My new book, Revitalizing Health Care Ethics: The Clinician’s Voice (2025)—co-authored with the psychiatrist Kasia Kozlowska of the University of Sydney Medical School—begins in classic philosophical style with a puzzle. Two senior physicians who had read our first book, Rethinking Health Care Ethics (2018), noted that in their clinical work, they inescapably address many ethical problems, large and small, on the spot, in the course of providing patient care. They also observed, however, that the resident bioethicist cautioned, when presented with one of their typical problems, that it would take him days or even weeks to reach a proper solution.
The new book—published by Palgrave Macmillan and available open access (like the first) from Spring Nature—is, in effect, an extended attempt to understand this puzzle. Summarizing our response in a brief blog entry is obviously not possible, but what I can do is provide an overview of the main themes—which, in the process, will also communicate how this book differs from standard accounts of bioethics. I will also try to raise some open-ended questions concerning the potential implications for how ethics, especially courses involving normative or applied ethics, is taught.
First, the book draws on Rawls’s distinction in A Theory of Justice between the formal ethical discourse of moral philosophers (or, by extension, bioethicists) and the informal ethical discourse used by everyone else. In the clinic, physicians and other health care clinicians use informal ethical discourse to understand and address ethical problems that arise either in their clinical work or in their life outside the clinic.
Second, the informal ethical discourse of any particular health professional, at any stage of their career, is a product of their previous life history. This life history includes social interactions of all sorts that begin in childhood and that continue through professional training, enabling each professional to become a member of a particular professional community (e.g., physician, nurse, or social worker). That is not to say that different clinicians will resolve ethical questions in the same way or that, if a group of clinicians got together to establish a consensus on a shared problem, they would all adopt the same course of reasoning in support of the consensus position, or conclusion. What remains the case, however, is that health care students bring with them an established, experientially based capacity to understand and address ethical issues as they arise on a daily basis—a capacity that is built upon and extended throughout professional education, clinical training, and later clinical practice.
Third, the informal ethical discourse used by health professionals is embedded in the language of everyday social and professional interactions. Rather than referring to principles or rules, and rather than being expressed through structured arguments or analyses, such informal ethical discourse involves what Stuart Hampshire, in Morality and Conflict (1983), described as “a complex array of historical realities and causal relations” that have generated, over time, various “conventions, customs and practices” defining a person’s “way of life” (p. 5). It is just these conventions, customs, and practices that health care students learn in the process of becoming members of what Stanley Fish referred to as the “interpretive community” defining each student’s prospective field of health care (Is There a Text in This Class? The Authority of Interpretive Communities [1980]; Doing What Comes Naturally [1989]).
Fourth, many, even most, clinical situations that raise what an ethicist might consider ethical questions are identified, understood, and addressed without using formal 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. With good fortune, the right choices are made: 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, or if the goals are not achieved, or if some sort of conflict arises, then the questions are “This presentation is tricky, should we discuss it with X?” and “Why has that happened?” and “What went wrong?” and “How do we move forward?” These instrumental questions—though largely ones of means and ends, and both conceptualized and answered in those terms—are the means of engaging in informal ethical discourse in the setting of clinical health care.
The main discontinuities between these clinical processes and both the literature and teaching in bioethics/normative ethics are twofold. First is that the language of publication and teaching is almost always that of formal ethics, which is not the language of the clinic. Second is that the ethical problems addressed in publications (and in classroom teaching) are generally the most difficult ones—for which the language and methods of formal ethics might prove most helpful. In both respects, what’s potentially learned through classroom teaching is likely to have a distant connection with the ethics of daily clinical practice.
Given the discontinuities between classroom teaching in bioethics/normative ethics and the clinical phenomena as presented above (and, in more detail, in the book), should these discontinuities be taken into account in teaching ethics or in planning your future courses (or even your next article or book)? Likewise, are your expectations for students or for what they will learn realistic? Do your lectures and discussions encourage learning that students will take with them into the future? Is there some way of more productively connecting the formal ethical discourse of lectures and readings with the informal ethical discourse of students? Does it matter whether your students, or at least some of them, are planning careers in health care? If these questions seem wide of the mark to you, what is it that you hope to achieve through your teaching?
Stephen Scher
Stephen Scher, PhD, JD, is Senior Consulting Editor, Harvard Review of Psychiatry, and Lecturer in Psychiatry, McLean Hospital/Harvard Medical School, and University of Sydney Medical School (Australia). He joined the editorial staff of the American Journal of International Law in 1999 and the editorial staff of the Harvard Review of Psychiatry in 2003. He served as Senior Editor of both journals, stepping down from the American Journal in 2016 and the Harvard Review in 2022.
