During his training as a clinical ethicist, Craig M. Klugman, PhD, rotated in a genetic medicine service with a physician who was generous with his time.
“He introduced me to each patient and would describe everything he was doing to and for them and why,” Klugman recalls.
One day, the physician casually asked to borrow a stethoscope. Klugman reminded him that as an ethics student, he did not carry one. “From then on, he was curt, rude, and basically ignored me, even allowing doors to slam in my face,” says Klugman, now a health sciences professor at DePaul University.
From that point forward, Klugman had to ask permission to enter rooms, ask the families to consent to his presence, and figure out what was going on in the case, all on his own. “At the end of that particular day, I thanked the doctor for his time. He turned to me with anger and said, ‘So, was I ethical?’” Klugman says. “Early in my training, I learned about the fear that clinical ethicists are the ethics police.”
During the first consult of Margie Atkinson’s career, she heard this statement from an ICU physician: “I don’t know why we consult ethics. You don’t do anything anyway.” For Atkinson, DMin, BCC, now the director of pastoral care, ethics, and palliative care at Morton Plant Mease Hospitals/BayCare Health System in Clearwater, FL, that remark was a powerful motivator. “This set me on a mission to improve our services, enhance our communication, and always investigate requests so that the consulting provider feels heard,” she says, adding that ethicists receive a “bad rap” from clinicians, family, and patients.
Family members or patients sometimes become upset right away if someone on the healthcare team calls in ethics. “They sometimes see ethics as the bad guys,” Atkinson says.
A provider might ask for a consult because an incapacitated patient’s family demands an intervention against the patient’s previously stated wishes. How the ethicist starts out in this type of case can mitigate tension. “The ethics team can explain to the family on the front end that the goal of the consult is to listen to all concerned,” Atkinson offers.
Some clinicians bristle at the mere mention of ethics. “They often feel like an ethics consult means they have gotten their hands slapped,” says Atkinson, noting that the solution is to involve everyone in the consult. “Providers begin to see the benefits of consulting ethics to resolve issues. It’s up to the ethics service to make this happen.”
Hospital signs that inform of an “ethics and compliance hotline” contribute to the problem. People receive the message that ethicists are enforcers, called if somebody’s doing something wrong. “I would like to see these signs changed to read strictly ‘compliance hotline,’” Klugman says. “The problem is that ethics is being used in two different ways in the hospital environment.”
In the realm of law and compliance, “ethics” pertains to whether someone is following the rules and regulations. If not, then the individual needs to be reported and possibly reprimanded. In clinical ethics, “ethics” means something different — an exploration of ideas and values.
“We are present to help and lack any authority to report, to spy, or to demand,” Klugman explains. “We exist to help deal with the moral dilemmas of medicine and healthcare.” Understandably, clinicians call ethics sometimes to report wrongdoing. “When we get a consult and when we send students onto the wards, we need to be sure to explain carefully what our role is, on the phone and again in person,” Klugman says. There are a few common scenarios involving ethics misconceptions:
- Clinicians report a problem that is not related to ethics.
Ethicists are tempted to “lend an ear” if someone has some type of professional problem and does not know where to turn. “While a very human response, it contributes to misunderstanding of what a clinical ethics service can do,” Klugman observes.
People have complained to ethics about everything from a supervisor’s negative attitude toward a patient who wants a second medical opinion. Some turn to ethicists with these troubles mainly because they have nowhere else to turn. “Ethics is often viewed as the problem-solver. They bring any problems that do not have a clear home,” Klugman says.
Good familiarity with all hospital units and departments helps ethicists connect people to the right expertise. “At times, when there is not a fixable or reportable problem or an ethics issue, I have listened to a person’s frustration,” Klugman adds. “That is often enough to help.”
- Clinicians ask ethics to convince someone to continue treatment.
Olubukunola Mary Dwyer, JD, MA, a clinical ethicist at University Hospitals Cleveland, once received a call from an angry surgeon. He explained that a patient had just received a left ventricular assist device (LVAD); the family demanded its discontinuation. Upset that he had “wasted his time in the OR,” the surgeon wanted to convince the family to continue. He asked, “Can you make the family get on board with continuing treatment?”
A flabbergasted Dwyer asked the surgeon to tell her more about the informed consent conversation with the family before the patient was taken to the OR. It turned out such a conversation never happened; there had not been enough time. Dwyer explained that ethicists do not convince people to continue with care. In this case, it became apparent that the family never wanted the LVAD in the first place. During a meeting shortly afterward, the family explained this, offering clear reasons why they wanted to discontinue treatment.
“The surgeon understood the family’s reasoning, but wished that this had been expressed before taking the patient to the OR,” Dwyer recalls. The surgeon left the consult with a better understanding of the ethics role. Ultimately, the LVAD was deactivated.
After this troubling case, the hospital changed the practice standard for nonemergent LVAD placement. Anyone considering this intervention now goes through a palliative care consult. This ensures that patients and caregivers receive a thorough, realistic view of what things might be like postoperatively. “Afterward, palliative care closes the loop with the surgeon,” Dwyer notes.
Other times, clinicians are more subtle but still make it clear they do not believe family members are making good decisions. Some are not shy about asking ethicists to tell the family. “As far as having a conversation to be sure people are making decisions appropriately, we are perfectly fine with that,” says Dwyer, a clinical assistant professor of bioethics at Case Western Reserve University.
The ethicist explains clearly to clinicians that the role of an ethicist is not to convince a family of something. “Rather, we explore what they understand about the clinical situation and what options have been presented to them,” Dwyer adds.
- Clinicians become defensive if they believe they are the subject of an ethics consult.
Occasionally, requests for ethics consults are anonymous. “Other team members don’t feel comfortable letting the team know they are calling ethics,” Dwyer explains. In this kind of case, no one knows who contacted ethics. Not surprisingly, the surgeon or attending in charge of the case becomes defensive.
Dwyer starts the conversation this way: “I’m not calling because someone did anything wrong. We just happened to hear about this patient. We wanted to have a discussion with you so we can all get on the same page with a treatment plan that’s best for the patient.”
Clinicians who work with ethicists usually are fine with this neutral, nonthreatening approach. “It’s the ones we have gone years without contact with who react negatively,” Dwyer observes. Some clinicians respond angrily: “Who are you to get involved with my patient?” Almost always, the situation can be handled without involving administrators.
To avoid mistrust of ethics, it is helpful to be present in clinical areas on an ongoing basis. “We don’t have a huge staff, so we can’t go everywhere. But we do as much as we possibly can,” Dwyer says.
- Clinicians call ethics only because a hospital policy says they should.
Generally, ethicists come into a case “by invitation only. We don’t go swooping in somewhere we have not been invited,” says Martha Jurchak, PhD, RN, HEC-C, executive director of the ethics service at Brigham and Women’s Hospital in Boston.
One exception is when written policies specify that ethics must be involved. Fifteen years ago, when donation of organs after cardiac death was a new practice, an addition was made to the hospital policy requiring clinicians to consult with ethics.
“It was an entirely new endeavor that needed fair and balanced discussion,” Jurchak explains. After a few years, there was less controversy, and the requirement to involve ethics was removed from the policy.
- Clinicians hold strong beliefs — and think others should, too.
Such a clinician calls ethics to be an “enforcer.”
“In my experience, sometimes people want the ethics police,” Jurchak says. “It’s for the same reason you want the regular police — to come and protect you.” Clinicians sometimes make requests of ethicists along the lines of: “Go get the DNR order because we can’t get it from the family.”
“We are happy to do an ethics consult and manage the discussion,” Jurchak says. “First, we have to educate [clinicians] on the role of ethics.”
The first question she asks is “How are you hoping ethics can be helpful in this situation?” Jurchak says it is helpful to discuss not only the recommendation but why an ethicist makes that recommendation.
Next, Jurchak explains that both sides can express concerns. The ethicist explores the benefits and harms of each point of view. Ultimately, the goal is to help all stakeholders come to some kind of consensus.
After this explanation, the caller usually has a better understanding of what ethics can do for them — but not always. “Sometimes, the response is to hang up,” Jurchak says. “You have to have a model and stand by the model. Sometimes, you disappoint people.”
Some clinicians seem to believe “You’re either with me or against me.” Ethicists operate in sharp contrast to this attitude because a more open-minded view promotes respectful communication that could lead all parties to find some common ground. “That idea [open-mindedness] has become so foreign,” Jurchak says. “We need to hold onto it.”