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Clinical ethicists can voice concerns not just during consults involving individual patients, but also more generally to address organizationwide issues. Bioethics experts suggest the following:
• Point out the financial costs of disparate care.
• Utilize conflict management skills to resolve patient grievances.
• Call attention to trends such as conflicts over withdrawal of ventilator support.
• Play a role in the emerging concept of population health management.
It’s not enough for bioethicists to tell hospital administrators what is right and wrong morally with decisions made at the organizational level, says James Corbett, JD, senior vice president of community health and ethics at Centura Health in Denver. Corbett is a fellow at Harvard Medical School’s Division of Medical Ethics and member of the National Institutes of Health’s Nursing Research Council.
“If you’re talking to executives and folks with different incentives, you need to connect ethical principles to the bottom line,” he says. Corbett says what’s needed is “ethics committee plus” — ethicists who are able to address both financial and ethical issues with hospital leaders. “You can advise all you want, but that’s not where the decisions are made,” he says. “The key is for bioethicists to be equipped to be at the table.”
Generally, ethics committees function in an advisory role. This limits their scope and efficacy, says Corbett. “Additionally, the decisions made in the C-suite often do not include bioethicists, partially because they are not equipped to be at the table,” he adds. Disparate care, for instance, has both financial and ethical implications. “There are a lot of reasons to address inequities, but the financial incentives are one big driver,” he says, pointing to the emerging concept of population health management.
“Health systems need to understand everything about that population in order to keep care under a certain budget,” Corbett says. In the past, for example, the fact that Hispanics may have a higher sodium intake might have gone unaddressed by health systems because it didn’t directly affect the bottom line; this is no longer the case.
“Hospitals are seeking to keep specific individuals under a certain budget while hitting quality metrics,” says Corbett. “This is a tremendous opportunity for ethicists.” Accountable care organizations give institutions an additional incentive to understand diverse communities and implement coordinated care efforts that reduce their cost of care, Corbett explains. “Some people do the right thing for the right reasons, and others need incentives,” he says. “We need to do a better job of incentivizing this behavior.”
Bioethicists typically don’t see payment models and financial penalties in health care as part of their purview. “When I talk to bioethicists about the importance of their role, they often ask, ‘Are you telling us we need to learn about health care finance?’” says Corbett. “They don’t think of it as part of their role.”
Corbett points to the history of bioethics, which made the transition from philosophy departments at academic institutions to medical institutions. “They learned that skill set,” he says. “All I’m arguing is that the learning is not done.”
Effective participation at administrative tables requires the clinical ethicist to develop another world view and to appreciate different priorities, says Steven S. Ivy, MDiv, PhD, senior vice president for Values, Ethics, Social responsibility, and Pastoral Services at Indiana University Health in Indianapolis.
When dialogue shifts from how an individual patient is treated to how patients are treated in general, the bioethicist’s orientation must also shift. “The clinician should not lose awareness of individual well-being, but must grow in appreciation for institutional well-being as another good to be nurtured,” says Ivy.
Ethics consultants too narrowly define their area of special expertise as having bioethical knowledge, says Autumn Fiester, PhD, director of the Penn Clinical Ethics Mediation Program and faculty in the Department of Medical Ethics & Health Policy at Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
“Clinical ethics consultants have a specialized skill area, and it is in navigating conflict among parties with often diametrically opposed positions,” she notes. Ethicists who are trained in conflict resolution could help to resolve various types of conflicts within the organization, including patient grievances.
“Many physicians lament the existence of what they deem the ‘difficult’ patient,” says Fiester. “In my view, these challenging clinical encounters can often be remedied with good conflict resolution techniques.”
Some health care systems make it easier than others for ethics perspectives to be addressed throughout the organization. “For example, many religious heritage organizations, both Roman Catholic and Protestant, include executives whose primary role is to ensure that moral perspectives and ethical expertise is brought to bear on clinical, administrative, and community functions of the organization,” says Ivy.
At these institutions, there are pathways in place for clinical ethics to affect systemwide processes. Some organizations have promoted an integrated clinical-organizational ethics continuum. “The ethics committee balances concerns for patient needs with attending to the processes which may challenge or further clinicians’ ability to act ethically,” explains Ivy.
Other organizations have not structured themselves to conduct interdisciplinary ethical discourse. “It is indeed more difficult to gain a seat at decisional tables,” says Ivy. “It happens best when clinical ethicists review their records so that they can identify repetitive or clustered issues.”
Ethicists may note, for example, that 50% of their referrals involve conflict between physicians and families over withdrawal of ventilator support at the end of life. In this case, they might develop relationships with key intensivists. Bioethicists could sit on review committees and bring this cluster of situations to the attention of leaders and begin identifying what processes can be improved.
“Or, they may note that a particular care unit has repeated calls from nurses unhappy with how physicians are managing a certain class of patients, which could be race, ethnicity, or religion,” says Ivy. In this case, ethicists could bring resources to the unit to increase diversity awareness.
During the past six months, Indiana University Health’s ethics team has been asked to prepare white papers and sit at policy tables regarding treating Ebola patients, proposed state government legislation, and solid organ transplants for persons who are not U.S. residents.
None of these issues involved a specific patient case. “All involved potential and actual groups of patients that administrators were seeking to address with foresight and integrity,” says Ivy. “‘Tone from the top’ really does matter.”