A hermeneutical rapprochement framework for clinical ethics practice

Introduction

A growing number of frameworks for the practice of clinical ethics are described in the literature. ¹ These strive to enrich the sophistication and rigor of this relatively new field of practice as well as provide orienting approaches for trainees and novices. Among these frameworks, some are characterized as interpretive or hermeneutical. ^2,3 For the purposes of this article, the terms “interpretive” and “hermeneutical” will be considered synonymous and the latter will be used to refer to both terms.

Hermeneutical frameworks have helped highlight the interpretive and contextual nature of clinical ethics practice. ^2,3 The aim of this article is to further advance this body of work by drawing on the ideas of Charles Taylor, a leading hermeneutical philosopher. Taylor’s hermeneutics is an especially promising foundation for the development of clinical ethics, because he has articulated an extensive moral framework as well as concepts for investigating the broader social context of ethical concerns.

I have developed a clinical ethics framework based primarily on Taylor’s hermeneutical “retrieval” and “rapprochement,” which I refer to as a Hermeneutical Rapprochement Framework. This builds on existing hermeneutical approaches for the practice of clinical ethics by articulating a framework with interpretive and reconciliatory scope that extends beyond the presenting “local” context. This framework considers broader socio-historical horizons and imaginaries grounded on Taylor’s expansive work in epistemological, ontological, political, and moral philosophy.

For the purposes of this article, the discussion focuses primarily on the practice of clinical ethics, which relates to the work of clinical ethicists. However, the ideas developed here may be relevant for all clinicians, as all clinical practice involves an ethical dimension. Although this work is addressed to a multidisciplinary audience, this is particularly meaningful for nursing ethics as well as everyday nursing practice, given the prominence of hermeneutical frameworks in nursing inquiry. ^1,4

This article builds on my earlier work, which was also published in this journal. ⁵ In this initial work, I developed a “thick” conception of pediatric clinical ethics practice based on a partial adaptation of Taylor’s work. Whereas this earlier work focused exclusively on pediatrics, this new article speaks to the broader practice of clinical ethics; even if examples that are drawn from my practice are predominantly based in pediatrics. In this earlier work, I argued for the merits of a hermeneutical approach to clinical ethics to examine the contextual basis of emerging moral concerns in clinical consultations and identify local moral meanings underlying these concerns. In turn, these concerns could be reconciled through a rapprochement of divergent moral outlooks, ⁶ drawing on Taylor’s adaptation of Gadamer’s “fusion of horizons.” ⁷ Rapprochement is discussed further in the following section.

In my earlier formulation, I focused predominantly on the contextual analysis of a presenting clinical case, using hermeneutical interpretation. Although this was meritorious, the broader framework developed in this article highlights that a Taylor-based hermeneutical analysis should also be mindful of the horizons of significance and social imaginaries within which the presenting clinical case is embedded. This can be achieved through Taylor’s ⁸ hermeneutical retrieval.

Overview of Charles Taylor’s hermeneutics

Taylor’s contributions to the development of hermeneutics are widely recognized and have served as a foundation for a number of innovations. ⁹ Taylor has articulated how all human inquiry inescapably entails an ontological examination of the “nature” of the things in question. ¹⁰

Understanding human experience and agency involves interpretation—including self-interpretation. ¹¹ Hermeneutical interpretation seeks clarity through three conditions: (1) identifying a field requiring clarification, (2) distinguishing the underlying sense or coherence that we are seeking from its presenting expression(s), and (3) specifying the subjects for whom the message is meaningful. Interpretation also involves a hermeneutical circle—an analysis of “part-whole” relations; seeking to understand the underlying meaning of the whole through a reading of its parts. Persons construct meanings in their relationships with other persons, in an intersubjective manner. ¹⁰ Intersubjective meanings are formed among people in line with their shared values and understandings. These are expressive and constitutive of a “shared world” within a group, such as a community or a society.

From philosophy to practice: understanding Kandace’s best interests

Having outlined relevant ideas from Taylor’s philosophical work, the rest of the article examines ways to adapt these ideas for the practice of clinical ethics. I begin with a case presentation, which I then examine in detail using Taylor’s hermeneutical framework.

The following case, drawn from the popular media, is presented as an illustrative exemplar. ¹⁴ Although the case involves a child, it reveals many common ethical concerns in clinical practice, including the difficult challenges involved with surrogate decision-making and life-sustaining treatments. Many of these concerns are discussed in subsequent sections.

In 1994, the Canadian popular press reported on the case of Kandace. She is an infant who appeared well during the first 3 months of her life, but was then diagnosed with a degenerative neurological disease (i.e. a mitochondrial defect or an inborn error of metabolism). A few weeks later, she was transferred to a pediatric intensive care unit (PICU) because her respiratory function was deteriorating, an expected consequence of her neurological condition. In the PICU, her vital functions were maintained through several life-sustaining treatments (e.g. mechanical ventilation). Kandace’s mother brought this case to the public media to report that the infant’s physician told her the treating team had decided that they would discontinue ventilatory life support in a few days. They had concluded that her degenerative disease left her with no hope of survival. In their opinion, continuing ventilator support was not in Kandace’s best interests. Kandace’s mother was opposed to this decision but felt she was given no say in the matter. She reported that the medical team claimed that this was a “medical” decision that was inevitable given the irreversible nature of Kandace’s disease and that ventilator support could not be continued “indefinitely.” The mother complained about what she considered to be an insensitive handling of the case by the physicians. She felt she had a right to have a say in this decision.

I will return to Kandace’s case intermittently, throughout the remainder of the article, to demonstrate how a Hermeneutical Rapprochement Framework can be operationalized in clinical practice.

Hermeneutical retrieval

In this section, I discuss how a key interpretive process for Taylor—hermeneutical retrieval—can be practiced in clinical ethics through: (1) a “part-whole” analysis of a specific case that draws on Guiding Questions as a concrete analytical method and (2) articulation of what I refer to as “An Interpretive Starting Point,” to demonstrate how hermeneutical analysis of a single case has to be examined in light of the broader moral terrain to illuminate which goods are particularly meaningful in that context (i.e. striving to understand the horizon of significance and SI that underlie a specific case).

Hermeneutical interpretation in the practice of clinical ethics should be modeled according to Taylor’s construal of the “hermeneutical circle.” This involves an analysis of “part-whole” relations. A serial reading of “parts” is undertaken and continually related to a provisional understanding of the “whole,” striving to understand the underlying sense through hermeneutical retrieval.

The “parts” of a presenting case or problem in the practice of clinical ethics can be examined through a “local” hermeneutical analysis. The particularities of the case should be examined to identify all of the morally meaningful elements, in a manner that resembles ethnographic contextual analysis, as described by Hoffmaster. ¹⁵ This “parts” examination seeks to identify the “local goods”; goods that are considered particularly meaningful by individuals or groups of individuals in a particular case. For example, a patient and family in a case may share a particular moral outlook, grounded in a constellation of beliefs, values, and practices, which can differ from the outlook shared by the healthcare professionals (HCPs). Moreover, such outlooks can differ among family members, between the patient and family members, or between the various HCPs involved with a case. For example, in the case of Kandace, a local (i.e. “parts”) hermeneutical analysis can identify that Kandace’s mother wishes to continue with long-term mechanical ventilation based on a personal conviction that life is valuable, regardless of the limitations that would be confronted in living with physical disabilities. This conviction may or may not be rooted in a recognized religious faith orientation. Regardless, she may believe that life is sacred and that it should always be preserved. For her, the “sanctity of life” is a “local good,” which she would uphold as if it was a hypergood. On the other hand, the treating physician—and/or other HCPs—may consider that the value of the life of a child is relative to the projected future for that child; specifically, the extent to which that child will be able to actualize the kinds of activities that are commonly valued for children. From this outlook, severe disability could be considered as significantly limiting a child’s projected future and therefore compromising the value of the child’s life. For Kandace’s physician, the “quality of life” may have been a “local good,” which he or she might uphold as if it was a hypergood. It should be highlighted that this discussion of Kandace’s case is speculative; a local hermeneutical analysis would require an engaged examination of the actual views held by the various persons involved with the case.

To conduct a local hermeneutical analysis of a presenting case or problem, the clinical ethicist would need an analytical model to identify relevant sources and orient the analysis of information obtained through these sources. A provisional model for a local hermeneutical analysis is outlined below. This is adapted from a Guiding Questions analytical structure that I developed in earlier work. ¹⁶ These questions could be considered as provisional starting points for hermeneutical retrieval, from which follow-up questions should be formulated according to emerging lines of inquiry.

Hermeneutical rapprochement

Taylor’s examination of multiculturalism and a “politics of recognition” provides a hermeneutical framework for striving to reconcile divergent horizons of significance. ⁶ Taylor relates multicultural tensions to the human need for recognition. He proposes a politics of recognition based on the premise

that cultures that have provided the horizon of meaning for large numbers of human beings…over a long period of time…are almost certain to have something that deserves our admiration and respect…What it requires above all is an admission that we are very far away from that ultimate horizon from which the relative worth of different cultures might be evident. ⁶

This adaptation of hermeneutical rapprochement in clinical ethics orients the practice of a clinical ethicist away from a role as a moral expert or arbiter, toward that of a mediational agent. As a mediating “agent of rapprochement,” seeking to bridge divergent moral outlooks (i.e. horizons of significance/SI), the clinical ethicist engages persons involved with the presenting case or problem in conversations that foster this process with a recognition of prevailing social and professional values, beliefs, obligations, norms, as well as relevant laws, which can reveal the related horizons of significance/SI. These values, beliefs, obligations, norms, and laws may sometimes conflict with the moral outlooks of those involved with a presenting case or problem, which sometimes precipitates or amplifies the emerging ethical concerns.

As divergent moral outlooks are identified through hermeneutical retrieval, hermeneutical rapprochement in the practice of clinical ethics should seek to identify “horizonal zones of moral convergence”; that is, identifying common ground and common language among the outlooks that are involved. For example, agents could agree that despite their divergent views, they all (1) want what is best for the patient, (2) wish to comfort the patient’s suffering, and (3) find acceptable means to achieve their respective conceptions of what is “best for the patient” and how to “comfort suffering.” Hermeneutical rapprochement recognizes that there is no pre-existing consensus on the ultimate goods that should be pursued; seeking a rapprochement of the various moral outlooks regarding the case, including those held by the patient, family members, physicians, nurses, other HCPs, the institution, the state, as well as recognized norms and standards.

In Kandace’s case, the mother and the HCPs are caught in a significant disagreement; whether or not her life should continue to be sustained with resuscitative technologies. This can understandably give rise to profound relational tensions, as the basis of the disagreement can involve foundational values and commitments toward doing what is right for children among parents and pediatric HCPs. Hermeneutical retrieval can help identify the underlying substantive moral grounds for everyone involved with the case; speculations on what these might be were discussed above. In turn, hermeneutical rapprochement can foster shifts in the understandings of the others’ outlooks, among parents, HCPs, and others involved with the case; for example, by highlighting the “morally good” basis for each participant’s views. This can facilitate the identification of treatment goals that everyone can agree on, such as maximal control of Kandace’s pain, distress, and suffering. This process should also highlight and seek to reconcile political power influences that may suppress particular perspectives, potentially narrowing the full scope of morally meaningful perspectives and interests at stake in the case.

These “zones of convergence” can be further developed through ongoing rapprochement, which can also help resolve relational tensions resulting from divergent outlooks. It should be anticipated, however, that some aspects of the multiple horizons of significance/SI may be incommensurable. For example, if the mother’s outlook is rooted in religious faith (i.e. that a miracle can cure Kandace through divine intervention) and HCPs views are based on a scientific model (i.e. that Kandace’s grave prognosis can be conclusively confirmed through predictive science), it should be recognized that hermeneutical rapprochement may not bridge substantively divergent explanatory grounds. Although rapprochement may not reconcile some horizonal differences, it can nevertheless foster continually clearer reciprocal understandings among those involved in the case. The mother may not agree with the HCPs’ proposal to withdraw life-sustaining treatments, but can come to understand that the basis of the HCPs’ views is rooted in deep regard for the child’s quality of life and suffering. Whereas the mother may have initially inferred that the HCPs wanted to withdraw mechanical ventilation because they devalued the importance of Kandace’s life or did not think she was worthy of such an investment of limited resources, the mother may come to understand that the HCPs’ reticence is in fact based on their commitment to do what they understand is good for Kandace; that they cannot bear to provide treatments that they believe are predominantly harmful. Likewise, whereas the HCPs may have initially believed that the mother’s refusal to withdraw mechanical ventilation was based on a psychological denial of the confirmed scientific facts regarding Kandace’s prognosis or parental belief in “fanatical” religious doctrine without consideration of the child’s current and projected suffering, hermeneutical rapprochement can help HCPs understand that the mother clearly understands the scientific facts, but interprets such facts within a faith-based moral order that attributes great value to Kandace’s life despite the limitations that she may live with. Although the mother wishes for a miraculous cure, she may also understand that this is highly unlikely but is nevertheless committed to assisting Kandace toward whatever life “God defines for her.” As stated above, these considerations regarding Kandace’s case are entirely speculative. In clinical ethics practice, these areas of horizonal convergence and divergence should be elucidated through hermeneutic retrieval.

In addition to being attuned to the malaises of modernity and modern pediatric medicine, for Kandace’s case, as well as malaises arising from divergent horizons of significance/SI, the clinical ethicist should also be attuned to malaises that can emerge through the process of hermeneutical rapprochement. For example, parents who are Jehovah’s Witnesses may come to fully understand that withholding blood products from their child will actually result in their child’s death, as the HCPs may have predicted. The parents can find themselves confronted with irreconcilable beliefs and values: upholding their religious commitment to refrain from engaging in a horrible spiritual act ²¹ versus ensuring the survival of their beloved critically ill child. Likewise, HCPs can come to a shifted understanding and regard for parents who are Jehovah’s Witnesses, recognizing the profound spiritual torment that blood transfusions imply within this community. HCPs can find themselves in a moral bind between practicing according to accepted standards of scientific pediatric practice (i.e. providing blood transfusions to children in hemorrhagic shock) and demonstrating regard for parental wishes and family cultural and religious continuity. Thus, clinical ethics practice with a Hermeneutical Rapprochement Framework involves an ongoing process, continually examining and engaging the unfolding moral terrain.

This analysis of Kandace’s situation has helped illustrate how a Hermeneutical Rapprochement Framework can make a valuable contribution in clinical ethics practice. It is strongly recognized that best interests are difficult to define for individual children and that pediatric ethical dilemmas frequently involve “rival” claims on a child’s best interests by adults who have a responsibility toward a particular child (e.g. parents, HCPs). Using a Hermeneutical Rapprochement Framework can (1) help elucidate the broad constellation of morally relevant interests that a child may have in a specific situation, drawing on a diversity of perspectives; (2) discern how these various interests are morally meaningful (i.e. through hermeneutical retrieval); and (3) reconcile (i.e. through hermeneutical rapprochement) this diversity of perspectives to specify which interests are this child’s “best” interests.

A Hermeneutical Rapprochement Framework characterizes the clinical ethicist as a reconciliatory agent, rather than a decisional authority. A clinical ethicist is not authorized to make a treatment decision. Authority for the many forms of decisions that need to be made in treatment planning is generally clearly designated in most jurisdictions among patients, surrogate decision-makers, HCPs, health services institutions and courts, among other bodies. The clinical ethicist using a Hermeneutical Rapprochement Framework can help clarify which decisions may be “ethically better” by promoting a stronger understanding among all interested agents of all the morally meaningful perspectives on the case at hand. This can help illuminate the moral underpinnings of any disagreements that emerge, which the clinical ethicist can help reconcile by helping each participant articulate what is particularly important to uphold when decisions are made. It is foreseeable that some disagreements may be irreconcilable and may call for legal or other formal arbitrational input, which may be better attuned to the complexities of the situation if the case has been managed through a Hermeneutical Rapprochement Framework.

Normative development in clinical ethics

This discussion has focused primarily on the practice of clinical ethics in the context of clinical cases or problems. A clinical ethicist can also practice hermeneutical retrieval and rapprochement for normative analyses and development.

Clinical ethicists are frequently called upon to examine existing ethical norms or develop new articulations of norms for emerging ethical concerns in clinical practice (e.g. development of ethics policies, guidelines, standards, position statements, or legislative changes). Analyses of emerging ethical concerns in clinical practice regarding the cessation of medically administered nutrition and hydration, life-sustaining interventions in the context of severe disability, or “medically-assisted death”—for example—can be commonly narrowed to polemic legalistic considerations; respectively considering: medically administered nutrition and hydration as a necessity of life or a medical treatment; sanctity of life—even a severely disabled life—versus a consideration of the worth of a life as relative to the “quality of life” that can be undertaken; the rights of patients and family members to mandate a medically assisted death in the context of terminal illness versus a universal prohibition toward the active ending of life as a permissible goal of medicine. Hermeneutical retrieval would seek to trace the substantive moral foundations underlying these polemic considerations, elucidating how these are morally meaningful, while identifying additional moral concerns involved with such problems. This process will sometimes find that some views may in fact be less polemic than they appear (e.g. sanctity of life and quality of life can become recognized both as foundational and incomparable goods, where one cannot be subordinated to the other in a SI where there may not exist one agreed-upon hypergood).

In turn, normative development would then seek to undertake a hermeneutical rapprochement of these apparently divergent moral goods, articulating practice orientations that are as attuned as possible to the ensemble of moral considerations for a given problem. For example, normative development in pediatrics using a Hermeneutical Rapprochement Framework would recognize and seek to reconcile the best interests of children with the interests of families, HCPs, as well as institutional and societal resources—elucidating the full scope of morally important goods that are in question. As with case-based clinical ethics practice, hermeneutical retrieval and rapprochement in normative development involves an examination and engagement of the full scope of the unfolding moral terrain. Moreover, normative development should identify and seek to reconcile political structures and processes that may unfairly suppress particular perspectives and interests; devoting significant attention to vulnerable patients, groups, communities, or populations.

Implications for clinical ethics education

The ongoing development of a Hermeneutical Rapprochement Framework in clinical practice will require adaptations in the educational preparation of clinical ethicists (as well as all HCPs). In addition to conventional bioethics theory and normative content—which should be maintained because clinical ethicists are expected to bring this substantive knowledge to clinical practice—educational programs should also help trainees develop the methodological knowledge and skills required to perform the analytical and interventive (i.e. reconciliatory) practices described in this article. Much of this methodological expertise can be adapted from anthropology, drawing on Hoffmaster’s earlier work on how “ethnography can save the life of medical ethics.” ¹⁵ Anthropological ethnography is a well-recognized framework for conducting research that strives to reveal local understandings and practices, as well as related political structures and processes. While examining the experiences of individual persons or groups, ethnography can also uncover how these experiences are morally meaningful and the ways that local as well as broader outlooks and practices have given shape to these meanings. Clinical ethics trainees can learn how to conduct ethnographic inquiry as an operational methodology for conducting hermeneutical retrieval, bridging the framework described in this article with anthropological ethnographic methodology. Relating a respected research methodology to practice also allows the clinical ethicist to draw on existing empirical research knowledge that can help orient the ethicist to how things are morally meaningful as well as documented inequities and power imbalances that the ethicist should be attuned to. For example, prior research can sensitize the ethicist to particular vulnerabilities that can be endured by specific populations (e.g. newborns, disabled persons, indigenous peoples, and migrants).

Moreover, the anthropological method called cultural brokering can be adapted for conducting rapprochement. ²² The former involves a process of reciprocal bridging of diverse perspectives and understandings; a form of “cultural translation” practiced by some interpreters. However, a clinical ethicist practicing from a Hermeneutical Rapprochement Framework is not merely a “translational” agent. As a “broker,” the ethicist is also required to interject relevant normative standards and empirical knowledge to ensure that the resulting decisions and actions are congruent with local conceptions of what is good, right, and just.

Given the complex socio-political contexts underlying clinical ethics practice, the attunement of clinical ethicists can be enriched by regularly drawing on local (stakeholder) advisors from a variety of perspectives. For example, an interdisciplinary clinical ethics committee can help clinical ethicists better understand the various disciplinary ethical outlooks that may be at stake in a presenting case or problem; directly informing how standards such as truth-telling, privacy, quality of life, conscientious objection (among others) are imagined and practiced within each tradition, elucidating what may be at stake for HCPs. Likewise, patient representatives, user groups (including youth advisory councils), as well as various community groups (including cultural and religious communities) can help orient clinical ethicists to the particular stakes that may be meaningful for them.

The development of all of these forms of knowledge and skills should be integrated throughout clinical ethics educational curricula, including classroom, clinical simulation, as well as clinical practice activities.

Finally, the ongoing development of a Hermeneutical Rapprochement Framework for clinical ethics practice also requires the promotion of ongoing research to advance our understanding of various clinical ethics problems and practice settings, to continually optimize the clinical ethicists’ attunement to the cases and problems that they encounter. I have described elsewhere how Taylor’s hermeneutical framework described here can be adapted as a methodology for clinical ethics research. ²³

A broader consideration of hermeneutical practice

Although this article has examined how a Hermeneutical Rapprochement Framework can be used for addressing emerging and anticipated ethical concerns, this can also be considered as a framework for everyday (i.e. non-morally problematic) clinical practice. It is oriented toward fostering ethically attuned reciprocal communication and understanding, which would be helpful for patients (i.e. adults and children), family members, as well as HCPs. For example, hermeneutical retrieval and rapprochement can help elucidate and bridge divergent “explanatory frameworks” (e.g. different understandings of the body, illness, and medical treatments) that can exist between patients and families on one hand and HCPs on the other hand. This can be particularly important in the context of cross-cultural diversity.

Concluding remark: revisiting Kandace

Clinical ethics practice is tremendously complex. The operationalization of how clinical ethicists—and all HCPs—conduct their everyday ethical analyses and interventions has been under-developed. Clinical cases, including profoundly conflictual ones like the case of Kandace, involve many local and broader moral dimensions that are commonly concealed. Indeed, cases that are less conflictual raise additional concerns because these concealed moral dimensions may remain largely unrecognized. The Hermeneutical Rapprochement Framework proposed in this article can help advance a more richly attuned ethical approach that can better anticipate, prevent, and reconcile ethical concerns in everyday clinical practice. Hermeneutical retrieval can bring to light meaningful moral dimensions underlying a presenting case that are otherwise difficult to access, while hermeneutical rapprochement can foster a “bridging” and reconciliation of highly divergent viewpoints among agents involved with the case. This can help support the complex practice of clinical ethicists in particular and all clinicians in general.