“The orchestration of moral collaboration [required in ethics consultation] will be complex. Parties will share morally problematic situations but may have different senses of what is relevant and understandably different personal stakes. The ethicist has special responsibility to enliven a process in which these common moral concerns stay in focus while differences are recognized and, ideally, mediated.”
—Margaret Walker, 1993, p. 39.
Mediation has received considerable attention in the bioethics literature on ethics consultation. The recent consensus report Core Competencies for Health Care Ethics Consultation issued by the American Society for Bioethics and Humanities acknowledges positive benefits of mediation training. In times when moral consensus in the most intractable of cases is not possible, mediation or other conflict resolution strategies might help the parties reach a resolution. Moreover, mediation training can help ethics consultants achieve mastery of the interpersonal elements of ethics consultation. However, to argue that mediation can be appropriately adapted as an ethics consultation modality is a more controversial matter. This paper surveys the bioethics literature regarding the role of mediation as a consultation modality and presents criticisms levied against bioethics mediation. The strongest criticisms concern the supposed neutral or impartial stance mediators must take to the conflicts in which they intervene. Such impartiality is either not appropriate for ethics consultation or it is impossible to achieve, opponents of bioethics mediation argue. In defense of the role of mediation in ethics consultation, I argue that these two strong criticisms can be overcome by suggesting a new understanding of impartiality for ethics consultation that comports with the approach posited in Core Competencies. Thus, if impartiality only extends to the parties and their values, not to the norms used to reach the outcome, mediation as a stand-alone consultation modality represents a viable option.
Mediation and Ethics Facilitation
Mediation has received considerable attention in the bioethics literature on ethics consultation. The recent consensus report Core Competencies for Health Care Ethics Consultation (hereafter Core Competencies) issued by the American Society for Bioethics and Humanities (ASBH) acknowledges positive benefits of mediation training. Consensus in intractable cases may not be possible. In this event, Core Competencies (1998) suggests “mediation or other conflict resolution techniques…can often help involved parties come to a mutually agreeable solution” (p. 8). In addition, “formal training in specific techniques such as mediation…is one way to obtain advanced interpersonal and process skills” (ASBH, 1998, p. 16).
Mediation refers both to a process and a set of conflict resolution skills. The mediation process traditionally features mediator impartiality or neutrality, confidentiality of the proceedings, an opportunity for parties to voice their concerns without interruption, and mediator-guided problem-solving, option generation, and option assessment (Hoffmann, 1994a). The goal is a feasible, joint agreement balancing the concerns that originally brought the parties to mediation.
Ethics facilitation, the approach endorsed in Core Competencies, involves two stages. The first involves fact gathering and sharing from chart reviews and interviews, followed by consultant use of bioethics knowledge and concepts to generate a range of ethical options for resolving the conflict or uncertainty. The second stage allows participants to voice their concerns about the options. Ethics consultants then use interpersonal facilitation skills to clarify participants’ values and views regarding the options and builds consensus for the selection of one option.
The stages of mediation follow a sequence similar to ethics facilitation. Before identifying and analyzing the conflict or uncertainty that has brought the parties to mediation, mediators explain the mediation process and its ground rules. Then, mediators listen attentively to each parties’ perception of the conflict or uncertainty and use communication techniques to acknowledge emotions often underlying interpersonal conflicts. Such a stage allows the building of rapport and empathy, first between the mediators and the parties, then, hopefully, between the parties themselves.
Mediation as an Ethics Consultation Modality: A Survey of the Bioethics Literature
The bioethics literature makes several references to the role that mediators, the mediation process, or mediation skills play in resolving bioethical problems. Despite its prevalence in the ethics consultation literature, few sources argue that mediation can serve as a stand-alone consultation modality. Nancy Dubler and Leonard Marcus (1994) outline such a model in their book Mediating Bioethical Disputes: A Practical Guide.
Like traditional configurations of the mediation process, Dubler and Marcus argue that a bioethics mediator must be impartial. The goal behind bioethics mediation is to help transform parties’ initial positional stances to a conflict or uncertainty into shared opportunities for dialogue and resolution. Dubler and Marcus argue that impartiality—where the mediator does not favor any particular parties’ position—facilitates this transformation. The goal of mediation should be a consensus solution, generated in light of common interests and in comportment with established and recognized ethical and legal standards.
Of the four mediation stages, the second focuses on narrative. Mediation participants relate their perspective of the situation in their own words and without interruption. The mediators acknowledge any emotive content in such narratives and use communication techniques like active listening or mirroring to represent the substance of the narrative to other participants. The goal is to ensure that all parties have an adequate understanding of the situation, that all parties have a comprehensive account of “the facts” as each of them understands them, and that the mediator has made the parties comfortable expressing their views and concerns.
An interesting literature has emerged focusing on narrative in moral thinking. Stories provide robust descriptions of our moral experiences, blending emotion, rationality, perception, and judgment into one corpus. One article in particular, Margaret Walker’s (1993) “Keeping Moral Space Open: New Images of Ethics Consulting,” relates narrative in ethics consultation to mediation. Unlike Dubler and Marcus, Walker does not posit a model of ethics consultation based on mediation. Rather, she argues that morality is best described as the exchange and mutual understanding of often divergent moral narratives. Morality thus becomes less concerned with theories and their application to specific cases and more with establishing “a medium of progressive acknowledgement and adjustment among people in (or in search of) a common and habitable moral world” (Walker, 1993, p. 35). The ethics consultant acts as an architect of the moral space where such a search can take place and a mediator of the divergent moral narratives within such space.Criticisms of Bioethics Mediation
Bioethics mediation supporters, like Yvonne Craig (1996), tout that mediation enhances patient autonomy. The reason concerns the impartial stance mediators take to disputes. Impartiality, Craig argues, empowers participants and encourages moral ownership of the problem. The claim of impartiality, however, has received significant criticism. Opponents argue that bioethics mediation is an inappropriate method for resolving particular clinical problems because the neutral or impartial role of the mediator is either not appropriate for ethics consultation or impossible to achieve.
The Façade of Mediator Neutrality and Impartiality.
Giles Scofield argues that ethics consultation should not be considered a profession, and thus efforts at professionalization should not be attempted. His rationale for this claim concerns an inability of ethicists to articulate, teach, test, and certify what amounts to ethical expertise. In addition, Scofield believes that ethics consultation, because it assumes that its practitioners somehow have the market on moral expertise, represents the antithesis to the democratic understanding of morality—that all persons are moral equals.
Scofield cites Walker as a scholar who seems to share his criticism regarding the inappropriateness of ethical expertise. Instead of suggesting that ethicists are experts or ethical engineers who master code-like theories and use this knowledge to solve moral problems for their owners, Walker proposes the idea that ethics consultants should be regarded as architects or mediators. Their role is not to solve moral difficulties for the parties experiencing them, but rather to create moral space where conversations can occur. Such a role should uphold and operationalize a commitment to moral pluralism—that all persons are moral equals. Moreover, it would emphasize the role of narrative dialogue and conversation above any expertise in moral theory the ethicist brings to the consultation.
Nevertheless, Scofield criticizes Walker’s mediator role. He argues that the consultant’s role as a mediator seems objective and impartial, but it is not. The mere involvement of the consultant violates any notion of objective neutrality: “It is impossible to mediate a discussion without affecting, even influencing, it. …[W]e should not delude ourselves into thinking that they [ethicists] do not, cannot or will not influence how others discuss and deliberate ethical dilemmas” (Scofield, 1993, p. 20). In essence, Scofield objects to the implicit moral superiority inherent in casting ethics consultants as architects or mediators. Both still presuppose some sort of ethical or conversational expertise, he argues, which “is hardly a benign claim. If consent is the essence of democracy, and conversation is the essence of consent, then the ethics consultant’s claim is that some individuals know better than others what needs to be said and how conversations ought to proceed” (Scofield 1993, 20).
The Paradox of Neutrality or Impartiality.
Author Diane Hoffmann takes Scofield’s criticism one step further and suggests that the supposed neutrality or impartiality of the mediator poses a paradox for its use in ethics consultation. Not only is impartiality impossible to achieve, it is not appropriate for ethics consultation.
Hoffmann argues directly against authors who suggest mediation enhances patient autonomy. If mediation enhances autonomy, Hoffmann posits, then the participants should be the primary decision-makers. The mediator should both refrain from inputting values into the debate and not force participants to use outside norms to reach agreement. Since mediators cannot help but shape the discussion with their own values, and bioethics mediation, in particular, must use relevant norms from ethics, policy, and the law (Scofield, 1993; Dubler & Marcus, 1994; Hoffmann, 1994b; Waldman, 1997a; Waldman, 1997b), then the argument that mediation enhances autonomy does not hold.
Traditional mediation, Hoffmann argues, attempts to place the decision-making onus on the participants by eschewing reliance on outside norms and by ensuring the neutrality of the mediator. The principles and rules of justice governing legal and civil interaction between persons are suspended in mediation and the parties are free to create their own understandings of such principles and rules. Neither are appropriate for ethics consultation, however. Core Competencies suggests that a pure facilitation (or a pure mediation) approach might yield a consensus that falls outside of culturally enshrined and socially acknowledged ethical and legal limits. Such criticisms seem to doom mediation from playing any appropriate role in ethics consultation.
The Use of Norms in Bioethics Mediation: A New Understanding of Impartiality
Three Types of Norm-Based Mediation.
On the basis of her critique of using mediation to resolve certain ethical conflicts, Hoffmann asks about the appropriate place of norms in mediation. Mediation, traditionally structured and practiced, presupposes that participants will generate the norms that will constrain the options and solutions to resolve a case. Ellen Waldman (1997a; 1997b) terms such traditional mediation norm-generation. She contrasts norm-generation with two other norm-based approaches to mediation: norm-education and norm-advocation. These three forms of norm-based mediation help to distinguish several subtypes of impartiality, one of which comports with the ethics facilitation approach promulgated in Core Competencies.
Waldman argues that norm-generation has its place in mediation and in bioethics. Some bioethical conflicts or uncertainties involve cases where no norm yet exists to guide resolution. Waldman points to futility disputes as an example. In contrast, norm-education involves educating the parties regarding the legal and ethical norms at stake, but allows the parties to judge how to apply or interpret such norms. Waldman argues that rarely is norm-education useful for mediating bioethical disputes. It would be inappropriate to educate the parties regarding a consensus norm in bioethics, but then tell them either to feel free to interpret it how they want or to disregard it altogether. Finally, norm-advocation involves educating the parties regarding the relevant legal, social, and ethical norms, but the mediator urges the inclusion of particular norms in the resolution.
Norm-advocation seems to mirror the stance in Core Competencies that consensus cannot be reached if it does not fall within a socially accepted range of ethical options. Moreover, norm-advocation seems to involve constraining the “substance” of agreements to ensure not only the fairness of the outcome (Hoffmann’s worry) but also accomplishes it in such a way that does not violate the autonomy of the participants or the democracy of the process (Scofield’s worry). Thus, while norm-advocation might be appropriate for bioethics mediation, norm-education is certainly not, and norm-generation, the traditional structuring of mediation, has limited utility.
The Use of Norms in Bioethics Mediation and a Parallel in Ethics Consultation.
Hoffmann argues that end-of-life disputes in particular ought not be resolved by traditional applications of mediation. First, mediation presupposes that all parties are competent to negotiate. In end-of-life disputes, often the party whose interests are the subject of the mediation is incapacitated or incompetent and cannot participate. Thus, Hoffmann worries that no one in mediation will be properly able to represent the values of the patient and negotiate in good faith on his or her behalf. Mediation may not be able to ensure the adequate protection of the patient’s rights, she argues.
Hoffmann’s worry regarding the use of norms in mediation has a correlate in ethics consultation. The bioethics literature has debated several questions related to the appropriate use of norms in ethics consultation. Should ethics consultants be patient advocates and ensure the protection of patients? Should ethics consultants make recommendations or merely provide moral advice? If ethics consultants make recommendations, should they stem from well articulated and supported personal positions or should they represent consensus opinions from the bioethics literature?
Core Competencies clearly argues that ethics consultants should not advocate for any one party. Such a role clearly violates the consultant’s facilitative role. Rather, ethics consultants should strive to ensure the equal protection of all parties’ rights and interests by balancing power, ensuring effective communication, and facilitating divergent moral views.
That ethics consultants should not advocate for any party suggests ethics facilitation requires a type of impartiality towards the parties and their values. Impartiality, in this sense, operationalizes an explicit respect for moral pluralism by not privileging any one set of values. Construing impartiality as limited to the parties and their values and preferences provides an answer to the second question above. According to Core Competencies, ethics consultants can and should provide recommendations, but in two very different senses. The result of the first stage of ethics facilitation should yield several ethically justifiable options. These are, in effect, the options that ethics consultants could recommend. However, ethics consultants do not have to recommend that specific options be implemented. The only admonition Core Competencies provides is that ethics consultants should make it known when they are recommending particular options, especially when such recommendations incorporate the consultants’ personal moral views. Disclosure will lessen the tendency such recommendations have to impose the consultant’s values on the parties and so usurp their decision-making authority and responsibility.
Core Competencies does not use the language of impartiality or neutrality to describe the role of norms in ethics facilitation. Nevertheless, its warning that ethics consultants be conscious of the influence of their personal moral views on the consultation outcome, coupled with its focus on participant decision-making ownership, suggests that ethics facilitation implicitly utilizes norm-advocation. If consultants do indeed recommend particular options, already determined to be ethically sound, they are advocating that particular norms determine the consultation outcome. The only proviso is that how such norms are advocated be made explicitly clear—consensus norms from the bioethics literature or personal moral views. Imposing one’s own values seems in direct violation of the facilitative role Core Competencies outlines. However, norm-advocation does not impose one’s personal values but rather socially and ethically enshrined values. A clear example concerns situations where the options generated are not ones the consultant would have generated or chosen, but they accord with acknowledged ethical and legal standards.
The challenge for consultants, then, becomes how to avoid imposing their values or seeming to do so by advocating for particular norms to decide the consultation. Strict impartiality is inappropriate for ethics consultation, but how does norm-advocation uphold the sort of impartiality to the parties and their values required by a commitment to moral pluralism? An answer to this question can be found by turning to one of the first publications to articulate the use of bioethics mediation, Dubler and Marcus’ Mediating Bioethics Disputes. These authors unknowingly posit norm-advocation as the goal of bioethics mediation.
Dubler and Marcus (1994) argue that the goal of bioethics mediation is a “principled solution”—a solution generated through application of the mediation process that both respects the interests of the participants but also accords with consensus ethical and legal standards (p. 34). A principled solution is Dubler and Marcus’ answer to the problem of pure facilitation discussed in Core Competencies. In order to protect against facilitated or mediated agreements falling outside of socially determined legal and ethical boundaries, agreements using bioethics mediation must not represent applications of pure norm-generating mediation. Ethical and legal consensus, where they exist, should guide the resolution in such a way that the ethical and legal norms match the expressed and articulated values of the parties. Where such norms do not exist, perhaps applications of norm-generation bioethics mediation may be appropriate, as Waldman suggests.
Conclusion: Overcoming the Problem of Impartiality
Both Scofield and Hoffman argue that mediator impartiality is a façade. The use of norm-advocation, which seems most appropriate for bioethics mediation, violates the strict impartiality of the mediator. Like Scofield claims, in order to ensure the integrity of the outcome, the mediator must advocate that certain values or norms take precedence in the consultation. Thus, while the mediator might appear impartial, advocating that certain values should help decide the matter not only usurps the democratic ideals behind traditionally structured norm-generating mediation but also makes the mediator’s supposed impartiality disingenuous.
I argue that we need to reconstrue impartiality. Scofield and Hoffman seem to contend that a mediator must be impartial or neutral to both the parties and the values or norms used to resolve the dispute. Ethics facilitation requires that consultants be impartial to the former, but not the latter. Thus, impartiality towards the parties—not favoring or advocating for one particular party—supplies an appropriate context for a form of impartiality in ethics consultation. Ethics facilitation clearly mandates that ethics consultants not impose their own values on the participants. In essence, a commitment to moral pluralism requires that the ethics consultants be impartial towards the participants, their values and preferences, and even the options generated, so long as they comport with established ethical and legal norms. However, ethics facilitation requires partiality towards the outcome—the decisions reached must accord with (or at least not violate) socially, ethically, and legally recognized standards. Thus, the ethics consultants cannot be impartial to the outcome or to the norms used to reach that outcome. These distinctions between three subtypes of impartiality—towards participants, towards outcome, and towards norms—indicate that Hoffmann and Scofield have conflated the notion of impartiality in their analyses.
Although the paradox of impartiality might apply to traditionally structured mediation, the paradox lacks applicability to norm-advocation bioethics mediation and the use of mediation processes and skills in ethics consultation. Ethics facilitation requires that no one person’s moral values or interests be accorded privileged status. The attempt to reach consensus in ethics facilitation represents a blending designed to uphold impartiality towards the parties and their values but also comportment with recognized ethical, legal, and clinical standards. Mediation modalities that incorporate norm-advocation, but eschew impartiality towards outcome and norms, comport with ethics facilitation and thus could serve as stand-alone ethics consultation processes.
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