Many healthcare providers rely on trade organizations to convey the value of their professions. “Bioethics has let itself get behind other fields. It has construed itself as clinical, but apart; clinical, but different,” says Paul L. Schneider, MD, FACP, chair of the bioethics committee at the Veterans’ Administration Greater Los Angeles Healthcare System.
Ethics professional societies tend to focus more on content, and pay less attention to how the field itself is perceived. “There’s only been preliminary effort to help ethicists trying to do a better job at representing ourselves in that way,” says Schneider.
Last year, the American Society for Bioethics & Humanities’ Healthcare Ethics Consultant-Certified program became the first such initiative to identify and assess a national standard for the clinical healthcare ethics consulting. Schneider says this is an important step, but “the tip of the iceberg. One of the challenges facing us in the field is a search for legitimacy. That’s what everything is about right now.”
The value of the work of ethicists is lost on some hospital leaders. “Hospitals are happy to defer issues to us in clinical ethics when we’re talking about low-risk cases that tend to resolve themselves well,” says Schneider. The legitimacy of ethics comes into question if cases are higher risk, with more potential for court involvement and lots of conflict.
“We are seeing increasing demand for accountability and exactly how we do our work and under what rules and policies,” reports Schneider. At the same time, many ethics services struggle to meet surging demand for consults. “The fire has been turned up, but with no increased resources,” says Schneider.
Ethics Resources May Be Sparse
Some private-sector hospitals have seen modest increases in ethics resources in recent years, notes Schneider. However, ethics resources are generally sparse in U.S. hospitals, except at major academic medical centers. As an ethicist, says Schneider, “I am expected to do my work out of my back pocket. I am given 25% time, but it’s not enough to do all the work that I do.”
This often leads to conflicting obligations on the part of a “volunteer army” of ethicists. “It’s almost like there are two colliding forces,” says Schneider.
The push for more accountability and a higher-quality work product is stymied by insufficient resources. “With the few exceptions of the places that are well-resourced, most are not,” says Schneider. “Ethics tends to happen due to extra effort of the people involved.”
Justifying ethics resources often is complicated by the field’s unique mindset and terminology. “There are ‘translation’ problems between ethicists and administrators,” notes Schneider.
Resource allocation decisions are based on data, outcomes, and return on investment, not ethical principles.
“The problem is that most of us as ethicists are not innately businesspeople,” says Schneider. “It’s not really our strength.”
Still, there is much common ground between the goals of administrators and ethics. For administrators, resource use always is top of mind. For ethicists, the principle of stewardship comes into play.
“We are doing ourselves a disservice if we run away from that. Ethics should be part of those decisions,” says Schneider.
Ethical and cost-effective care are not necessarily mutually exclusive. “You are not doing it to save money, but it does save money in the long run,” says Schneider. “The bottom line is that doing the right thing is also cost-effective.”
Increasingly, hospital leaders are recognizing that ethics expertise “can help in the boardroom as well as at the bedside,” says Tim Lahey, MD MMSc, director of clinical ethics at the University of Vermont Medical Center in Burlington.
Lahey says ethics input can help institutions:
• make challenging decisions about whether to notify patients about an error;
• address unprofessional behavior;
• determine how to satisfy the organization’s promise to serve the community — even if a clinic that serves vulnerable populations is not performing well financially.
Ethicists can do more than just help organizational leaders make wise decisions. “They can help organizational leaders show that their decision-making process was inclusive, well-considered, and wise,” says Lahey.
To benefit from ethics expertise at an organizational level, hospital leaders need to figure out these two things, says Lahey:
• how to adequately support individuals with ethics expertise;
• how to embed them in decision-making processes.
“It doesn’t help the organization to have ethics expertise if the ethicist is never in the room when major decisions are made,” says Lahey.
When decisions are made about conflicts of interest or the care of vulnerable populations, ethicists need to be there. Some hospital leaders already understand this. If so, ethicists can garner even more support, says Lahey, “by being pragmatic instead of overly academic and willing to roll up their sleeves.”
Some hospital leaders, less attuned to the need for embedded ethics expertise, are focused only on the short-term bottom line. To face this uphill battle, Lahey says to look for a crisis that allows the ethicist to help in a concrete way. The ethicist can then offer continued help, says Lahey, by making a comment such as, “That was fun helping out. In the future, if you’d like me to help prevent that from happening, please let me know how I can help.”
• Tim Lahey, MD MMSc, Director, Clinical Ethics, University of Vermont Medical Center, Burlington. Phone: (802) 847-4595. Email: firstname.lastname@example.org.
• Paul L. Schneider, MD, FACP, Chair, Bioethics Committee, Veterans’ Administration Greater Los Angeles Healthcare System. Email: email@example.com.