Expand bioethics role: Become more involved in organizational ethics
Bioethicists have much to contribute
EXECUTIVE SUMMARY
Some bioethicists are expanding their role beyond case consultation into organizational ethics, but may encounter barriers such as lack of support from leadership. Bioethicists can:
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Identify members of the Ethics Committee who can obtain executive support for a particular initiative.
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Use an in-depth case study to illuminate systemic issues.
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Propose grand rounds on an organizational ethics issue that impacts a particular department.
The expansion of clinical bioethicists' activities into organizational ethics has, at times, been criticized, largely on grounds that clinical bioethicists lack the appropriate expertise, says Anne Lederman Flamm, JD, staff in the Department of Bioethics at the Cleveland Clinic, and director of e-Ethics, a program to help other health care organizations respond to ethical challenges in delivering care, at the Cleveland (OH) Clinic's Center for Ethics, Humanities & Spiritual Care.
"Lacking support and direction from leadership, or from major stakeholders in a particular organizational issue, would be a significant obstacle," she adds.
Setting boundaries on bioethicists' role as case-based consultants may short-change the organization in terms of the contributions bioethicists might make, suggests Flamm. This is especially true in light of new expectations that health care organizations will establish the quality and value of their services in an environment with limited resources.
"Beyond the analytical skills bioethicists might bring to organizational ethics issues, they can offer experience in facilitating communication about sensitive topics, summarizing stakeholders' positions, and articulating options and reasons why one action may be better than others," says Flamm.
Flamm adds that bioethicists might be perceived as more neutral or objective than particular factions with longstanding affiliations or clear self-interests within the organization. Here, she suggests some specific activities that bioethicists could consider to expand their role beyond case consultation into organizational ethics:
• Participate on an operations or quality assurance committee.
The committee can provide an entry point for the bioethicist to learn more about the organization's delivery of health care and the people who deliver it.
"Committee settings often generate decisions that are 'organizational,' in that they direct or guide actions for groups extending beyond the committee," says Flamm. Such decisions can raise explicit or implicit ethical issues, such as resource allocation or access to care.
"Moreover, hearing about the challenges caregivers and non-clinical employees face exposes the bioethicist to systemic issues," says Flamm. These may be related to issues the bioethicist often encounters in the context of a specific patient's case.
Hearing about patient flow through pre-operative care, surgery, and peri-operative care might illuminate consent or handoff challenges. "Learning how tissue samples are stored and retrieved might inform the ethicist's perspective on research consent or incidental findings," says Flamm.
• Engage the Ethics Committee in consideration of organizational issues.
In this way, the Ethics Committee can become an intermediary among the various stakeholders within the organization. "The Ethics Committee can have a breadth of perspective conducive to seeing the 'forest' of organizational systems and practices above the 'trees' of individual cases brought to the consultation service," says Flamm.
Leadership's receptiveness to the Ethics Committee's involvement in organizational issues may depend on how it views the Committee's role. Flamm says the diversity of members' roles within the organization could "ease the path" if the Committee identifies an issue outside a narrower case-based function.
"A committee-wide endorsement that an issue deserves broader attention may compel leadership's attention to it," she says. For instance, if an entire committee comprised of physicians, nurses, social workers, chaplains, and community members agrees that the organization's commercial advertising campaign is misleading, the vice president of media relations might consider the claim more seriously than if asserted by a lone voice.
Members of the Ethics Committee might also be willing to act as "champions" for a particular initiative that significantly affects their area. For instance, an obstetrician/gynecologist member may be interested in crafting ethical guidelines for a new high-risk delivery unit, or an intensive care unit nurse may want to lead a task force designing a bed allocation scheme.
• Incorporate organizational ethics issues into education events.
Even when bioethicists' primary responsibility is case-based consultation, education opportunities can encompass organizational ethics. Flamm offers an example of using an in-depth study presentation to illuminate a systemic issue, such as how shortcomings in caregiver training resulted in a delayed discharge.
"Bioethicists might also propose grand rounds on an organizational ethics issue that impacts a department, such as examining privacy and truth telling for the psychiatry department following an organization's decision to release clinic notes directly to patients," says Flamm.
SOURCES
- Anne Lederman Flamm, JD, Staff, Department of Bioethics/ Director, e-Ethics, Center for Ethics, Humanities & Spiritual Care, Cleveland (OH) Clinic. Phone: (216) 636-0287. E-mail: [email protected].
