Bioethicists obliged to help impaired clinicians
Peers reluctant to report
Clinicians are typically reluctant to report impaired colleagues, while impaired clinicians are often in denial about the problem.
"For the colleagues of impaired clinicians, a significant ethical challenge is to prioritize the primacy of patient and clinician welfare over other legitimate fears and concerns," says Catherine V. Caldicott, MD, FACP, program director of the Professional/Problem-Based Ethics (ProBE) Program, offered by the Center for Personalized Education for Physicians, Denver, CO.
Colleagues may feel that approaching a peer about impairment is disloyal. "However, as part of medicine’s contract with society, they have a professional responsibility to hold themselves and their colleagues accountable to high standards of conduct," says Caldicott.1 Here are some ways in which bioethicists can play a role:
• Keep your involvement separate from that of legal, risk management, administrative, or any other aspect of the process.
"Blurring or overlapping of the bioethicist with any of these other functions creates confusion among clinicians as to the role of the bioethicist, and can destroy trust in the bioethicist," says Marianne L. Burda, MD, PhD, a Pittsburgh, PA-based ethics consultant and educator.
• Ensure that the confidentiality and privacy of impaired clinicians is respected, the same as with any other individual seeking medical care and treatment.
"Lack of confidentiality and privacy, or the perceived lack of these, can be a major barrier to impaired clinicians seeking treatment," says Burda.
• Assist administrators in creating a confidential process for reporting and investigating concerns or observations about impaired clinicians.
"Colleagues covering up for an impaired clinician can put patient care at risk, creating an unethical situation," says Burda.
Impaired clinicians who remain unreported or unassisted can suffer consequences to their ability to practice, families, professional relationships, and self-esteem that are worse than the shame, embarrassment, and possible restrictions on their licenses that may result if their impairment is reported, says Caldicott.
• Be clear about the distinction between a professional ethics issue and a clinical ethics issue.
M. Sara Rosenthal, PhD, director of the program for bioethics and chair of the Hospital Ethics Committee at University of Kentucky in Lexington, says that generally, clinician impairment is a professional ethics issue that should not directly involve a clinical ethics service. "The issue is entangled with employment and HR issues that are completely outside a clinical ethicist’s role or purview," she explains.
Rosenthal says a good clinical ethics service should have a "referral rubric" for handling a range of professional ethics issues, including impairment and/or clinician incompetence. "Typically, the chief medical officer would handle such an issue. The role of the clinical ethicist would be to refer the situation to the appropriate individual," she adds.
• Offer health care professionals advice on how to proceed when an impairment is suspected or observed in a colleague.
A concerned co-worker experiencing moral distress over how to approach, support, or report an impaired clinician may seek the guidance of the institutional ethics committee or consultation service. "A bioethicist can help that person develop the moral courage to act by thinking through the ethical justification for approaching or reporting the impaired clinician," says Caldicott.
If the impaired clinician contacts the clinical ethicist directly to discuss his or her impairment, then Rosenthal says the clinical ethicist should take these steps:
- Point out the ethicist’s professional ethics obligation to report the situation to the chief medical officer, as opposed to promising confidentiality to the clinician who has come forward;
- Offer to support the clinician by accompanying the clinician to a meeting to self-report;
- Facilitate locating institutional or state resources for the clinician to get help;
- Offer to accompany the clinician to a medical appointment, should that clinician feel isolated and require such support.
- In cases where a clinician comes to discuss a possibly impaired colleague, Rosenthal says the clinical ethicist can do the following:
- Help the colleague to understand when it is appropriate to report — usually at the point where patient safety is compromised;
- Offer to report the impairment. "Patient safety would be a priority over the political comfort of the consult requestor," says Rosenthal.
1. Cruess SR, Cruess RL. Professionalism and medicine’s social contract with society. Clinical Orthopaedics 2006;449:170-176.
- Marianne L. Burda, MD, PhD, Pittsburgh, PA. Phone: (724) 933-0265. E-mail: firstname.lastname@example.org.
- Catherine V. Caldicott, MD, FACP, Program Director, The Professional/Problem-Based Ethics Program, Denver, CO. Phone: (303) 577-3232. E-mail: email@example.com..
- M. Sara Rosenthal, PhD, Director, Program for Bioethics/Chair, Hospital Ethics Committee, University of Kentucky, Lexington. Phone: (859) 257-9474. E-mail: firstname.lastname@example.org.