Michigan Medicine’s clinical ethics service recently started weekly proactive ethics rounds in the three ICUs at C.S. Mott Children’s Hospital.
“Given the known systemic biases within healthcare, we were concerned that this new service could unintentionally perpetuate existing biases,” says Janice Firn, PhD, MSW, a clinical ethicist at Michigan Medicine Center for Bioethics and Social Sciences in Medicine.
Ethics rounds can help providers, patients, and families address complex issues. “We also acknowledge that bias can be present and is something not easily eradicated,” Firn says.
Healthcare providers display a similar level of implicit bias as found in the general population.1 “There is risk for bias, stereotyping, or prejudice when the care team and patient or family are dissimilar in terms of race, ethnicity, religion, or culture, and when there are power imbalances between privileged providers and underprivileged patients and families,” Firn observes.
During the rounds, ethicists routinely ask providers to reflect on patients and elicit ethical concerns. “We were concerned that minority groups and/or those with less privilege socially, who are more likely to be subject to bias, may be disproportionately identified as having ethical issues,” Firn explains.
Ethicists wanted to better understand the effect of the ethics rounds on socially vulnerable groups. “As clinical ethicists, we have an obligation to regularly evaluate whether and how our services impact socially vulnerable populations and work to address and reduce bias through the services we provide,” Firn says.
Firn and colleagues compared sociodemographic factors between patients admitted to an academic children’s hospital during ethics rounds in the PICU, PCTU, and NICU in 2017 and 2018 who were identified as having ethics issues and all other patients admitted to those same units during the same period.2 The researchers expected racial and/or socioeconomic differences between the groups, with socially vulnerable patients disproportionately identified as having ethical issues on rounds.
However, Firn and colleagues did not find this to be the case. There were no significant differences on the basis of sex, religion, ethnicity, age, primary language, or socioeconomic status. “There is concern that bias could go the other direction and that minority patients could be less likely to have ethical issues identified, and have less access to ethics review and support,” Firn notes.
Still, investigators found no racial, ethnic, or insurance differences between the groups, suggesting an equal level of access. “We were both surprised and relieved to find that patients with ethical issues identified during interprofessional ethics rounds are demographically similar to overall patients admitted in these units,” Firn says.
The exception was patients who were ventilator-dependent were much more likely to be identified as having an ethical issue. This was the case regardless of other demographics.
Ethical issues in those cases included disagreements about the goals of care; concerns about medical futility, inappropriate, or non-beneficial treatment; identifying the correct decision-maker; disagreement between parents or joint decision-makers; and concerns about discharge details and placement options. “This suggests that patients with increased medical severity are more likely to have ethical issues identified during interprofessional ethics rounds,” Firn concludes.
- FitzGerald C, Hurst S. Implicit bias in healthcare professionals: A systematic review. BMC Med Ethics 2017;18:19.
- Kana LA, Feder KJ, Matusko N, Firn JI. Pediatric interprofessional ICU ethics rounds: A single-center study. Hosp Pediatr 2021;11:411-416.