Executive Summary

Clinicians occasionally refer to consult services as the “ethics police;” misconceptions are typically behind this negative perception. Experts suggest the following approaches:

• Emphasize that final decisions are primarily between the provider and patient.

• Explain that the consultant is outside of the patient/physician relationship.

• Speak directly to clinicians opposing the involvement of ethics.

 

At times, providers react negatively to the involvement of ethics; “ethics police” is an often-used derogatory term reflecting this attitude. “The key to avoid being perceived as the ‘ethics police’ is to emphasize that final decisions on how to proceed are primarily between the healthcare provider and the patient,” says Michael A. Rubin, MD, MA, chair of the ethics committee at UT Southwestern Medical Center in Dallas.

Rubin always introduces himself as an advisor, not as a representative of the hospital administration or a judicial board. He tells both the patient and the person requesting the consult that he’s a third party outside of the patient-physician relationship.

“Furthermore, if I have my white coat on, I remove it to indicate that I’m assuming a different role in this particular interaction,” says Rubin. “While some people might perceive this as weakening the role of the ethics consultant, I believe it is a source of influence.” This is because it makes it clear that the roles of provider and advisor are separate.

People who react negatively to ethics consults are often uninformed about what services are actually provided. “The skeptics will call risk management, and often find that the risk managers want us to get involved,” says Rubin. “I usually tell them that our legal folks define the black and white, and the ethicist helps the physician and patient explore the gray.”

How the consultant reacts to the term “ethics police” or other negative comments colors the rest of the encounter. “If the consultant’s tone indicates preparation for a conflict, there will be a conflict,” says Rubin.

If an ethics consultant hears the term, “ethics police,” he or she should be able to explain why such a characterization isn’t accurate. “This means being able to say what the role of ‘ethics consultant’ is charged to do in the institution,” says Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles.

Some physicians worry that the Health Care Ethics Committee (HEC) will interfere with the patient’s care or challenge the physician’s authority. “A physician’s explicit opposition to an ethics consult should be a rare event at a hospital that fosters a moral and just community; however, it certainly does occur,” says Rubin.

At times, consults are called because members of the care team disagree about the direction of care. “As there is a power differential — or at least a perception of one — between these various stakeholders, the HEC may be involved to facilitate resolution of a disagreement,” says Rubin. Rubin recommends that bioethicists consider the following practices if they encounter resistance to ethics consults:

• Refer to the hospital ethics consultation policy.

“A well-written policy will indicate that it is appropriate for an ethics consult to be called even in the opposition to a treating physician,” says Rubin.

• Insist that conflicting parties first make an attempt to resolve their disagreement through their usual hierarchies.

For example, in the case of a nurse-physician conflict, the nurse manager and medical director should be involved. Rubin first asks if the usual pathways have been attempted. “This will decrease the likelihood of the perception that the HEC is being used as a ‘punitive’ consult, or perceived as being intrusive,” says Rubin.

• Attempt to speak personally with the clinician opposing the involvement of the HEC.

“If they absolutely refuse, at least they have been given a chance to privately indicate their objection,” says Rubin. “They may be less resistant when given the chance to speak freely outside of earshot of the other stakeholders.”

If individuals insist a personal conflict is the real reason why a colleague called an ethics consult, Rubin simply proceeds with the process. In other situations, providers may have had previous experiences with ethics consultants that were not helpful. “Establishing the specific goals of the consult will often allow better cooperation,” says Rubin.

Supporting providers is part of role

An important role for ethics consultants is to allow patients and families to articulate their goals, values, and preferences, but they are also there on behalf of providers. “Ethics consultants help and support healthcare providers in articulating the values embedded within their professional and institutional roles and associated responsibilities,” says Finder.

Although the role of the ethics consultant is typically advisory, those who provide ethics consultation must be attentive to the potential influence their participation can play in a situation.

“Having the role ‘ethics’ associated with one’s activities often causes others to grant the ethics consultant a kind of moral authority that may well be unwarranted,” Finder explains. “This can shut down others from seeing their own moral experiences as having legitimacy and being worthy of attention.”

Involved parties aren’t likely to speak freely about their concerns if they fear being judged or disrespected. “This is especially so if the individual — be they patient, family member, or staff — holds values that may not be common or mainstream,” says Finder.

SOURCES

• Stuart G. Finder, PhD, Director, Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles, CA. Phone: (310) 423-9636. Fax: (310) 423-9638. Email: Stuart.Finder@cshs.org.

• Michael A. Rubin, MD, MA, Chair, Ethics Committee, UT Southwestern Medical Center, Dallas, TX. Phone: (214) 648-8513. Fax: (214) 648-0341. Email: Michael.Rubin@UTSouthwestern.edu.