several scholars have attempted to articulate notions of ethics expertise that do not rely on contested claims of moral theory. Several of these scholars published papers collectively in a recent issue of the Journal of Medicine and Philosophy, generated from a workshop on ethics expertise at Wake Forest University (Iltis and Rasmussen 2016; Rasmussen 2016; Ho 2016; Iltis and Sheehan 2016; McClimans and Slowther 2016). In these papers, we identify and argue against two trends of (1) attempting to avoid meta-ethics by denying that clinical ethicists have ethics expertise, and, (2) attempting to articulate an ethics expertise that can resolve disputes without meta-ethics. We conclude that these trends detract from what clinical ethics consultation was founded to do and ought to still be doing—provide moral guidance, which requires ethics expertise, and engagement with meta-ethics. To speak of ethicists without ethics expertise leaves their role in the clinic dangerously unclear and unjustified.

Rasmussen’s “Better” Decisions—A Standard Without Reference

In her paper, “Ethics Consultants are not ‘Ethics’ Experts: But They Do Have Expertise,” Lisa Rasmussen makes three important moves to justify her conclusion that clinical ethicists need not be ethics experts. First, she rules out the possibility of meta-ethical justification in clinical ethics based on a descriptive claim about society. Second, Rasmussen attempts to avoid the need for any discussion of meta-ethics by distinguishing between “ethics” expertise and “normative” expertise. And third, she maintains that the clinical ethicist can help guide patients and their families to make better decisions. In this section, we will address concerns with all three moves.

From the beginning of her paper, Rasmussen clearly states that clinical ethicists ought to make recommendations in their consultations. However, she states that “the expertise in clinical ethics consultation is expertise in making morally relevant decisions” and that ethicists “should not claim expertise in a universally accepted moral foundation, and their recommendations will not be justified with certainty” (Rasmussen 2016, p. 385). This is a familiar move; many thinkers take the fact of moral pluralism in society to alleviate the need to have an objective, meta-ethical justification for their recommendations. But we are nonetheless left in an awkward situation where the clinical ethicist must make recommendations on what ought to be done.

While we agree that there is no consensus in society concerning the nature of morality, meta-ethical justification is nonetheless needed to support Rasmussen’s claim. She says that “there is deep and abiding pluralism and disagreement about these [meta-ethical] foundations, and no reason to think this will ever change” (Rasmussen 2016, p. 394). One might read Rasmussen as simply saying she does not see the possibility of agreement given our pluralist society, but she is not actually making a meta-ethical claim. We contend that Rasmussen does make the meta-ethical claim that there is no objective foundation for morality, albeit implicitly. She says that “judgments in clinical ethics consultations…are not—cannot be—justified by a meta-ethical argument about the correct foundations of morality, even if they were available. We need to pursue a different standard of justification for such decisions” (Rasmussen 2016, pp. 388–389). The emphasis is added, and we take this to mean that, in principle, judgments in clinical ethics consultations cannot be justified by meta-ethical arguments. Rasmussen is free to make such a meta-ethical claim, as many in philosophy have done so before, but she cannot defend this meta-ethical claim using the descriptive fact of moral pluralism in society. To assume that there is no objective foundation of morality is a meta-ethical claim about the nature of morality that needs defense in the form of an argument about the nature of morality.

Rasmussen’s second move is to design a conceptual framework of expertise that avoids any meta-ethical discussions in the first place. She does this by distinguishing between “ethics” expertise and “normative” expertise. This passage describes her move:

However, it is false to equate normative guidance with ethical guidance, so we have been mistaken in thinking that the expertise in clinical ethics consultation is ethics expertise. Clinical ethics decisions are all-things-considered judgments. They surely involve “ought” claims and value judgments, but they are rarely, if ever, merely moral decisions unless we assume that moral obligations always override or eliminate all other obligations (Rasmussen 2016, p. 388).

We take Rasmussen to be drawing an untenable distinction between normative and ethical guidance. For Rasmussen, ethical guidance involves consideration of the “merely moral” features of a case. She does not offer sufficient clarification of what a “merely moral” feature might be. We can only speculate that she has something in mind like guidance regarding traditional moral issues such as the moral status of an embryo or the sanctity of life. In contrast to ethical guidance, she holds that normative guidance involves competing considerations to the merely moral considerations; such competing considerations include “legal, financial, psychological, interpersonal, or other factors” (Rasmussen 2016, p. 388). She seems to be making a distinction between two kinds of competing influence on what one ought to do—ethical (e.g., status of an embryo or sanctity of life, etc.) and normative (legal, financial, psychological, etc.). We find this distinction between kinds of normativity to be a problematic ad hoc move. Importantly, this distinction grounds Rasmussen’s move from ethics expertise to normative expertise. We contend that normativity is just normativity, and the mental gymnastics required to say otherwise further confuses rather than clarifies what the clinical ethicist does.Footnote 3

Furthermore, these ethical and normative features must be balanced against one another to arrive at a decision. How they are to be balanced and weighed is left unclear. Do ethical features weigh more than normative features, do all normative features weigh the same or do some (legal) weigh more than others (financial)? Rasmussen’s normative expertise is predicated on drawing a clear and plausible distinction between the ethical and normative features in clinical ethics cases, yet we are skeptical that such a clear distinction exists.

Because we do not recognize a distinction between ethical and normative features of a case, we believe even Rasmussen’s normative features are implicitly ethical. For instance, doctors have legal responsibilities to act in a certain way, financial reasons to act in a certain way, familial reasons to act in a certain way, medical reasons to act in a certain way, etc. All of these responsibilities, or duties, demand that doctors ought to do certain things and avoid doing other things. How are these considerations distinctively different from the more traditional ethical features of a case (e.g., status of an embryo, etc.)? Does a doctor have a moral duty to provide for his family? If a doctor was asked to perform a procedure to which he conscientiously objected, yet he also needed his job to provide for his family, would his duty to financially support his family be an ethical feature of the case, or a normative-financial feature? For Rasmussen, normative features of a case must somehow involve ought claims because they do make a claim on what we should do, while remaining wholly distinct from ethical features, but she does not provide us with a clear way to differentiate normative features from ethical ones. We think Rasmussen fails to recognize that these competing normative factors are actually ethical factors, value-laden through and through. Given the implausibility of the distinction between the ethical and normative features of a case, her distinction between normative expertise and ethics expertise cannot be maintained.

To argue that there is a distinction between kinds of normativity necessitates engagement with meta-ethics—even to deny such a distinction entails implicit assumptions about the nature of morality.Footnote 4 Either way one comes down on this question, we are back to doing meta-ethics, the very thing these recent trends in the literature have tried to do without. We argue that these meta-ethical debates are an unavoidable and critical feature of theorizing about clinical ethics expertise, and should retain a prominent place in the literature.

Her recent JMP essay is not the first-time Rasmussen has attempted to salvage the expertise of the clinical ethicist by qualifying the domain. In a 2011 article, she articulates “an expertise for clinical ethics consultation, which I call ‘ethics’ expertise to distinguish it from a more robust, singular ‘moral’ expertise” (Rasmussen 2011b, p. 649). Here, Rasmussen distances the expertise of the clinical ethicist away from decisive access to objective morality—much like she does in her latest article. We think Rasmussen’s move in both articles fails for the same reason: trying to avoid meta-ethical commitments by using different terminology does not change those commitments. Whether clinical ethicists are “moral” experts, “ethics” experts, or “normative” experts, the fact remains that their expertise in knowing what objectively ought to be done allows them to guide patients and families to better decisions, which leads us to a critique of Rasmussen’s third move.

The final move that Rasmussen makes in her latest article is to avoid moral relativism by arguing that clinical ethicists can guide the relevant decision-makers to better decisions. She says “it is not the fact that they [clinical ethicists] can offer meta-ethical certainty, but rather the fact that they can help decision makers make better decisions that grounds their expertise” (Rasmussen 2016, p. 396). Rasmussen wants to defend the expertise of clinical ethicists, and she does this by saying that they can help decision makers make better decisions—but what can “better” amount to on her view? In another place, she says “we need to understand how to make good decisions in conditions of uncertainty” (Rasmussen 2016, p. 396). We added emphasis to show that Rasmussen is smuggling in an objective moral standard. Throughout the entire article, Rasmussen is trying to move past discussions involving objective morality and meta-ethics, but she justifies the expertise of clinical ethicists in their ability to make better decisions than non-experts.

Rasmussen cannot identify a better decision from a worse one without some sort of standard. She tries to articulate what a bad decision might look like, and she concludes that ignoring empirical data, socioeconomic considerations, and cultural differences would constitute a bad decision (Rasmussen 2016, p. 396). This indicates that a “better” decision is one that follows some sort of explicit process so to ensure that all the important questions are asked. However, to design and justify such a process would inevitably appeal to some sort of meta-ethical justification; implicit metaphysical and meta-ethical commitments ground a process in the same way explicit commitments do. Another problem for Rasmussen lies in explaining how to approach a case in which the decision rests on a clear moral dilemma—such as when a woman becomes pregnant via rape. In such a case, a traditional Catholic ethicist will defend the pregnancy based on a specific view of the human person; a secular ethicist could come to the opposite conclusion based on socioeconomic factors. Can Rasmussen say that one decision was better than the other? After all, Rasmussen rejects any claim to certainty and access to objective morality, how can we be confident that clinical ethicists do, in fact, guide patients and their families to better decisions? If Rasmussen can only say that clinical ethicists are experts because they “ensure that the right kind of questions have been asked,” then the clinical ethicist can be no more than a mediator, and ethical conflicts must be reduced to problems of communication. Furthermore, Rasmussen is unable to give a substantive role to the clinical ethicist because access to meta-ethical justification is, in principle, impossible. She adds that:

Justification in clinical ethics consultation decisions could be offered, at least partially, by formulating a list of important factors that go into clinical ethics consultations and demonstrating that one has investigated them…[t]his justification is quite prosaic…[b]ut I think it is the best we can do in this kind of circumstance (Rasmussen 2016, p. 396).

On such an account, the clinical ethicist lacks the “teeth” necessary to criticize obviously wrong moral decisions—Rasmussen only tells us what questions to ask but offers no guidance on how to answer them. Rasmussen realizes this justification is problematic, so she qualifies it with “at least partially,” but, given her aversion for meta-ethics, we do not see how she can flesh this justification out further. Rasmussen has cornered herself into articulating a view of the clinical ethicist that trivializes the nature of ethical conflict so common in consultations.

In sum, Lisa Rasmussen attempts to alleviate the pressure to make meta-ethical justifications for clinical ethics consultation decisions. However, in doing so, she inadvertently makes meta-ethical claims that she does not defend. Her move to distinguish between normative expertise and ethics expertise is problematic because she does not clearly distinguish between the ethical and normative features of a case. Furthermore, such a distinction necessitates engagement with meta-ethics. Finally, in an attempt to defend the expertise of clinical ethicists, Rasmussen claims that ethicists can make better decisions than non-experts, but, given her explicit rejection of objective standards of morality, it is not clear how she can distinguish between objectively bad, good, and better decisions in healthcare.

Dien Ho—Ethics Expertise Without Meta-ethics?

In the same Journal of Medicine and Philosophy issue, Dien Ho argues that lack of agreement about fundamental metaphysical claims is not unique to ethics, but persists in many disciplines without issue. Furthermore, he offers a method for resolving moral disagreements that functions without reliance on contentious meta-ethical or metaphysical claims. We argue here that neither of these solutions survive critique.

Dien Ho has attempted to point out that the lack of agreed-upon metaphysical foundations is not unique to ethics. He points to the unsettled debates between realism and anti-realism in physics; between natural law and legal positivism in jurisprudence; and over the ontological status of numbers in mathematics. He argues that despite such foundational disagreements, these disciplines all manage to proceed unscathed. If, Ho argues, we are to throw out ethics because of unsettled questions of meta-ethics, it seems we would also have to throw out physics, mathematics, and law (Ho 2016, p. 372).

While Ho is correct to point out that all disciplines rely on metaphysical foundations that are often left unresolved, it is not clear that the metaphysical disputes in physics or law cause the kind of problems that metaphysical disputes in ethics produce. This is because one can practice science without resolving—in fact, usually without even being aware of—the realism/anti-realism debate. Similarly, we can learn algebra while having no opinion of the ontological status of numbers. However, in ethics, how one judges many moral claims will be heavily influenced by one’s meta-ethics. Whether one believes abortion is wrong often hinges upon a belief in moral truths that are themselves dependent upon a god who establishes such truths. Moral judgments that arise in ethics, particularly the momentous kind we see in clinical cases, will often reach deep into the foundations of one’s worldview. Ethics cannot reasonably proceed detached from these foundations any more than a race can be run without a track. John Stuart Mill makes this observation when, in Utilitarianism, he notes the first principles of science often come at the end of analysis, but moral principles must come first. Mill writes that disagreement over the first principles of mathematics occur “without much impairing, generally indeed without impairing at all, the trustworthiness of the conclusions” (Mill 2002, p. 234). However, with respect to ethics, “the contrary might be expected to be the case with a practical art, such as morals. All action is for the sake of some end, and rules of action, it seems natural to suppose, must take their whole character and colour from the end to which they are subservient” (Mill 2002, p. 234).

Ho argues that we can make normative progress in ethics without appeal to meta-ethics by simply agreeing to resolve moral disagreements by an appeal to reason. Ho claims that a “default principle” arises in such situations that says that if A wishes to X, and B wishes for A to refrain from doing X, then B cannot justifiably prohibit A from Xing without sufficient reason (Ho 2016, p. 376).Footnote 5 The burden of proof is always on the person trying to prohibit the behavior of another. Ho recognizes that shifting the burden of proof to the one who wishes to prohibit the other’s behavior creates a “permissive bias,” such that where reason does not decide the issue (i.e., there is a “tie”), then there is no reason to restrict the behavior. He then goes on to fill in what counts as giving a “sufficient reason” in this system by pointing to arguments by parity, which operate on the assumption that we ought to treat similar cases the same. Arguments by parity look for a commonly held moral belief between the two discussants that is similar to the case they currently disagree on. Using the commonly held belief they can then resolve their disagreement by pointing out that like cases should be treated the same (Ho 2016, p. 378).

Ho provides the example of two individuals who disagree about whether eating meat is morally permissible. Because both individuals probably agree that eating dogs is not morally permissible, the vegetarian could argue that because dogs do not differ from cows and pigs from a moral point of view, then—from argument by parity—we ought to not eat cows and pigs (Ho 2016, p. 378). Arguments by parity require that disputants (1) agree that sufficient similarity exists between two cases and (2) that even if similarity is established, they share a belief about which direction the resulting conclusion ought to go.

The trouble with this strategy is that where it is successful, it will be successful because the disputants already share similar metaphysics. Where it breaks down, it will break down on account of differences in metaphysics. For example, Micronesians would draw a very different conclusion from Ho’s argument by parity with regard to eating meat. Micronesians have developed a taste for dog. To them, pointing out that dogs are morally equivalent to cows and pigs counts as a reason to eat dogs—not as a reason to refrain from eating cows and pigs.Footnote 6 Are dogs morally similar to cows or pigs? If dogs are morally similar to cows and pigs, is this a reason to refrain from eating cows and pigs, or a reason to eat dogs? These are metaphysical differences that will make all the difference in arguments by parity. In addition to these metaphysical troubles, Ho's argument by parity and default principles are themselves meta-ethical assumptions. He has not avoided, but merely presupposed his meta-ethics. Because metaphysics and meta-ethics are still deeply involved, Ho's strategy does not provide a way to make normative progress without them.

Iltis and Sheehan—Re-defining the Role of the Clinical Ethicist?

Iltis and Sheehan do some excellent work in clarifying the terminology used in the literature on expertise in clinical ethics. They conclude:

[T]hat “ethics expertise” most appropriately refers to expertise in knowing what ought to be done or being better at making moral judgments than nonexperts. We have further suggested that any attempt to articulate expertise with respect to knowing what ought to be done must include an account of ethics that either specifies the nature of moral truth and the means by which we access this truth or provides a theoretical account of ethics such that expertise in another domain is linked to knowing or being better at judging what ought to be done and the standards by which this “knowing” or “being better at judging” is determined (Iltis and Sheehan 2016, p. 431).

We completely agree with this statement, and we hope that future discussions on expertise in clinical ethics tackle the meta-ethical concerns head-on. However, Iltis and Sheehan make an interesting move from this point. They argue that clinical ethicists need not be ethics experts to be clinical ethics consultants (Iltis and Sheehan 2016, p. 432). They suggest that “being free from the label of ‘ethics’ expert will help to liberate this process from worries about ‘moral authority’ and place it on a much more pragmatic footing” (Iltis and Sheehan 2016, p. 432). This echoes Rasmussen’s move away from ethics expertise, but it is different in an important way.

By concluding that clinical ethicists need not be ethics experts, Iltis and Sheehan are making a claim about the nature of the clinical ethics consultation. Whereas Rasmussen’s argument against ethics expertise is problematic, we think that Iltis and Sheehan do a good job in clarifying the terminology in this debate and they argue that any discussion of ethics expertise in clinical ethics must be grounded in meta-ethics. Likewise, where Rasmussen and others explicitly reject the possibility of making certain meta-ethical claims, Iltis and Sheehan seem to think such a move is possible: they say “we do not go so far here as to argue there can be no ethics experts” (Iltis and Sheehan 2016, p. 423). But on their view, an ethics expert is one who knows what ought to be done, in an objective and normative sense, so by clarifying what an ethics expert is and then concluding that clinical ethicists need not be ethics experts, we think Iltis and Sheehan are making a substantial claim about the nature of clinical ethics consultation.

For Iltis and Sheehan, the role of the clinical ethicist appears even murkier compared to Rasmussen’s ethicist. Recall that Rasmussen holds that the clinical ethicist does make better decisions than non-experts. Given the thorough clarification of ethics expertise done by Iltis and Sheehan, we are not sure that clinical ethicists can make such a claim. In fact, we are not sure what a clinical ethicist is for Iltis and Sheehan. Since they are consistent in their view and rightly conclude that ethics expertise involves knowing what ought to be done and being able to secure the meta-ethical grounds for such claims, Iltis and Sheehan cannot defend the view that clinical ethicists know what ought to be done. They say:

[N]one of this is to say that clinical ethicists do not have something important to contribute to the clinical or other relevant setting. Nor is it to say they have no expertise. It is only to point out that without an account of the standard by which knowledge of what ought to be done is judged, CECs may not be called ethics experts, that is, experts knowing what ought to be done (Iltis and Sheehan 2016, p. 432).

We laud Iltis and Sheehan for not attempting to smuggle in some meta-ethical claim without justification, but their conclusion really changes the nature of the clinical ethics consultation. On their view, the possibility and the need for doing the right thing are taken off the table. What then, can the clinical ethicist do? Mediate? Alleviate problems with communication? While mediation and clear communication are certainly important features of a clinical ethics consultation, more is needed to resolve deep-seated moral dilemmas that are commonly found in the context of health care ethics. To revisit a scenario from above: what happens in a case of genuine moral disagreement, like in cases involving pregnancy resulting from rape? Iltis and Sheehan prohibit the clinical ethicist from helping those involved make a better decision—so are all decisions equal? Iltis and Sheehan might counter by saying that decisions must be made with all the relevant information, with mutual understanding of the implications of the possible decisions, etc. But in cases where there is a genuine moral disagreement, is there a way to judge alternative choices?

In sum, we think Iltis and Sheehan rightly affirm that ethics expertise must entail both the capacity to make the right decisions and the necessary meta-ethical justification to back them up. However, they conclude that the clinical ethicist need not be an ethics expert. Furthermore, an implication of their consistency and resistance to smuggle in meta-ethical commitments is that the role of clinical ethicist substantially changes. No longer is the ethicist able to make recommendations of what ought to be done. Iltis and Sheehan take the fact of pluralism to justify their move away from ethics expertise. In contrast, we think that more work needs to be done in making explicit the meta-ethical and metaphysical commitments necessary to ground the kinds of normative recommendations that clinical ethicists do, and should, make. Furthermore, any attempt to do away with such theoretical commitments will inevitably undermine the attempt to professionalize and standardize clinical ethics consultation.

Conclusion

We have argued that two recent trends in the dialogue over ethics expertise in clinical ethics consultation are problematic. Neither arguing for a view of clinical ethics consultation that does not include ethics expertise (Rasmussen), nor the insistence that one can claim ethics expertise without trespassing on the ground of meta-ethics (Ho), are adequate to the job of a clinical ethics consultant. Ethics expertise need not be understood in the overly-confident sense which some critics of clinical ethics have used to caricature the field. No one is arguing for a clinical ethicist who bursts into the clinic and proclaims, “Don’t get that abortion! It’s ok, I’m an ethicist, here’s my badge.” This seems to be the fear that critics like Christopher Cowley have in mind when he writes, “The ethicist comes to the committee and makes his moral judgment ‘euthanasia should be legalized’ and offers his reasons (utilitarian, deontological) etc.” (Cowley 2012, p. 340). The nature of ethics expertise required for the facilitation approach laid out by ASBH is far more modest than these critics have in mind.

In the second edition of ASBH’s report Core Competencies for Healthcare Ethics Consultation, the taskforce endorses a facilitation approach to clinical ethics consultation, which sees the ethicist as one who helps “the relevant decision makers fashion a plan that respects the needs and values of those involved and that is within the bounds of ethical and legal standards” [emphasis added] (ASBH 2011, p. 7). This need to be an authority on ethical boundaries is critical because “the ethics consultant may be faced with involved parties who are opting for a course of action that is clearly outside the parameters of what would be ethically acceptable” (ASBH 2011, p. 4). In another passage, the taskforce argues that “a proposed course of action may be unethical and the consultant should recommend against it” (ASBH 2011, p. 8). We agree that such moral parameters exist, that ethicists are trained to identify them, and ought to be vested with the authority to enforce them, but this requires a notion of ethics expertise. To have ethics expertise is to know what ought to be done, and what a trained clinical ethicist ought to do in the face of a medical moral dilemma is set the ethical boundaries and then proceed to build a consensus within those boundaries among the relevant stakeholders. The recent trends in the literature on ethics expertise have no theoretical resources by which to identify or defend such ethical parameters given the aversion for ethical theory and meta-ethics. We believe the ability to set such ethical parameters are a critical function of the clinical ethicist, a function in line with the history, theory, and future of the field.

Historically, health care ethics was born of the notion that greater ethical oversight was needed in human research and medicine. From Tuskegee to Willowbrook, disturbing moral violations gradually eroded the public trust in medicine and human research. In his now famous exposure of these “troubling charges,” Henry K. Beecher writes, “what seem to be breaches of ethical conduct in experimentation are by no means rare, but are almost, one fears, universal” (Beecher 1966, p. 65). David Rothman’s Strangers at the Bedside details the collapse of the physician–patient relationship in the middle of the twentieth century. He asserts that the erosion of this relationship made the invisible visible—the decisions once made behind closed doors by doctors acting unilaterally suddenly became public business as “Outsiders to medicine—that is, lawyers, judges, legislators, and academics—penetrated its every nook and cranny” (Rothman 1991, p. 3). The Belmont Report, which had a large influence on the development of principlism, explicitly states one of its purposes is to “identify the basic ethical principles that should underlie the conduct of biomedical and behavioral research involving human subjects and to develop guidelines which should be followed to assure that such research is conducted in accordance with those principles” (The Belmont Report 1978). The Belmont Report itself reaches back further to the Nuremberg Code, which both morally condemned the “tortures and barbarities” of Nazi doctors and scientists on concentration camp prisoners during World War II while outlining ten points for conducting ethical research on human subjects (Annas and Grodin 1992, p. 2). Such condemnation and guideline setting at the historical roots of health care ethics is fundamentally normative work. These documents do not merely attempt to ensure that future physicians ask all the right questions before passing moral judgment; rather they give normative guidelines to guide the content of those moral judgments. Nazi experimentation, Willowbrook, Tuskegee, and unchecked physician discretion were condemned, in no uncertain terms, as moral transgressions that should not be carried out again. If we expect ethicists to denounce the Willowbrooks and Tuskegees of the future, we must provide them with the normative theoretical resources to do so. These theoretical resources are what is at stake in the ethics expertise debate. This normative spirit must not be lost upon the field of clinical ethics consultation.

In more recent decades, the fact of moral pluralism along with the rise of new technologies has spurred uncharted moral territory that begat clinical ethics in its modern form (Fletcher 2004, pp. 433–439). Clinicians found themselves faced with many difficult moral questions they felt ill-equipped to handle and turned to the humanities for sustained reflection on these topics (Zaner 1996, p. 256; Ruddick 1981, p. 16). The rapid pace of technological development has left us far more certain of what we can do while stumbling in the dark for whether we should. With big moral questions looming around the seemingly inevitable development of ever more powerful technologies, the need for a discipline to help us answer questions about what ought to be done is greater than ever.

In the end, it seems that critics of ethics expertise in clinical ethics consultation are applying a double standard. After all, what field does not make normative claims at its foundation? That we should care about truth at all and ought to deploy our best methods in discovering it are moral assumptions that lay at the foundation of even the hardest science. All disciplines must rest on a host of assumptions—both factual and moral in nature. To not permit experts to endorse moral claims—to be noncommittal when it comes to knowing what ought to be done—would threaten far more than the legitimacy of clinical ethics consultation. If we do not permit such radical skepticism to weaken the foundations of biology, astronomy, or physics, then why is clinical ethics consultation any different?

Instead of trying to truncate the domain of clinical ethics, we should focus on ways to justify the normative recommendations that clinical ethicists do make, and should make, every day. We recognize this is no easy task and also that we have not offered a positive project in this paper as to how this should be done. However, we plan to tackle positive projects in future papers and are calling upon our colleagues to do the same. We should resist giving up on these questions by citing the past failure of moral theory to resolve them. We believe moral theory is in need of a deep rethinking, a conceptual renaissance that will connect theory to practice in novel and satisfying ways. But no renaissance will occur if we attempt to avoid meta-ethics altogether. Theorists of clinical ethics ought to focus on working through these hard problems as opposed to working around them.