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Abstract

Health-care consultation is a common phenomenon that comes in many forms and shapes. In US hospitals, everyday consultation scenarios concern medical, ethical, psychiatric, social, or legal issues. Outside hospitals, consultations may involve public polls about health-care legislation or private companies’ assessments of health-related situations.

This entry examines why health-care consultation formats differ and which ethical challenges arise in consultation contexts in both local and global settings. While the concept of consultation seems obvious and simple, the speciﬁcs of consultation practices are complex. Aside from differences in outline and goal, consultation processes vary due to differences in nature, location, resources, discipline, and culture.

In search for common features of health-care consulting, the question is if there is a particular format that should be used for consultation. This entry illustrates that many aspects of consultation are controversial. What consultations should look like is therefore debatable, especially in a common global context.

Introduction

This entry examines why health-care consultations differ in process and format and which ethical challenges arise in both local and global consultation contexts. These challenges are summarized by questions like: What should a consultation process look like? What should be expected from the process? What should the role of the consultant be? In a global context, these challenges are exacerbated by questions of how to address culturally embedded practices in ethically controversial domains.

While the concept of consultation seems obvious and simple, the speciﬁcs of consultation practices are complex. Aside from differences in context, consultation processes vary due to differences in nature, location, resources, discipline, and culture. What to expect from health-care consultations depends on time and place.

In search for common features of health-care consulting, this entry highlights that many aspects of consultation are controversial. What consultations should look like is therefore debatable, especially in a global context.

Background

Consultations can be requested for a host of reasons while varying in scope and end point. A typical medical consultation scenario involves a physician consulting with his or her colleagues about the feasibility of interventions like surgery or anesthesia, as the attending physician lacks expertise or privilege to perform such procedures. When these consultants have provided their opinion or service, their consultation ends.

Section “Ethical Dimensions” contains a scenario exemplifying some further reasons for consultation. Although the scenario may not be very common, it succinctly highlights some typical and ethically challenging dimensions of health-care consultation. To illustrate these challenges, this entry uses primarily ethics consultation examples followed by medical consultation scenarios.

Conceptual Clarification

The word “consultation” derives from the Latin word “consultare,” which means “to take counsel.” The concept has been traced back to the early sixteenth century as a sense of “deliberate together, confer.”

Speciﬁcally for the health-care context, Geppert and Shelton (2012) have deﬁned consultation as a meeting with a practitioner, who has special expertise and who is asked to help in the care of a patient by another. This deﬁnition refers to a trilateral relationship. As such, the consultant is either an insider or an outsider, i.e., someone who continues with the patient after a ﬁrst consultation (e.g., psychologist), or someone who will not be involved in the treatment relationship after the consultation (e.g., ethics consultant). Consultation can, however, also be a dyadic relationship between patient and provider or between a general provider and an expert.

Providing a conceptual clariﬁcation of consultation is challenging. Ultimately, a consultee seeks an opinion, action, or information from an expert, followed by a discussion of the consultant’s input. This input can be related to the perception, the reaction, or the prevention of a problem. But beyond these elements, consultation processes do not seem to have many common features.

Concepts of consultation will depend on the discipline in which it is conducted. Ethics consultation, for example, differs from medical consultation according to Geppert’s analysis of the “ten commandments of effective consultation” (Geppert and Shelton 2012). While urgency and brevity are important in both models, she identiﬁes that educational components are essential to ethics consultations but not to medical consultation. Education in ethics consultation serves to prevent future requests on the same matters. In medical consultations, however, such prevention could compromise patient care.

Consultation can vary between areas of expertise. Surgeons and internal medicine physicians, for example, have different preferences about format and process of consultation (Salerno et al. 2007). Surgeons desire comanagement of consultants, including the ability to write medical orders. Internists, in contrast, prefer a more limited involvement; their consultant ideally only advises the attending physician but does not write orders (Salerno et al. 2007). Furthermore, consultation processes depend on the role of the consultant and the purpose of the consultation. Ethics consultants, for example, have been given eight different roles, ranging from risk manager to priest to educator (Rasmussen 2002). In each role, consultation practices would differ in terms of process, recommendations, and format. As a risk manager, the consultant would highlight the physician’s due diligence in gathering many different opinions, and the consultation note would serve to illustrate that the physician cannot be held liable for adverse outcomes. As a priest, the consultant would address factors of moral distress and merely report on the process that ought to relieve the distress.

Conceptually, consultation has been contrasted with advising. Consultation would involve a request for a consultant to assist in a speciﬁc problem and to provide an opinion about this problem. The consultee identiﬁed this problem and needs help to resolve it. Advisees, on the contrary, request the advisor to observe a situation with a bird’s-eye view, to uncover potential problems of this situation, and to highlight the necessity to solve these problems. For example, advisors may be asked to look at a web application tool, to assess its suitability, and to see if there are any problems with the application. Consultants, in turn, may be asked to assist with the web application where a breach of privacy has resulted in a problem.

Ethical Dimensions

Local

Ethical challenges in the health-care context are generated by questions about the who, what, when, where, why, and how of consultation. Formats, processes, and outcomes of consultations depend on their answers, raising further questions about the ideal format of consultation: What should consultation look like?

The following scenario illustrates some of these challenges and below the following paragraphs will expand on four of these challenges:

Carine and Dominique wish to have children and consult Dr. Brozy (hereafter: Brozy), an endocrinologist in a university hospital. Carine is likely to have unhealthy mitochondrial DNA, and her DNA would have to be replaced with a donor’s healthy cytoplasm to conceive a child. They would ideally also embark on tissue typing, to select a healthy embryo; Dominique is a potential carrier of the gene causing Huntington’s chorea, a neurodegenerative genetic disorder. Dominique experiences tremors, and displays forgetful and aggressive moods. He does not know and does not wish to know if he has Huntington’s. Brozy recommends that they see Dr. Ali for a psychological and genetic consultation. Brozy also asks Dr. Franz, a neurologist, to consult on Dominique’s forgetfulness and aggressiveness, whether this could have a neurologic origin. Brozy ﬁnally calls the ethics consultant: Dr Edward (hereafter: Edward). Brozy explains that he feels some discomfort with the fertility request and Dominique wish to remain ignorant about his disease status. Brozy wonders how the best interests of the future child should be measured against Dominique’s right not to know? Brozy’s discomfort is further related to the fact that a recent public consultation evidenced opposition to three-parent embryos, i.e. embryos that have three genetic parents. Although the legislature has not prohibited the practice, Brozy is concerned about public outrage. He is worried that a three-parent baby would likely result in negative publicity for the hospital.

The purpose (the “what and why”) of the consulting process may create differences in consulting practices and may result in ethical challenges. That is, the question asked will affect the way the consultation is approached, and such mandates may cause conundrums for the consultant. For example, the consultant may identify problems outside the purpose of the consult or outside its scope. In the scenario, Brozy may have consulted Edward, who has a PhD in bioethics, as a content expert. Trying to determine a moral standing in the three-parent embryo, Brozy may be asking Edward for information about the ethical pros and cons and to gain a broader perspective on content. Alternatively, Brozy could also have sought Edward’s help as a process expert for generating support if he decides to accept the request or to offer a perspective on organizational ethics. Brozy could fear repercussions of the hospital’s administration if the case attracts media attention while feeling compassionate and compelled to comply with Dominique and Carine’s request. Brozy may seek information about what parts of the hospital’s administration and leadership are important to agree with his decision and to understand what should certainly be done organizationally to allow the request to go forward. Another ethical challenge may arise if Edward is aware of the public opposition about a threeparent embryo, while Brozy is unaware of this. Should Edward act on his own account to raise this issue, especially if Brozy has only asked for a perspective on leadership and does not tend to care about public opinion? What if such observations generate liability issues for Brozy? Edward may further encounter challenges in formatting the consultation. His recommendations will be different whether the consultation note serves to persuade the hospital’s leadership or to prevent a lawsuit. For this latter setup, the report would have to reﬂect that Brozy has considered all the options and consequences. Medical consultations face similar challenges. Ali may detect a personality disorder on Dominique’s end. The question is whether Ali should engage with this problem outside of his mandate, especially if this diagnosis would interfere with the rest of the care plan.

The method (the “how”) of consultation is another area of complexity. Ethical dilemmas arise in determining which method, approach, and theory of process are most suitable to structure the consultation process. This issue is easily illustrated in both domains of ethics and medical consultation. Rhetorical persuasion tactics are part and parcel of consulting methods, and acceptability of such persuasion tactics will depend on the context and consultant. The American Society of Bioethics and Humanities (ASBH) identiﬁes a spectrum of ethics consultation methods, varying from consensus building to an authoritarian approach (ASBH 2011). Edward may wonder if the consultation process or recommendations could include the rhetoric of persuasion or even coercion in conveying the ethical concerns. Brozy, Ali, and Franz face similar dilemmas in thinking about the strategies to communicate with their patient or colleague. Should the consultant be more authoritarian where the patient or colleague is less knowledgeable, or should he retain their nondirective counseling style?

Likewise, the client (the “who”) is a source of variation and entanglement between consultation processes. Identifying the client in the consulting process impacts the consultation’s setup and outcome. Ethical dilemmas arise around the question whose interests should be served by the consultee. The scenario highlights at least three potential clients: (1) Brozy, (2) the hospital, and (3) Carine and Dominique. In order to write his recommendations, Edward will have to decide whose interests are most important, regardless of the fact that Brozy initiated the consultation. Ethical reﬂections and outcome of the consultation are different for the patient than for the physician or for the hospital; Carine and Dominique’s request may be reasonable and compelling, but Brozy will have to consider his ability to care for other patients; the hospital needs to consider its institutional status, with ﬁnite resources, employees, and other patients. In medical consultations, questions about who is the client arise frequently. For example, a physician may detect a sexually transmissible disease, and the question arises whether his consultation encompasses a duty to warn the patient’s spouse or mistress.

Global

Most of the primary ethical challenges in a global context are similar to those on the local level. They query: What should a consultation process look like, which interests should it represent, and which goals should it aim to fulﬁll?

Cultural and moral differences on a global scale, however, raise additional challenges for the consultation’s process, function, and content. Questions are: What should be the authority of the consultant? Which stakeholders should be included in the consultation? How should the cultural moral framework impact the recommendations? For example, patient engagement in the consultation process is a standard practice in the US model of ethics consultation, but it is not in France. Based on the scenario, Carine and Dominique’s input would be asked for in the USA but not necessarily in France. Perhaps the more paternalistic model of health care in France explains this difference, without suggesting that this model is adequate or inadequate. Whichever approach is better may depend on time and place.

A comparative global perspective highlights challenges. Especially where consultants may be aware of the cultural context as a deﬁning feature, consultants face questions of how to balance competing moral and cultural frameworks.

Authority

Questions about the consultant’s authority arise due to differences in the patient-physician model. Many variations of this model exist, ranging from a paternalistic to a shared-decision relationship. The consultant’s authority will depend upon the nature of this relationship and on his position as an insider or outsider in the dyadic or trilateral relationship. Where the physician is the consultant himself in a dyadic relationship, his role is likely to be more authoritarian if this relationship is more paternalistic. Where the relationship resembles a consumer-based model and shared decision-making is a central feature, his recommendations are likely to be more suggestive rather than fully ﬂedged decisions.

Cultural patterns have been used to explain issues around the authority of consultants. Rasmussen and Gibbs explain that interpersonal relationships may be more important than instrumental relationships in certain cultures, because of historical circumstances, cultural and social norms, and values (Rasmussen 2002; Gibbs 1980). Where consultants are functioning as outsiders and only sporadically communicate with the patient, consultants typically build less trust. Their status will likely be weighed differently, depending on their professional involvement, the frequency of their involvement, and whether they are able to become “insiders.” Accordingly, regardless of their expertise, such consultants will have more difﬁculty in ﬁnding authority and recognition due to cultural factors.

Stakeholders

Who should count as a stakeholder in the consultation process raises further challenges. Variability between recognition of stakeholders is highly visible in cultural comparisons and exacerbated in a global context. Should the interests of the patient’s family, community, or even the patient’s wider society be included in the considerations and recommendations? And if so, to what extent?

Many Western countries focus on the individual patient alone and his or her independent best interests. Autonomy is the pivotal principle in a therapeutic relationship. However, contrasting cultural, social, or moral frameworks suggest that individuals cannot be disconnected from his family and should not be seen as independent entities. Family decision-making frameworks are often associated with Asian countries or African societies. Here, the question is if a patient’s family should be recognized as a key stakeholder or even as decision-maker with potentially decisive interests.

Ethical challenges arise in situations where the family’s wishes go against the patient’s and include the challenge of who should be considered as “family.” Controversies may arise in recognizing the authority of the extended family member in the decision-making process or the short-term partner, the estranged partner, child, or mistress. In an international context, this is even more convoluted; “family” does not always refer to “biologically or legally related,” and the term is more connected to closeness instead. A “church sister” may be very important for some patients. How decisive their voice should be and who would determine the weight of this voice are signiﬁcant concerns.

Whether to recognize a patient’s society or community as a stakeholder in the consultation process is another challenge. The role of community stakeholders differs between cultures and health-care systems. In many developing countries where health care is scarce, community concerns are much more visible and decisive. Fadare and Jemilohun (2012) describe how the issue of “discharge against medical advice,” where the patient leaves against the physician’s orders, is approached differently in a developing than in a developed country due to community concerns. As health-care ﬁnancing is more community based in developing countries, principles of distributive justice will play a different role in readmitting of the patient. Similarly, the technological imperative, or the idea that because a technology is available it should be used, may dissipate under community concerns where the use and waste of resources impact the community directly.

Whether the consultant is a stakeholder varies in a global context. Consultants may function as stewards of resources, and this type of rationing may be more acceptable in cohesive communities than in individualistic-based models. Western societies, with extremely diverse communities, often explicitly condemn bedside rationing. Once a patient is in the hospital for a kidney dialysis, for example, it would not be acceptable to refuse this dialysis because it is too expensive. Especially in the USA, a melting pot of cultures and religions, such concerns are kept away from the physician and consultant’s hands. These decisions are transferred into the hands of policy makers who are chosen to represent a societal melting pot of cultures and religions. In more cohesive communities and in more socialwelfarist models of health care, however, the consultant will have more responsibility to represent the community’s ends.

Recognition of stakeholders is an ethical challenge in consulting models and a familiar question in bioethics. In this scenario, the question is whether the public and its opposition should be recognized as a valid stake. Should Carine and Dominique abandon their project due to public opposition? Answers depend on frameworks around independent autonomy, relational autonomy, and community autonomy. The role of stakeholders in the consultation process is intertwined with family, culture, ethnicity, and moral frameworks.

Moral Frameworks

Finally, moral and cultural frameworks cause variations and challenges in consultation practices. For example, moral frameworks impact truth telling, as a general feature of the treatment relationship or speciﬁcally at the end of life. Should a physician disclose a terminal prognosis to a patient in the face of objecting family members? De Pentheny O’Kelly et al. describe how this question relates to culture: “Truth telling, a cardinal rule in Western medicine, is not a globally shared moral stance. Honest disclosure of terminal prognosis and diagnosis are regarded as imperative in preparing for the end of life. Yet in many cultures, truth concealment is common practice. In collectivist Asian and Muslim cultures, illness is a shared family affair. Consequently, decision making is family centered and beneﬁcence and non-malfeasance play a dominant role in their ethical model, in contrast to patient autonomy in Western cultures” (de Pentheny O’Kelly et al. 2011, p 3838).

Similarly, differences in moral frameworks around autonomy have caused variations in consultation process and recommendations. As illustrated above, patient autonomy is a benchmark in many Western cultures. In different cultural settings, however, the patient’s autonomous voice may be suppressed by other voices, and the patient may acquiesce to this tradition. In paternalistic societies, for example, the female’s voice may have little value, but she may accept this position.

Ethical challenges arise when consultants apply “Western” moral frameworks in non-Western settings and vice versa. Imagine a Western-educated consultant, who adheres to their framework of truth telling or autonomy and who is involved in a case about an end-of-life diagnosis somewhere in Asia. Should the consultant apply a consulting framework that is based in local norms or adhere to a framework that the consultant may feel most appropriate according to his educational background?

Common Features Of Consulting

This entry explains why it is difﬁcult to ﬁnd common features of consulting in a global context. Health-care consultation is not a simple single phenomenon. Searching for global features of health-care consultation, this entry highlights that consultation processes depend on many variables due to differences in nature of the consultation. The ten golden rules of effective consultation (i.e., question setting, self-awareness, urgency, brief, precision, and concision provide contingency, honor turf, talk, and follow-up) would be speciﬁc to the medical consultation context, according to Geppert (Geppert and Shelton 2012). These features cannot be unequivocally translated to the ethics consultation context or to the social work context, where time, patience, and support seem more important than urgency and precision. Even within a single profession, differences in nature, goals, and context of consultation resulted in few commonalities and many ethical challenges. Consultation is culture dependent.

While consultation is often connected to starting points like democracy, equal moral respect, or independence, these features are not necessarily shared either. Where the consultant is deemed the moral expert in knowledge about content or process, other perspectives would be automatically undermined. Consultation models which forego to include the patient or the patient’s family cannot be deemed democratic or based on equal moral respect. Such models exclude majority and minority perspectives, despite that these models may ﬁt the local setting most adequately. Equal moral respect is an idealistic threshold but not a real one; public consultation may be based on process requirement rather than on equal moral respect for the public. Finally, autonomy or independence of the consultant may be an ideal feature in consultation but hard to guarantee. In a dyadic relationship, the consultant may be chosen because of its connection to outside resources, so that independence is far from a common requirement. Similarly, in a trilateral relationship, a consultee may seek someone who adheres to the same school of thought, so that the consultation aligns with the consultee’s position.

In an uncontested deﬁnition, consultation is a request to assist in a speciﬁc decision-making problem, ﬁlling a gap of knowledge, expertise, or mandate. However, beyond the features of request, discussion, and decision, as set out in the introduction, there are few uncontroversial features which dictate what a consultation would look like in a global context. The nature of consultation will depend on the situation; the cultural, medical and social setting; the question at hand; and the person of the consultant.

Conclusion

This entry is based on a moral pluralist understanding of consultation. Rather than describing what consultation should look like, this entry outlines some reasons why consultation and consultation formats differ from case to case and place to place. Variations in consultation formats exist as a result of differences in problem focus, outcome goal, intervention methods, power base, and value system. The amount of people involved in the consultation, the nature of the topic at stake, the parties’ personal preferences , the status of specialized medicine, and the area of medical expertise are further factors that cause health-care consultation to look differently. Who should be included as a voice in the consultation process, whose interests play a signiﬁcant role, as well as the role of the consultant will depend on differences in social, moral, and cultural context. Consultation in the three-parent baby scenario, as described above, would be addressed differently depending on the weight that is attributed to the patient, the provider, the institution, or the public.

In the global setting, no single uniform format of consultation would seem applicable to all types of health-care consultation. The American Society for Bioethics and Humanities describes the ideal ethics consultation format as one of (ethics) facilitation: “The ethics facilitation approach is fundamentally consistent with the rights of individuals to live by their own moral values and the fact of pluralism. It, therefore, responds to the need for ethics consultation as it emerges in our society” (ASBH 2011, p 5). However, this facilitation model of consultation has been justiﬁed in a pluralist society, but may not be ideal in any cultural context or clinical situation. Consultation in a global context is nuanced. What a consultation relationship should look like will depend on many factors including the stakeholders’ independence, the role of the community, the extent of moral pluralism, and the prominence of the technological imperative.

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