Culture, values, and the role of clinical ethicists in end-of-life care.

Modern medicine broadened the circle of protagonists standing at the bedside and informing clinical decisions. Strangers at the bedside was the unsurpassed metaphor coined by David Rothman in 1992. The classic ensemble standing around the bedridden patient was enlarged by new characters like the healthcare chaplain and the clinical ethicist, but also the lawyer or the administrator. Also, in the fields of palliative care, a new "company" gathered around the patient. This interprofessional team stood for a comprehensive culture with a set of axioms that claimed the naturalness of dying, the relevance of controlling effectively the symptoms of an incurable disease and the allowance to ask the question of meaning in the face of suffering. Clinical ethicists have been trusted companions in deciphering the ethical issues, e.g. when patients requested assistance in dying or – conversely – support in the hope of living on. They challenged the traditional axioms of the palliative care culture. According to George Khushf, apparently cultural issues between patients, families and the healthcare team should be seen as ethical issues expressed in the language of culture. They may contradict delivered values, but deserve the same attention, accuracy and intellectual rigor in exploring the reasons which can stand behind. The task of clinical ethics at the end of life is to bring these values fore, to avoid the conspiracy of friends at the bedside when "culture" is used as a pretext for silencing claims that may be legitimate, and to resume the role of a detached, but deeply sympathetic stranger, who listens to the context in which values are expressed, fosters understanding and facilitates negotiation.