A patient is brought to the hospital because he had lost consciousness and collapsed in public. The patient is suffering from complications in his lungs and kidneys. The only thing the medical team can do for this patient is to put him on a breathing machine, surgically place a feeding tube, and start dialysis three times a week. None of these interventions will cure the patient, but they will keep him alive.
The patient is unconscious with no expectation that he will ever regain awareness He has no known friends or family, anyone that would know his medical wishes and could serve as his representation. Since the patient cannot communicate and has not documented anything, the medical team is unsure what the patient would want and concerned about keeping him alive in a state that he might not want.
Who should make medical decisions for this patient? How aggressive should the medical treatments be? What is the “right” thing to do for this patient?
This is actually a fairly common scenario for a clinical ethicist in the hospital. A clinical ethicist is a specialty consultant brought in to assist in the care of patients in the most challenging situations. Often, these situations involve patients without someone to act as their decision-maker, patients that have reached the limits of what medicine can do but families want them to continue, and infants born prematurely and the family struggling to decide how far they should go in approving invasive treatment.
Clinical ethicists also work with questions regarding organ donation and scarce resource allocation policies. According to the Core Competencies for Healthcare Ethics Consultation via the American Society for Bioethics and Humanities (the predominate society regarding bioethics), a clinical ethicist is, “A professional in a healthcare setting who seeks to identify and support the appropriate decision maker(s) in a given situation involving ethical questions and to promote ethically sound decision making by facilitating communication among key stakeholders, fostering understanding, clarifying and analyzing ethical issues, and including justifications when recommendations are provided”.
Another way of thinking about it, a healthcare ethicist is an individual who works with patients, families, and medical teams to ensure that the care being delivered is to the highest ethicist standards.
Putting Ethics Into Practice
How does a clinical ethicist do this? How does an ethicist make these challenging recommendations without bias?
An often-used system is called principlism, which can be seen as an approach to ethics that uses a framework of principles that are basic and universal. These include respect for autonomy, nonmaleficence, beneficence, and justice. These principles “state prima facie (or non-absolute) moral obligations that are rendered practical by being specified for particular contexts. Moral problems arise when principles or their specifications come into conflict with each other” (Beauchamp & Rauprich).
The goal of medicine is to provide ethically sound care, which can be understood as care that upholds all four of the ethical principles. Ideally, medical care is provided in accordance with the patient’s stated preferences, balances the harms and the benefits, and focus on fairness and equity. Unfortunately, situations often put these principles in conflict with each other, making it difficult to find a plan that values and supports all four principles.
What if the patient is declining life-saving medicine for an alternative treatment? What if the patient is requesting aggressive measures that the physician believes would only increase suffering and not provide any benefit? What if there is a shortage of a particular medication, how do you prioritize patients? All members of the healthcare team want to do what is best for the patient. The difficulty is that it is not always clear what options are the best. By utilizing these ethical principles, the clinical ethicist is able to ensure that recommendations are to the highest ethical standards. Clinical ethicists strive to be as neutral as possible by following ethical principles in their decision-making.
Some clinical ethicists work independently from the hospital to ensure that they are as neutral as possible and not conflicted by being an employee of the hospital system. Clinical ethicists are also trained to make recommendations free from bias or conflicting interests. By utilizing a systematic ethical decision-making process that is influenced by the four principles, the clinical ethicist is able to make recommendations that are consistent for all patients in similar medical situations. This belief regarding fairness and justice goes back to Aristotle whose formal equality principle mandates that two persons of equal status must be treated equally (Aristotle, Nicomachean Ethics, V.3. 1131a10–b15). This is commonly phrased that people (patients) should be treated alike. This means that the race, creed, religion, or status of patients should not matter in what treatments or care they are offered or received.
Rationalization and Communication
Still, it is not enough for the clinical ethicist to use rationalization and ethical decision-making to make recommendations. Those recommendations need to then be communicated to the patient and the medical team efficiently and effectively. Situations that require the skills of a clinical ethicist often involve some level of conflict, either between the medical team and the patient or among the medical team itself. Clearly communicated rational recommendations are necessary so that those who might not fully agree with the recommendation can appreciate and understand how that recommendation was made.
When a recommendation is not clearly articulated, it can lead to moral distress among the medical team and dissatisfaction by patients and their families. This is often present in cases when autonomy and nonmaleficence are in conflict. In these situations, should the patient be able to make decisions that will only further harm, or should physicians prioritize their obligation to “do no harm”? In situations where patient autonomy is prioritized, it can be difficult for the medical team to support a decision that in all likelihood will result in harm towards the patient.
A trained clinical ethicist, through rationalization and communication, can explain that patients define their quality of life. While the medical team does not have to agree with the patient’s decisions, if the patient has capacity then they should be able to make their own medical decisions. The involvement of a clinical ethicist can give clarity and understanding to some of the most complicated and challenging scenarios that arise in medicine.
Invisible Until Needed
Medical ethics is a highly valued field. Yet, when people think about modern healthcare and all the different specialties that are involved in patient care, clinical ethics is rarely among them. We expect our doctors, nurses, social workers, etc. to act ethically and with integrity, but we do not always realize how challenging it could be to even know what is ethical and what is not.
Clinical ethicists are not at the forefront of patient care and many patients are unaware that they even exist, -- until they are needed. Then they see how valuable and insightful these humble experts are when dealing with the most complicated and morally challenging situations imaginable. Clinical ethicists work through these scenarios, mitigate personal and professional bias, and support patients and their families.
About the Author
Ryan Pferdehirt serves at the Center for Practical Bioethics as the Vice President of Ethics Services. He is also an Instructor of Bioethics at Kansas City University. His work focuses on developing and growing competencies of member ethics committees, individual consultants, and the general public. His research areas include moral philosophy, end-of-life ethics, philosophy of language, and advanced care planning ethics.
About the Center for Practical Bioethics
The Center for Practical Bioethics raises and responds to ethical issues in health and healthcare. We call this work “practical bioethics” because the Center applies bioethics to real-life challenges and decisions. These include helping Kansas City families, patients, and providers when they face complex care or end-of-life questions or decisions. Ethics Services provided by the Center can improve patient-centered care while supporting departments throughout your healthcare or hospice organization. The is also helping enact processes that make the use of Artificial Intelligence safer and more responsible.