Imagine a frail, 91-year-old patient who is ill and approaching the end of life.
When she was brought into the Emergency Department, she told the nurse, “Don’t let them put me on machines,” but her family requested that she be “full code” — which includes chest compressions, defibrillation, intubation and mechanical ventilation — even though her physician told her family the procedures would likely cause injury and pain in the last minutes of her life without changing the outcome. How do we determine the right course of action when a patient, a patient’s family and physician do not agree? Who gets to decide the best way to treat a debilitated patient when the end of life is near?
We hear about business ethics, environmental ethics and committees on ethics in political arenas. Medical ethics is unique because, in its most effective form, it occurs at the level of the individual human being who shows up at the clinic or the hospital with a problem situated in a very personal location — their body.
Ethical dilemmas in medicine often arise at a crossroads where an individual person’s beliefs and values differ from those of the larger powers that shape institutions.
A physician may recommend a medication or procedure that is denied by the patient’s insurance. Someone on Medicaid might need a month of rehabilitation to return to full function, only to discover that none of the rehabilitation centers in their area have any so-called “Medicaid beds” available. The unmarried, but long-term, life-partner of a sedated patient on a ventilator might not be allowed to make decisions for the patient because, in such a case, the law gives more decision-making authority to the patient’s adult children, even if they have been estranged for many years.
These, and a thousand other challenging situations, occur on a daily basis in a system set up to care for people who are sick, suffering, debilitated, injured and dying.
This is why it is crucial to have a well-supported Ethics Committee led by a full-time ethicist who can dedicate the time and expertise required to address these complex issues and to provide ethics education. We need a committee made up of community members and hospital staff representing a wide range of economic, social, religious and cultural backgrounds. We need a committee that is stable so it can grow in wisdom, skill and knowledge over time, allowing the members of the committee to earn the trust of the community. We need a committee that is not only permitted, but expected, to remain committed to assessing the truth of a situation and then speaking this truth even if it is not in line with institutional priorities related to such things as decreasing length of stay, maximizing profit and avoiding controversy.
For many years, Mission Hospital had a robust Ethics Committee led by a clinical ethicist and made up of experienced people who were well-regarded by their peers.
The most recent clinical ethicist, Mary Caldwell, provided ethics consultation in every clinical unit in the hospital. She contributed to policies guiding the use of technologies such as ECMO, (a life support therapy). Crucially, she led frequent education programs inside and outside the hospital system to educate people about importance of medical ethics. Monthly meetings were well attended by its hospital-based and community members who viewed the hospital system as an integral part of the community, and who saw the work of the hospital as something about which the community had much to say and the right to say it.
The Ethics Committee is an important point of contact, and even partnership, between the community and the hospital. Unfortunately, we have not had a dedicated clinical ethicist at Mission for the past several years, and this has diminished the effectiveness of the consultation service and education efforts.
But this work is needed more than ever as new technologies such as artificial intelligence are introduced and the balance of power among top decision-makers continues to evolve. We are working to rebuild the Ethics Committee. The quality of the work will be vastly improved if Mission’s leadership will support a dedicated clinical ethicist. Meanwhile, we hope to reenergize ethics consultation and education through collaborative relationships between the hospital and the community. The hospital system belongs to all of us, and reinvigorating a culture dedicated to the work of medical ethics is an indispensable part of renewing the system in a way that best serves our community.
More:Opinion: Once-storied Mission Ethics Committee lost support after HCA Healthcare purchase
More:Opinion: The moral imperative of medicine: Getting it right
Mary Caldwell is a chaplain and clinical ethicist who led ethics consultation and education for many years at Mission Hospital.
Ray Barfield is a writer and physician on the palliative care team at Mission Hospital.
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