Angel Petropanagos and Andria Bianchi highlight the lack of agreement about what “advocacy” means in healthcare and suggest that a narrowly defined advocacy role is necessary for the work of practicing healthcare ethicists.

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The question of whether practicing healthcare ethicists should be advocates has been highlighted by recent calls to action in relation to speaking out against racism and other forms of structural and systemic oppression that exist in healthcare. In Canada, practicing healthcare ethicists (or just “ethicists” for brevity) are moving toward professionalization and considering which values and standards should guide their practice. The question of whether ethicists should be advocates has been especially divisive. This disagreement isn’t new. However, we suggest that a lack of conceptual clarity and lack of agreement about what the term “advocacy” means is fueling this disagreement.

In the most basic sense, “advocacy” means defending or standing up for something or some person(s). Based on our experiences in the field of healthcare ethics, we’ve found that ethicists typically answer the question of whether or not to be an advocate in one of the following ways. First, some maintain that ethicists should not be advocates. This position is often grounded in the belief that ethicists should be neutral or objective on ethical issues. Advocacy is seen to be in tension with the obligation to be neutral or objective because it involves “taking a side”. Accordingly, the worry is that advocacy could raise questions about loyalties, allegiances, or conflicts of interest.

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Second, some ethicists think that neutrality and objectivity are not necessary or possible and that ethicists are uniquely well-position to take sides on ethical issues. From this perspective ethicists should advocate for a “morally right” position, as determined by ethical analysis. Further, some might believe that choosing not to advocate in ethically challenging contexts, like when witness to harms involving discrimination or systemic oppression, not “taking a side” amounts to taking the side of the oppressor. In this way, not advocating could exacerbate the harm or undermine the ethicist’s integrity.

Third, some ethicists express a middle ground that allows for advocacy by ethicists with respect to some activities or subjects, but not others. For example, some ethicists might think that it’s appropriate to advocate for the needs of a particular patient, but not okay to advocate for a political position or policy. We imagine other perspectives on advocacy also exist among ethicists.

The disagreement about whether ethicists should be advocates seems to be, at least in part, rooted in different conceptions of what’s meant by “advocacy.” Ethicists disagree about what counts as “defending” or “standing up for” and also about what things or persons ethicists should be advocating for. Would advocacy require ethicists to engage in a particular kind of debate regarding governmental or organizational funding decisions? In acting as an advocate, would ethicists advocate for individual patients, patient groups, or other healthcare professionals or organizations? The scope, processes, and reasons for advocacy are also unclear. Further, there are different interpretations of the role of ethicists, as ethicists are not yet professionalized. Consequently, individual ethicists may have different practices that inform how they understand what advocacy could mean in the context of their role. Ethicists will need conceptual clarity and agreement on what’s meant by “advocacy” before deciding whether advocacy should be part of the role of a clinical ethicist.

As a starting place for contributing to the literature and debates about advocacy, we offer a narrow conception of “advocacy” namely, that ethicists should advocate for certain procedural values and processes. For example, deciding the appropriate end of life treatment plan can be ethically challenging and reasonable people can disagree about the most ethically-justifiable course of action. In this case, the role of the ethicist, at minimum, would be to advocate for an ethical decision-making process – one that is grounded in procedural values, upholds role clarity, and is patient-centred. We think it’s essential for an ethicist to advocate for an ethical decision-making process. Ethicists may disagree about which procedural values should be part of the process, but arguably, a commitment to transparency, respect, patient-centeredness, and accountability (especially as it relates to role clarity) are crucial and ethicists should advocate for these values in the process.  

While ethicists may need (or choose) to be neutral with respect to the best position or outcome for any ethical dilemma, they shouldn’t be neutral in relation to decision-making processes. In fact, we think it would be a failure to do our job well if we are neutral in relation to decision-making processes since not implementing an ethical process can sabotage the ethics of the outcome. 

To summarize, ethicists need conceptual clarity when discussing “advocacy” within the role of healthcare ethics. In an effort to help ethicists attain some degree of conceptual clarity, we argue that at minimum, ethicists should advocate for an ethical decision-making process grounded on certain procedural values. If ethicists are on-board with engaging in this narrow conception of advocacy, then perhaps we may be one step closer to clarifying what we do as ethicists and how advocacy can be part of our role.

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Angel Petropanagos is an Ethicist at William Osler Health System and the co-editor of Impact Ethics @APetropangos

Andria Bianchi is a Clinical Ethicist at Unity Health Toronto and serves on the Board of Directors of the Canadian Association of Practicing Healthcare Ethicists – Association Canadienne des Ethiciens en soins de Sante (CAPHE-ACESS).