Massachusetts Medical Society: Hiding in Plain Sight: How Clinical Ethics Shape Everyday Care

Hiding in Plain Sight: How Clinical Ethics Shape Everyday Care

By Sarah Ruth Bates, MBE, MMS Government Relations and Research Analyst
How Clinical Ethics Shape Everyday Care

Bioethics tends to bring to mind the “big” questions: Should a patient with terminal cancer get access to an experimental therapy still in trial? Should geneticists modify the human germline to prevent genetic diseases? These are examples of ethics in the headlines. But ethical dilemmas come up in daily clinical care, too; we just may not recognize them as such.

For example, when a procedure carries a small risk of death, should anesthesiologists use the D word? Anesthesiologists vary widely in their answers to this question, says Robert D. Truog, MD, director of the Harvard Medical School (HMS) Center for Bioethics, professor of medical ethics, anaesthesiology, and pediatrics at HMS, and lead author of the seminal article “Microethics: The Ethics of Everyday Clinical Practice” (Hastings Center Report, 2015). “Some never [say ‘death’]; some always do. Relational judgments like these are rarely framed as ‘ethical’ decisions. Yet these kinds of choices arise in everyday clinical encounters, and even seasoned professionals struggle with how to think about them,” says Dr. Truog.

Everyday Microethics

The term microethics refers to such everyday quandaries. Even physicians who don’t think they encounter ethical dilemmas in their work actually do, says James E. Sabin, MD, professor of population medicine and psychiatry at HMS. Dr. Sabin, who also directs the ethics program at Harvard Pilgrim Health Care, interviewed physicians for a book on ethics. He asked them to list ethical issues that came up frequently in their work, and they often couldn’t think of any. Then he asked, “What keeps you up at night? What worries you? What concerns you?” They started talking, he says, and “all sorts of things emerged that we would put under the heading of ‘ethics.’”

The link between ethics and what physicians care about runs deep, says Lachlan Forrow, MD, associate professor of medicine at HMS, and director of ethics and palliative care programs at Beth Israel Deaconess Medical Center (BIDMC). “The words ‘moral’ and ‘morale’ come from the same word in Latin, suggesting that 2,000 years ago in Rome you couldn’t even think of one without the other.” Dr. Forrow’s metric for ethical care reflects that link: “Every physician should go home justifiably proud of the care they’ve given, and every patient should go home justifiably grateful for the care they received.” Collaborating with ethicists can help to achieve that goal. Never worry alone, he tells his colleagues. At BIDMC, “ethics is everyone,” embracing the entire clinical team and staff.

Ethics as the Physician’s Calling

Ethics can be defined positively as well. It has roots not just in what worries physicians, but also in what brings them to medicine. “Ideally,” Dr. Sabin says, “one can understand ethics as what makes us get up in the morning, see our patients, and have the privilege of taking care of people. Ethics is at the core of what our profession is about. It’s the essence of our identities as physicians, and our basic forms of caring about our patients, our profession, and our societies — the meaningful moments that come out if you talk to colleagues about why you went into medicine in the first place, or what experiences bring you joy as you recollect them.”

Ethics Facilitates Care

Ethicists can help with working effectively together through difficult cases — though this may surprise some physicians, who “associate the word ‘ethics’ with reproach and scolding,” says Dr. Sabin. The ethicist’s job is not to correct bad behavior, but rather to facilitate “collaboration around shared ideals.”

Ethicists generally weigh in through case consultations. At some institutions, an attending can call for an ethics consult in the same way they would call for a nephrologist or a cardiologist. Patients and families can call for ethics consults as well. The consult itself can take myriad forms: an ethicist or group of ethicists meeting with the clinician(s), the patient and/or family, sometimes repeatedly; or a committee convening to discuss the case, deliberate on the best course of action, and issue recommendations.

Ethics Consultations

A particularly troubling case, one that highlights the need for a policy change, or is emblematic of an issue that arises frequently, might occasion a case conference, similar to a morbidity and mortality review. In addition, some ethicists conduct regular rounds with clinical staff, most often in acute care settings such as the ICU or the ER. Those rounds allow staff members to talk through ethical issues that arise in their practice.

Large institutions tend to offer more robust ethics programming. Most small and independent practices lack access to such services. The paucity of ethicists is due in part to the relatively recent emergence of ethics as a profession. Bioethics has, in a sense, existed for as long as physicians have practiced medicine, but bioethics as a discipline is still being defined. Physicians who lack access to institutional ethics services can connect with the Society’s Ethics and Grievances Committee, which holds two Ethics Forums per year (at the Annual Meeting and the Interim Meeting).

Case in Microethics: It Is OK to Hug Your Patient? — the story of a recent case conference at BIDMC.

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