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Bioethicist must remain neutral, non-judgmental
Amy M. VanDyke, MSW, PhD, vividly recalls a particular ethics consult that occurred years ago, because of the attending physician’s unpleasant response.
The consult involved a patient who lacked decision-making capacity, with no readily available surrogate decision-maker. "The attending had been unilaterally making non-emergency treatment decisions because it was for the patient’s health,’" she recalls
One of the patient’s nurses requested an ethics consult, believing that the physician’s actions were unethical and in violation of a hospital policy.
"The physician made it very clear that she did not wish to have the assistance of ethics in any form, because she was the attending and knew what was best for her patient," says VanDyke, now medical bioethics director at Kaiser Permanente West Los Angeles Medical Center.
The attending physician publicly accused the nurse of being insubordinate. "It was a very confrontational situation overall," says VanDyke.
Attempts to squelch or divert ethical discussion can come up in many forms, some more difficult to manage than others. "Not all attempts to impede ethical discussion are the same. Intentionality is very important," says VanDyke. Here are some reasons that physicians may try to impede ethical discussions, she says:
Physicians don’t want to slow down the clinical process.
VanDyke once got an unpleasant response from a physician, with whom she’d had a solid working relationship for years, because an ethics consult was requested.
"He made a face at me and said something to the effect of, Great, I guess I will be here for another several hours till you get done doing your ethics stuff. Then I can finally finish up with the patient’s discharge,’" says VanDyke.
The physician clearly saw ethics as an unwelcome intrusion. "I couldn’t disagree with him that the ethical discussion which needed to take place would likely slow him down a bit that day," says VanDyke. "It all turned out fine for the patient in the end."
If physicians display this attitude, VanDyke advises stating, "I hope that you will actively participate in this process, but you can choose not to. If you choose not to, the ethics consultation will still happen, it will just happen without your input. Your choice and reasons for abstaining from the process will be noted in the ethics consultation."
Sometimes, this is enough to get a reluctant physician to participate.
"If not, it may be important to have recourse to the department chief, who can explain the importance of the process and the involvement of all parties," says VanDyke.
Physicians may view an ethics consult as an indication they aren’t providing good care.
"Generally, all orders go through the attending physician — except this one particular kind of consult, which is out of their control," says Mathew David Pauley, JD, MA, MDR, director of medical bioethics for Kaiser Permanente, San Bernardino County Service Area in Fontana, CA.
In this situation, it can be helpful to remind the physician that ethics is a consultative service. "Like other services, the attending can choose to disregard what is written in the recommendations of an ethics consult," says VanDyke.
Bioethicists need to be careful to remain neutral. "An ethics consultation interference can also make the ethics consultant defensive and positional — Don’t you know that you can’t cancel ethics consults, doc?’" says Pauley.
Recently, a physician became upset because a social worker called an ethics consult to determine who the appropriate surrogate was for a patient.
"My initial reaction was to point out what the policy says — that anyone can request an ethics consult, and that attendings do not need to give permission," Pauley says. Instead, Pauley reminded himself that such resistance "is likely an indicator of lack of trust, uncertainty, and ultimately vulnerability, on the physician’s side."
It also helps to bear in mind that only very rarely is a physician acting irresponsibly or without a desire to do good for the patient. "They are human beings struggling with this as well," says Pauley.
Physicians may want to continue with more aggressive treatment because they believe it will help the patient.
"If the physician feels they can get the patient out of their current condition, they may fear that ethics will come in and convince everybody that the patient should be allowed to die," says Pauley. In this scenario, the physician takes on a patient advocate role in their mind.
This can be very difficult to confront because physicians sometimes don’t see their own personal bias, says VanDyke, "and even if they do, they may wrongly believe they can impose their values, citing a lack of futility of the treatment."
Things become more difficult if the ethicist practices in a system where the balance of power is skewed in favor of physicians as the primary moral arbiters.
"In essence, in these facilities the doc holds the moral power," says VanDyke. "The moral agency of other healthcare professionals is not as readily recognized."
Physicians may perceive that clinical ethics consultants are subjugating the doctor-patient relationship or overriding clinical decision-making.
In order to preserve the trust and respect of the involved parties, ethics consultants should be ever-mindful to respect the primacy of the clinician-patient relationship, says Andrew G. Shuman, MD, assistant professor at the Center for Bioethics and Social Sciences in Medicine at University of Michigan Medical School in Ann Arbor.
"It behooves ethics consultants to remain non-judgmental and respectful of the intentions and motivations of the involved protagonists, whenever possible," says Shuman.
Mathew David Pauley, JD, MA, MDR, Director, Medical Bioethics, Kaiser Permanente, San Bernardino County Service Area. Phone: (909) 302-7790. Fax: (909) 427-7359. Email: Mathew.D.Pauley@kp.org.
Amy M. VanDyke, MSW, PhD, Medical Bioethics Director, Kaiser Permanente West Los Angeles Medical Center, Los Angeles, CA. Phone: (323) 857-3431. Email: email@example.com.
Andrew G. Shuman, MD, Assistant Professor, The Center for Bioethics and Social Sciences in Medicine at University of Michigan Medical School, Ann Arbor. Phone: (734) 232-0120. Fax: (734) 936-9625. Email:firstname.lastname@example.org email@example.com.