Do We Still Need Doctors? (Reflective Bioethics)
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What goals do we have in mind? Ensuring the best care for the patient? Defusing conflict? Reducing length of stay? How do we know if we are successful in meeting these goals? Should our evaluative measures focus on the experiences of stakeholders, including patient or staff satisfaction?
Health Care Ethics
Or should we favor more procedural measures, like whether the conflict was resolved or legal action was averted? Or should we concentrate more on longitudinal effects, like enhanced awareness of the moral dimensions of care and reduced moral distress? In fact, without much empirical evidence to the contrary, we are guessing that the answers to these questions are likely to be widely divergent because we all enact our roles differently, with different goals in mind and with different degrees of success. Perhaps the first and most valuable step is to name our own biases about what we think are the hallmark features of ethics consultation, and to offer some account and defense of them.
Ethics consultants must be prepared to articulate their distinctive role to stakeholders throughout the consultation process, and to defend the boundaries of this role when others attempt intentionally or unintentionally to shift or cross these boundaries for example, by recruiting us as advocates for their perspective.
Or to be passive observers. Or even to offer a supportive presence. We ought to have something unique and value added to contribute. It should be grounded in the discipline of ethics and should contribute something recognizably different and valuable to the equation. This is one of the unique contributions of ethics consultation to the social world of healthcare. Procedural clarity : The ethics consultant ought to bring form, structure, and discipline to what otherwise might be an idiosyncratic and even freewheeling approach to the difficult questions that give rise to requests for ethics consultation.
By taking responsibility for keeping the focus of ethics consultation on the ethical issues at stake, and for bringing the tools, frameworks, and resources of the field of ethics to bear on the particular case, the ethics consultant helps ensure consistency and quality across ethics consultations. Though the methods of implementation employed to achieve those ends might vary, all ethics consultants ought to have ways to make their services known and clear mechanisms through which they can be accessed.
And once accessed, we contend that ethics consultants must take responsibility for defining the nature, structure, scope, and even pace of the ethics intervention. There should also be certain key recognizable components for which the ethics consultant should take responsibility such as: 1 Investigating and identifying what is the case? What is the ethical dilemma? What is known factually? What values are at stake? Who is involved and what are their perspectives on the ethical dilemma?
What options have been or might be considered? What might be possible? Which possible next steps might be ethically defensible and which might not be? How do the options connect with the values of the various stakeholders? Procedural transparency is an essential part of ethics consultation to engender trust and integrity. Thus, it is important for involved parties to understand that ethics consultations have beginnings and ends, and to know where they are in the process, and what the ethics consultant is doing and why along the way.
Critical self-reflection : Another hallmark of ethics consultation should be the creation of space for self-reflection about our own practices and about where we stand in the stories in which we get engaged.
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This is arguably an important practice for all health professionals. How do my own histories and biases influence how I approach stakeholders, how I comport myself, what I say and when? Humbly, we must acknowledge the influences on our behaviors and thoughts, and in some cases, we might even need to disclose these influences to others to ensure the integrity of the process. How effective was I in staying true to my role and scope? What was the quality of my normative analysis? Ideally, we should have access to multiple sources of data to appraise the quality of our work client satisfaction surveys, anecdotal feedback, peer support, etc.
Yes, we should listen respectfully. Yes, we should acknowledge emotion. Yes, our presence is often supportive. However, if this is all we do, are we really doing what is more properly the work and legitimate role of other professionals such as chaplains and social workers, who are better equipped and trained to provide that specific kind of support? And this is not an uncommon scenario. This brings us back to the issue of expectations. In addition to hoping the ethics consultant will be able to provide support to the family, he also hopes the ethics consultant will be able to delineate the ethical issues involved in the care of this terminally ill patient.
The ethics consultant ought to be responsible for not only identifying but also actively engaging in discussion of the ethical issues, offering an analysis, and, where appropriate, making some recommendations.
Throughout the narrative we found instances of potential role confusion, either in terms of how the ethics consultants were conceiving their contribution or how others perceived them. This underscores for us the importance of being crystal clear about our unique role and contribution. We must be prepared to educate patients, families, and our colleagues about our role, and we must be constantly prepared to defend the boundaries of our role. In this way we can maintain a sense of integrity and protect against inappropriate uses of ethics consultation.
But what in fact was he trying to do? And did he make that clear to the family?
When the family first approached Finder, he could have taken that opportunity to tell them a little bit about the role of the ethics consultant in general; this may have helped to diffuse their frustration with his colleague Moore. In addition to myself, Dr. Smith, ICU attending, Dr.
Nonetheless, the family continues to request the patient be maintained as a full code and that dialysis be considered. We will continue to talk with the family and try to help them understand that these measures are not going to be helpful and most likely might be harmful, including shortening her life.
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The family fully understands these issues. All their questions have been answered. They remain at bedside and have told me that if the patient codes, at that point they will let the medical staff know if the patient should be intubated or not. Patient will remain at this point full code. Hamadani Finder : Can this goal be achieved? What is really driving their decision-making? How might this scenario play out? Who is the appropriate surrogate decision-maker?
Who is the legal surrogate decision-maker? What are the obligations of the parties involved? Does local law articulate how families are supposed to make decisions for incapable patients?
What is the nature of this harm? How do different health professionals perceive the case differently?
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How can they be supported to articulate and address their moral distress and to work together as a team? Mention is made of a hospital policy about medically inappropriate treatment. Why is this not applied in this case? And most importantly, where is the patient in all of this? What is her day-to-day experience like now?
Who is she?