"Here come the ethics police!” “Somebody called ethics on me!”

Are these the first thoughts providers have when they are approached by a clinical ethicist? “There is a pervasive misconception that our primary focus is to find what is ethically inappropriate, and assign blame or fault,” says Adam Pena, MA, an instructor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy in Houston. Pena is also a clinical ethicist at Houston Methodist Hospital’s Biomedical Ethics Program at Texas Medical Center.

“Another common misconception is that we espouse an agenda to endorse comfort care or non-aggressive interventions in every case, or that our services adds complexity to the situation,” says Pena.

In addition, clinicians sometimes confuse the clinical ethicists’ role with other ancillary services, such as social workers, palliative care practitioners, and chaplains. “While our skill set may overlap with other healthcare professionals, our role is unique,” says Pena.

Providers are sometimes completely unfamiliar with the clinical ethics consultation service and have no idea how to access it. “Providers may not know if a particular issue is an ethics issue,” adds Pena. “They may be unaware of the range of services a clinical ethics consultation can offer.” Here are some scenarios where clinical ethicists can be helpful, but are typically not utilized:

Clinical ethicists can prevent ethical issues from occurring in the first place.

For example, if a patient has a history or recent diagnosis of HIV, a clinical ethicist could talk with the patient about preferences related to disclosure of status, establish parameters for disclosure, and help identify potential surrogate decision-makers should he or she lose capacity. “In this way, the clinical ethicist may help prevent ethical concerns related to maintaining confidentiality and disclosure of status,” says Pena.

Clinical ethicists can anticipate concerns with advance care planning.

For example, if a patient is undergoing a transplant or ventricular assist device evaluation, a clinical ethicist can meet with the patient and surrogates, to elucidate expectations and goals related to device therapy. “This prevents misalignment of expectations related to treatment outcomes between patients, surrogates, and healthcare team members,” says Pena.

Clinical ethicists can seek to build relationships with a wide range of colleagues, advises Katherine Wasson, PhD, MPH, director of the Bioethics & Professionalism Honors Program at the Stritch School of Medicine, Loyola University Chicago.

She recommends that ethicists:

• Offer educational sessions for different units, such as ICUs, where many of the complex cases arise. “These can be regular case-based discussions where the clinicians bring tough cases from the unit and the ethicist helps them reflect on the ethical issues,” says Wasson.

• Round with particular teams to get to know the individuals and types of issues they encounter.

• Build relationships with key clinicians, such as residency directors, nurse managers, and department chairs, who see the need for ethics input.

Some clinicians perceive an ethics consult as a sign that someone has done something wrong and is going to be judged accordingly by the ethicist and others. “Sometimes clinicians who are involved in a challenging case but aren’t the ones who request a consult feel that they are being deemed a ‘bad’ clinician or person,” says Wasson. Clinical ethicists can clarify that their role is not to condemn or judge anyone.

“People sometimes have the misconception that the clinical ethicist will enter into the case and simply tell people what to do,” says Wasson.

When ethics committees in hospitals first began, many clinicians were wary about their role, notes Rosalind Ekman Ladd, PhD, a visiting scholar in philosophy at Brown University in Providence, RI. Physicians, understandably, did not want to have their ethics questioned, and did not want to be told what to do.

“Medical people and scientists in general were used to having one ‘right’ answer to a problem, and were unfamiliar and uncomfortable with what seemed like the ambiguity of ethical issues,” she explains. Ethical discussions sometimes end by admitting that there is no single right answer, or that either of two answers is ethically permissible.

Ethics committees as a forum for discussing challenging cases became more acceptable with the rise in patient autonomy as opposed to medical paternalism. “Some of the younger physicians were happy to give up the role of taking sole responsibility for making tough decisions,” says Ladd. To promote ethics, she recommends finding a respected physician to be chair of the ethics committee. “Another good method is to invite a clinician to present a case for discussion at an educational session of the committee,” she suggests. “Or invite clinicians to participate in discussions of hypothetical cases with the committee.”

If these approaches go well, ethicists can follow up by presenting a case discussion at grand rounds. “Do a survey of staff; ask for anonymous suggestions of ethical issues that bother people,” suggests Ladd. “Deliver the message that it is a strength and not a weakness, to include ethics issues in all case discussions.”

SOURCES

  • Rosalind Ekman Ladd, PhD, Visiting Scholar in Philosophy, Brown University, Providence, RI. Phone: (603) 788-4864. Email: rladd@wheatonma.edu.
  • Adam Pena, MA, Instructor, Center for Medical Ethics and Health Policy, Baylor College of Medicine/Clinical Ethicist, Houston Methodist Hospital Biomedical Ethics Program, Texas Medical Center, Houston. Phone: (713) 798-2515. Fax: (713) 798-5678. Email: Adam.Pena@bcm.edu.
  • Katherine Wasson, PhD, MPH, Director, Honors Program in Bioethics & Professionalism, Neiswanger Institute for Bioethics, Loyola University Chicago. Phone: (708) 327-9201. Fax: (708) 327-9209. Email: kawasson@luc.edu.