The Science and Art of Bioethics Consultation: A Tribute to the Methodology and Teaching of Robert D. Orr, MD, CM

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Competence in bioethics consultation is considered an essential aspect of being a bioethicist. People rightly expect that proficient bioethicists will be able to provide well-reasoned and well-informed guidance on ethically thorny biomedical issues. Being able to offer such help is why many individuals enroll in bioethics training. Consequently, when training curriculum shifts from foundations to applications, students often feel excited, but also apprehensive. Bioethical matters are weighty, and the impact of recommendations are substantial. Even motivated and professionally experienced students can doubt their competence to participate in or lead an effective consultation.

Such it was for me as a motivated and professionally experienced student in the Master of Arts in bioethics program at Trinity International University (Deerfield, Illinois, USA). After several years studying the foundations of bioethics, I enrolled in “Clinical Issues in Bioethics,” an applications course taught by Dr. Bob Orr. It was a much-anticipated course not only because it was my last semester in the degree program but because previous students had promised, “It will all come together when you take Dr. Orr’s class!” And so it did. His instruction on the science and art of consultation demonstrated that bioethics is not only about theoretical discourse but also practical approaches for resolving real-world issues. Moreover, his practicum style of teaching instilled confidence in his students and motivated us to achieve the positive impact we aspired to make.

Is Dr. Orr’s approach to bioethics consultation unique? I cannot say, as I have not had another instructor in consultation methodology. Is his approach to bioethics consultation effective and efficient? That I can answer affirmatively. My team and I used his methodology with over 300 biopharmaceutical research and development consultations during my ten years as head of the bioethics program at Eli Lilly and Company. Further, I continue to use it as a foundation for my biopharmaceutical bioethics consulting and training business, EthicsMatters LLC. The fact it can be tailored to diverse environments speaks highly of its utility and of Dr. Orr’s legacy.

Fortunately, Dr. Orr was motivated to reach an audience beyond the classroom and thus documented his methodology and extensive case study experience in a 2009 book[1] and peer-reviewed article.[2] Although these content-rich publications are highly useful resources, they lack the dimensionality afforded to those fortunate enough to sit under his masterful tutelage. In this article, I am privileged as a former student to provide additional perspective on the science and art of Dr. Orr’s approach to bioethics consultation and teaching and his subsequent legacy.

The Science of Bioethics Consultation

Reflections on Consultation Methodology

For those with a clinical or biomedical research background, the “science” of bioethics consultation can be a welcome change from seemingly endless philosophical musings about a bioethical issue. Dr. Orr, himself a physician, appreciated this. In a clinical setting, a bioethics consultation must be timely, practical, and actionable if it is to have value. It also must reflect consistent reasoning across patients if it is to be considered reliable. To that end, it needs a respectable and replicable process and format.

Relying on physician experience, Dr. Orr and his colleague Wayne Shelton, PhD, MSW modified a clinical consultation process and format for bioethics consultations.[3] With this adapted model, a bioethics consultant does the following after receiving a consultation request: (1) completes a chart review, (2) speaks with those involved, (3) analyzes the case and writes a report, (4) presents individual cases at a weekly case conference for collegial input (similar to clinical grand rounds), and (5) follows up on the case to learn from outcomes. The recommended format for the bioethics consultation report follows a widely used method for documenting patient encounters—that of the Subjective, Objective, Assessment, and Plan (SOAP) note. By adapting established clinical structures, Dr. Orr aligned bioethics consultation with an approach familiar to action-oriented clinicians, thereby giving it credibility.

Reflections on Teaching Style

To teach the “science” of this bioethics consultation methodology, Dr. Orr’s class was light on didactic lecture and heavily weighted towards skill-building. The course description stated: “This course will engage students in the process of doing ethical analysis in group discussion and in writing ethics consultation reports on specific cases” [emphasis added]. “Doing and writing” were the themes of the class. Students implemented the prescribed process and format over and over and over again—in whole class discussions, in small groups, and as individuals—all guided by the master consultant, Dr. Orr himself. As a healthcare professional, he appreciated the importance of practical skill building and engaged a clinical style of teaching where skills are refined with repetitive practice under the watchful eye of an experienced and patient mentor. Like a good clinician-teacher, he showed students how to use the methodology by describing his own real-life examples. Then he guided students on how to use it by engaging group discussions of real-life cases. Finally, he required students to use it themselves by assigning analysis of real-life cases as homework.

The Art of Bioethics Consultation

Reflections on Consultation Methodology

What is it that separates an excellent bioethics consultation from an average consultation? As presented by Dr. Orr, it is the “art” of: (1) acknowledging the uniqueness of each case; (2) looking beyond the way in which the issue was initially framed; (3) identifying all stakeholders, including those involved in the case and those who could be impacted by a course of action; (4) engaging stakeholders to understand their needs and values; (5) appreciating the case context (e.g., outpatient vs. inpatient or end of life vs. standard care); (6) considering hidden dimensions (things people either do not know or are reticent to discuss); (7) identifying concerns conflated as ethics issues; (8) reasoning well; and (9) thinking creatively about recommendations.

In other words, Dr. Orr admonished students not to take a case at face value by assuming too quickly that issues or answers are readily apparent. An excellent consultation, we learned, is detective work that incorporates subjective and objective case facts (the S and O of a SOAP note) into analysis and planning (the A and P of the SOAP note). Knowing what to ask of whom, how to ask, and when and how to present follow-on questions is half of the art of bioethics consultation. The other half is appropriately applying bioethical standards and precedents to a context-specific case. This requires that the consultant be able to comprehend the nuances of case settings, discern key bioethical issues, not be distracted by irrelevant details, and stay current with the breadth and depth of bioethical thought.

Reflections on Teaching Style

As with any skill, there is a continuum of bioethics consultation proficiency. Consultation mechanics can be taught rather readily, but the “art” of the skill must be acquired through experience. How can someone tutor classroom students in the art of bioethics consultation without the advantage of a real-life clinical setting? Dr. Orr’s teaching style emphasized and quickly established professor-student and student-student interaction. More specifically, within this interactive climate, he brought the real world to students through his vast library of clinical cases and by role playing.

To teach the art of inquiry, he would play the role of the requestor and/or attending physician and students the role of consultant(s). In setting up a case, he warned he would provide basic information but would withhold additional information until requested. If students did not ask, he did not disclose. Sometimes he intentionally presented irrelevant factors to see if we were appropriately discerning. Not until we presented our recommendations would we know if salient features had been missed or we had gone astray in our thinking. This instruction method was highly effective. It did not take long until we peppered him with questions to gather relevant information and discard the irrelevant.

The art of bioethical analysis and recommendation were approached in a different manner. These were learned through Dr. Orr’s thoughtful discussions and critiques of verbal and written skills. He emphasized that an accurate and thorough case background was the foundation for a consultation, but the analysis rationale was the linchpin. Thus, the words used to explain the rationale were critical. Students were required to express their thoughts in a manner that appropriately represented bioethical principles, standards, and theories while using language that someone without a bioethics background could understand. Flowing from this, recommendations had to be practical and actionable but could not be directive. All of these consultation requirements were to be encompassed in a written report strictly limited to two pages using 12-point font! We quickly appreciated the challenges inherent in bioethics consultation but also learned they are not insurmountable. By detailing how he handled a case and revealing the subsequent outcomes, Dr. Orr cultivated our critical thinking and communication skills.

Reflections on Legacy

Dr. Orr’s practicum style of teaching the science and art of bioethics consultation was the primary benefit of the “Clinical Issues in Bioethics” course, one that reading an article or book unfortunately cannot afford. It is, in fact, a large part of his legacy. As he interactively guided students through his methodology, Dr. Orr transformed insecure apprentices into self-assured specialists who could build upon his methodological foundation in their own careers. For me, the credibility of his structured approach to bioethics consultation clearly demonstrated its applicability beyond a clinical setting. As I adapted and engaged it within a biopharmaceutical research and development context,[4] I realized that although objectives, constraints, stakeholders, and vernacular may differ across settings, the effectiveness of the methodology holds true. The transportability of his approach speaks to Dr. Orr’s formidable professional insight and acumen. It also demonstrates that his investment in students continues to yield dividends, although perhaps in ways not initially envisioned as the course was being developed.

But there is another aspect to Dr. Orr’s bioethics consultation legacy—one which likely he cared about more. This aspect of his legacy underscores the importance of the “faith factor” in bioethics.[5] As a Christian, he asserted that the biblical passage Micah 6:8 is “the semester class in ethics.”

He has shown you, O man, what is good;
And what does the LORD require of you,
But to do justly,
To love mercy,
And to walk humbly with your God? (NKJV)

He explained that the ethical requirements outlined in the Hebrew prophet’s question parallel the secular biomedical ethics principles of “justice,” “beneficence,” “nonmaleficence,” and “respect for persons,” also known as “autonomy.”[6] The principle of justice directly relates to “justly” and the principles of beneficence and nonmaleficence directly relate to “mercy.” The principle of respect for persons or autonomy directly relates to “humbly,” although the relationship may not be immediately apparent.

Dr. Orr proposed that Micah’s call to walk humbly with your God sustains the meaning of this secular principle but not its extent. He explained that because a biblical perspective acknowledges the existence of a Creator-Savior God, affirms that all human beings are equally created in his image, and recognizes the limitations of human wisdom, knowledge, and understanding, Christians should approach life and ethics with humility. The fact that God’s own Son, Jesus, came into the world not to be served but to serve (Mark 10:45) heightens this obligation for Christ followers. Linking back to secular bioethics principles, one way humility can be demonstrated is to respect others by protecting and facilitating their ability to make autonomous decisions. However, the very same biblical reasoning that supports personal autonomy does not allow for unmoored self-determination. Rather, godly humility necessitates that attitudes and actions be tethered to and guided by an authority higher than we ourselves. As Dr. Orr concluded, “We must be subservient to our Lord and submit to His will.”

These are wise words from a man who was a role model of the justice, mercy, and humility of Micah 6:8. From what we, his students, experienced, he lived what he taught. In particular, “walking humbly with your God” was a hallmark of the Dr. Bob Orr we knew, and so, not surprisingly, it is a hallmark of his approach to bioethics consultation and teaching. He encouraged his students to make it theirs as well. What better tutor can there be? If the present generation of bioethicists goes and does likewise, what better legacy can there be?

References

[1] Robert D. Orr, Medical Ethics and the Faith Factor (Eerdmans, 2009).

[2] Robert D. Orr and Wayne Shelton, “A Process and Format for Clinical Ethics Consultation,” Journal of Clinical Ethics 20, no. 1 (2009): 79–89.

[3] Orr and Shelton, “A Process and Format for Clinical Ethics Consultation.”

[4] Luann E. Van Campen, Albert J. Allen, Susan B. Watson, and Donald G. Therasse, “A Pharmaceutical Bioethics Consultation Service: Six-Year Descriptive Characteristics and Results of a Feedback Survey,” AJOB Empirical Bioethics 6, no. 2 (2015): 53–62, https://doi.org/10.1080/23294515.2014.957363.

[5] Orr, Medical Ethics and the Faith Factor.

[6] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7^th ed. (Oxford University Press, 2013).

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