All-Volunteer Model Risks Marginalizing Ethics
It is hard to imagine tasking a hospital risk manager with reviewing legally problematic cases without compensation just because they enjoy handling that task. Yet, that is what some hospitals ask of their “volunteer army” of ethicists.
“The real tragedy is that so much of the clinical ethics work that goes on happens based on the goodwill of the people who do that work,” says Joseph J. Fins, MD, MACP, FRCP, chief of the division of medical ethics at Weill Cornell Medical College.
Many individuals who perform clinical ethics consults or serve on ethics committees do so on a strictly volunteer basis. That, in addition to their other role as a clinician, administrator, nurse, or chaplain. “While volunteer efforts are laudatory, the failure of the organization to recognize this activity as worthy of support marginalizes it in comparison to other clinical activities,” Fins argues.
Some hospital administrators just do not see the value of ethics. That makes it easy to cut any resources that already are dedicated to it. “It will be the first thing to go when people are pressured by economic constraints,” Fins observes.
Financial support for ethics varies widely. Many major academic medical centers include divisions, departments, or centers of medical ethics. “There is support for many people to do some of this work,” Fins notes. “I suspect that the falloff might be in places like community hospitals.”
Evidence that ethics consultations are cost-effective can help move the dial toward compensating the people who do it. According to Fins: “It’s good for patients and families, and may be very good for the fiscal well-being of institutions.”
The advice that ethicists give “can be incredibly consequential,” Fins adds. For example, many consults result in decisions on whether to withdraw or withhold care. The operational aspects of those clinical activities are compensated. “It seems kind of anachronous that counsel that might lead to certain kinds of decisions would not be similarly supported,” Fins says.
Ethics consultation services are helpful in building resilience, says Fins, “both for individual clinicians and also institutionally.”
Ethicists can help clinicians talk about difficult cases and enlighten them on the ethical issues behind particular actions, such as withdrawing life-sustaining interventions. “Clinicians can deal with their angst and then pick themselves up and continue to serve patients and families,” Fins offers.
Ethicists often find a way to resolve conflicts that otherwise would have ended up in the legal system. “One significant lawsuit that’s prevented can pay for an ethics service for many years,” Fins says.
Reduced length of stay, less unwanted care, and better patient satisfaction are other factors that demonstrate the utility of ethics services from an economic standpoint. “It’s important that we get a better handle on the epidemiology of the economics of ethics case consultations,” Fins argues.
Of course, saving money is not the sole reason to offer ethics consultation services. Fins emphasizes: “There is a moral and value-driven rationale for that. Nonetheless, there is economic justification.”
Speaking the language of healthcare economics can help ethicists move toward paid positions. “You can write the treatise on why this is important, or you can present a one-page spreadsheet that the people who make budgetary decisions understand,” Fins offers.
Healthcare systems can take advantage of well-intentioned ethicists. Many people freely volunteer their time because they are passionate about ethics. “People so enjoy doing clinical ethics that their goodwill may be taken advantage of a little bit,” Fins admits.
However, it is not just ethics. Other hospital services such as palliative care, chaplaincy programs, and consultation liaison psychiatric programs also struggle to receive financial support. “There is a kind of family resemblance here,” Fins says. “These are all activities that are essential but often are not compensated commensurate with need.”
Frequently, a staff member will stop an ethicist walking through the hospital because someone wants to ask a question or express a concern. These “curbside consults” are less than ideal because the ethicists do not know all the facts. “There is a risk of giving advice to a partially complete story,” Fins says. “But it’s a biomarker of need.”
It still is hard for some organizations to view ethics services as something that needs to be paid for. “We value the technical procedures. We probably overcompensate for technical ability, but we underpay for instrumentalism or pragmatism in the clinical context,” Fins says.
One reason is that the effect of ethics — on clinicians, on patients and family, on the institution — is difficult to measure. After a successful ethics consultation, the family might end up making the same decision they would have made otherwise. “But the process is a lot better. It is more considered, more thoughtful, and deliberative,” Fins says.
A family who went through this kind of process may experience less complicated bereavement or be less likely to sue. A nurse who went through it may be less likely to experience burnout or leave the profession. “We don’t tend to think of that longer arc of consequence,” Fins adds.
Proof that ethics prevented a lawsuit, a nurse quitting, or an unhappy family is often elusive. “These considerations are apparent to more visionary leaders,” Fins says. “They may be less obvious to people who have not been thinking about this in a more holistic way.”
Compared to other programmatic requests, ethics does not require a large amount of resources to sustain itself. “There is no capital investment here. It’s all about people. It’s not a lot of money, generally,” Fins says. Building alliances with the clinical services that use ethics is one way to engender support. Fins offers a few approaches:
• Identify clinicians who support ethics. “An endorsement from a clinical leader or department chair could be incredibly valuable,” Fins says.
• Invite people helped by an ethics consult to consider joining the ethics committee. The goal is to build a community of people who are like-minded. Ultimately, all of them can be advocates for improving ethics at the institution.
“The ethics committee member is an ambassador between ethics and their home department and can serve as an intermediary between those two areas,” Fins explains.
If the head of a clinical department warmly introduces the ethicist during grand rounds, it grants the ethicist considerable credibility. “It brings clinical ethics into the clinical mix,” Fins says. “We are all, after all, in the common pursuit of quality care.”
• Go on a “listening tour” to better understand what clinicians need from ethics. “Taking all of those points together, summarizing them, and presenting them to leadership is a way to engender an interest in this,” Fins says.
• Educate clinicians on ethics as a way to improve the quality of care. “This sensitizes people to a need that exists, that they were not aware of,” Fins notes.
This can happen even if ethicists lack the resources to set up a clinical consultation service. “The person doing the education could be a cultural change agent within the institution, helping to promote the service that will eventually come to pass,” Fins says.
The work of ethics takes time, a precious commodity to today’s clinicians. “Increasingly, clinicians are unable to cost shift within their sphere to be as generous with their time as they have been,” says Fins, noting that some volunteer ethicists are expected to assist whenever someone requests a consult at any time of the day. “Like any clinical service, it’s not sustainable to do as a volunteer activity.”
If clinicians do not have the time to devote to ethics work, then the work will not be completed. “These activities will die of attrition, to the detriment of patients,” Fins says.
Ultimately, ethics is a service that patients and families need. If hospitals and health systems do not recognize that and support it so it is sustainable, says Fins, “it’s really an abdication of responsibility. It’s like saying, ‘We’re not going to have lawyers or chaplains or infection control.’ This is part of what a modern hospital requires.”
Recently, Fins was taking a review course for a board of internal medicine recertification exam. The group was given five choices for each question, with about 80% choosing the correct answer each time — until an ethics question came up. Suddenly, the responses were evenly split, with each answering right at about a 20% response rate. The instructor noted Fins’ presence and asked him to explain the reasoning behind the correct answer.
“What it showed me was that all these people who were so well-trained in every clinical area, when it came to ethics, were all over the map,” Fins observes. “Their level of preparation was not commensurate with all the other areas they were studying.”
This encounter underscores the need for professionals with ethics expertise in the hospital setting, Fins says. The question that hospital leaders should be asking, says Fins, is “Why should this activity, alone among all activities, be the sole activity that is not supported?”
“It is illogical and is untenable,” Fins argues. “And it doesn’t make sense economically.”
A few years ago, ethics leaders at a half-dozen hospitals in northern New England hospitals informally compared funding at each of their hospitals. The range of support ran from none to two full-time ethicists. “Naturally, ethicists with more funding felt they had more time to support the needs of patients, clinicians, and leaders,” says Tim Lahey, MD, MMSc, director of clinical ethics at University of Vermont Medical Center.
Small, rural hospitals usually only worked with volunteer ethicists charged with few responsibilities. Larger healthcare systems employed several ethicists in paid positions, which came with more responsibilities.
Whether ethicists are paid is connected, at least in part, to how well they quantify the avoidance of unnecessary or unwanted care, lawsuits, or regulatory problems, according to Lahey. “Our preventive role and engagement in the most complex cases poses a structural quandary. Our impact is either uncountable or detectable only in expensive, outlier cases,” Lahey says.
Lahey says ethics probably will be better supported in value-based care systems. There is no billing code for clinical ethics work. “Funding it via doing clinical consults piecemeal in the same way other clinical work is funded in a fee-for-service environment isn’t feasible,” Lahey explains. Therefore, hospitals need to invest in ethics just because they believe it contributes to quality of care. “In a value-based system, by contrast, hospitals can invest in preventive measures like clinical ethics without having to consider how many widgets of clinical care that work equates to,” Lahey says.
Evidence that ethics consultations are cost-effective can help move the dial toward compensating the people who do it.
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