Toward a Theory of Process

Abstract

Bioethics has no theory of process. The field has labored to develop a widely shared set of substantive values, but has been slow to spell out what processes those values command. Nor has the bioethics literature examined process itself, to gauge the impact of different procedures and debate what we should value in process itself. There is no overarching approach to designing procedure for institutional bodies such as ethics committees. And we lack a systematic approach to structuring the link between institutions, such as court review of a case heard previously by a hospital ethics committee.

The lack of work on process poses a significant threat to patients. It is widely agreed that health care professionals have substantive ethical commitments to serve the patient’s good and respect patients’ exercise of autonomy. Yet this commitment to the patient falls apart when we turn from substantive principles to process. The procedures used in health care settings may undermine or support the proclaimed ethical commitments. We see no systematic effort to study process itself, yoke it to appropriate values, and demand that process do right by the patient. This is a gaping hole in medical ethics. We are willing to say the patient comes first, but not yet to enact that commitment by guaranteeing procedures that protect patients’ interests.

This failure to think procedurally has made it nearly impossible to resolve a number of key issues, such as the process obligations of ethics committees in reviewing patients’ cases, and the proper judicial approach to review of ethics committee determinations. This article is an attempt to sort out those problems. But in doing so, the article attempts something broader: to move toward an ethics of process. Specifically, the author urges an ethics of patient-centered process. What would it look like if we were as patient-centered in our procedures as we claim to be in our substantive ethical commitments? This article spells that out. It is not enough to talk the language of respect for patients. That respect must be enacted. This is the work of process.

Keywords: Bioethics, health law, due process, process values, process norms, patient-centered process, ethics of process, ethics committees, ethics consultation, judicial review, law and ethics