2. What’s the importance of clinical ethics in the health care field?
The complexity of contemporary healthcare, particularly medical care, has created innumerable problems that healthcare professionals, patients and their families are poorly prepared to address. Traditional ethics has not adequately come to terms with the complexity and diversity of problems that arise in the actual care of patients. For this reason clinical ethics has risen with in bioethics as a response to the questions and troublesome cases that arise and pose ethical problems and questions for health professionals as well as patients and families. Technology is often thought to underlie the many clinical ethical problems that arise in medicine, but it is only a partial component. Institutional structures and organizational practices, the complex relationships and coordination that is required between healthcare professionals and the enormous problems posed by the way that health care is financed create ethical problems that often result in conflicts and communication occlusions which impede the quality provision of healthcare. Thus clinical ethics is now an essential component of healthcare and leading healthcare institutions have come to the realization that developing and supporting solid clinical ethics support programs is essential for the efficient and ethical functioning of their organizations.

3. Some interesting experiences to share with us?
I started to do ethics consultation in connection with my work in psychiatry in the late 1970s while I was an assistant professor of medical humanities and psychiatry at southern Illinois University School of Medicine. I was asked to assist in a humanities project in a state psychiatric hospital. In my interactions with staff and patients very quickly turned in the direction of addressing ethical questions and problems that arose routinely in the course of everyday care. The relationship was formalized and I was appointed as ethics consultant and I helped the institution to organize its first ethics committee. Parallel to this, I was teaching medical students’ and found that lecturing on medical ethics did not seem to impact the students’s behavior in their clinical training. I was invited to work with several clinical departments and to develop modules and seminars that follow the students during their clini cal rotations. Addressing actual ethical problems as they arose greatly increased the relevance of medical ethics in the training of the students.

In 1997, I left Southern Illinois University medical school to take the chairmanship of the department of bioethics at the Cleveland Clinic, one of the world’s leading healthcare institutions. The issues that I confronted in that setting certainly included what had become “routine” conflicts and confusions over end-of-life care, but more importantly involved a brand-new range of ethical questions about innovations in medical treatment. The Cleveland Clinic is an institution committed to developing cutting edge medical interventions. It was not uncommon for a leading physician, surgeon, or department chair to ask for help in thinking about the ethical problems associated with an emerging, innovative medical treatment for which there was no ethical literature developed. Whereas previously, clinical ethics problems that I confronted primarily involved addressing problems and finding solutions for existing conflicts; now, the clinical ethics questions were focused on how to structure a practice so that ethical problems might be avoided or
addressed in advance before they become issues that adversely affected the care of actual patients.

In all my clinical ethics experiences, I think the most important feature of my experience is the remarkable receptivity and openness of physicians and other healthcare professionals to responsibly addressing ethical problems. My most memorable experiences are the respect and collaboration that was shown towards me as a clinical ethics consultant, so that the environment of work, though fraught with tension, was one of immense satisfaction
and reward.

4. Are there educational needs in the area of clinical ethics and ethics consultation?
This is a very important question. In fact, I would say that one of the most important needs in clinical ethics and ethics consultation involves education. As an academic and trained philosopher who has worked in bioethics for his entire career, I take the rather unusual position in thinking that more work in philosophy or philosophical ethics is not the only or primary educational need for ethics consultation. To be sure, competence in medical ethics
and clinical ethics is essential, but one does not need bea scholar in these fields to function effectively in many hospital settings in which ethics consultation mainly involves standard conflicts between patients, families, and health care providers. In these settings, a firm, but general
foundation in bioethics and clinical ethics theory is important, but it must be augmented by an understanding of the applicable healthcare law as well as institutional and professional guidelines, which together provide the normative context within which individual decisions need to be framed.

Because most of the work in clinical ethics and ethics consultation is provided by volunteer healthcare professionals who function on hospital ethics committees, these individuals are not able to stay abreast in the field of clinical ethics. Thus, the education that is needed is a continuing process of improving their ethical understanding and sharpening their skills in analyzing ethical problems. To be sure, some of this education will involve
developing the capacity for conceptual and case analysis along the lines of philosophical bioethics, but beyond that academic work, healthcare professionals working on hospital ethics committees need updates on the bioethics literature, healthcare law, professional ethics guidelines, and institutional guidelines, because these latter undergo constant revision and evolution and they provide important normative content for actual clinical ethical decision-making.

5. In relation to the ICCEC series: what was the founding goal for these congresses?
The International Conference on Clinical Ethics and Consultation grew out of my personal frustration in the lack of academic support and continuing education for ethics consultants in the United States. Some individual institutions were providing continuing education conferences, but their scope and outreach was limited. In discussions with my colleague, Prof. Stella Reiter-Theil of the University of Basel, we decided that problem was widespread. The field of ethics consultation and clinical ethics had simply grown so fast, that the academic impetus to mobilize education in clinical ethics and consultation had not materialized. We thought that sustained academic work and empirical research on clinical ethics and ethics consultation was needed. After much discussion,
we came to the idea that an international series of conferences organized on a biannual basis might be successful at pushing the field to develop a strong academic base.

Initially, our expectations for these meetings were quite modest, but we thought that the risk of supporting these conferences was a worthwhile professional contribution to the field. We explored the idea of doing these meetings in collaboration with professional organizations, but decided that these organizations have their own interests that did not always coincide with what we thought were the genuine needs of the field of ethics consultation.

Since we realized that the educational challenges were broader than our own national experience and that clinical ethics and ethics consultation was quickly spreading from North America around the world, we decided that the conferences should be truly international in scope. We hoped to promote the kind of dialogue that would energize the field by structuring a meeting that focused exclusively on ethics consultation and clinical ethics and not general bioethics. I organized the first conference in Cleveland, Ohio in 2003 and we moved the second meeting to Basel, Switzerland in 2005. These meetings were so successful and the response so positive that we decided to continue the conferences on a biannual basis alternating between Europe and North America. Since the first meeting was held in the United States, I decided that it would be appropriate to choose a location in North America outside the United
States. Because the early work in clinical ethics and ethics consultation was seen primarily as a US development, Stella and I thought that the future of the field was clearly international and that ICCEC should advance the field and not any national or regional interests. For this reason, Toronto, Canada was chosen as the site for the third meeting that was hosted by the Joint Center for Bioethics at the University of Toronto to mount a very successful program
in 2007. By coincidence, I was asked to Chair the Scientific Committee for the 9th World Congress of Bioethics held in Rijeka, Croatia the next year. Since it was the custom of the World Congress to support satellite meetings, I proposed that we deviate from our biennial schedule of meetings to meet with the Congress in September of 2008 and to focus the meeting on the needs of new and emerging ethics committees. This seemed propitious since the interest in organizing future meetings has grown so much that we have now moved to an annual cycle. Subsequently we held meetings in March of 2009 in Taipei, Taiwan and in Portland, Oregon in May, 2010. Three future meetings are in process. The ICCEC will meet in Amsterdam, The Netherlands on May 18-21, 2011 and, as you know, in São Paulo on May 16-19, 2012. In 2013, we will meet in Munich, Germany probably in the month of March, but the final date has not yet been set.

The founding goal of these meetings was to promote the development of the field of clinical ethics and ethics consultation. A secondary goal was to promote the first goal internationally and to develop the conferences as a collegial context within which clinical ethicists and ethics consultants could address the common themes and concerns arising in their work. It is important that these conferences not advance the individual agendas of particular institutions or professional societies. We think we have largely succeeded in making the ICCEC a collegial and academic space within which clinical ethics and ethics consultation are uniquely and openly discussed.

6. What kind of expectations you have for the Brazilian Conference?
I am afraid that I have very high expectations for the São Paulo conference, but I’m sure that I will not be disappointed. First, the São Paulo conference will be the first ICCEC conference held in South America. Many Europeans and Americans are largely unaware of the development of bioethics and clinical ethics in South America; therefore, one goal is to bring the work in clinical ethics and ethics consultation of our colleagues in South America to the attention of the international audience.

A second goal is to promote the development of clinical ethics and ethics consultation in South America by bringing international attention to this field within the region. Our previous meetings have had the effect of stimulating ethics consultation in areas where it in the early stages of development and we hope the São Paulo meeting will give greater attention to the field and render greater support for it within South America.

Third, the theme of the São Paulo meeting is diversity in clinical ethics. A central philosophical question for the field is whether or not there is a single canonical approach to clinical ethics that can resolve ethical problems in all institutional settings. Some believe that a universal human rights approach or an approach based on a common morality will provide such a foundation. Others recognize that there are diverse moral communities and that the
concrete and particular value commitments of these communities are so complex and compelling that they should be sustained. Beyond these broad questions, there are differences that emerge between legal jurisdictions as well as process and procedural differences between institutions that make the provision of ethics consultation services much more complicated than is often appreciated. Understanding how these differences shape ethics consultation
and to what extent they alter the normative foundations of the field will be an exciting component of this meeting.

A fourth goal is a personal one, namely that coming to São Paulo for the 2012 ICCEC will allow me to get to know better my Brazilian colleagues. One of my books was translated into Portuguese and published by Edições Loyola and Centro Universitário São Camilo Dependência e autonomia na velhice: um modelo ético para o cuidado de longo prazo. I hope to have the opportunity to discuss this work during my visit and to make new friends.