“That’s unethical!”  So begins many a conversation (or sometimes maybe just an accusation) that prompts the input of an ethics consultant to help manage an ethical conflict in patient care.  This column will review what an ethics consultant does, when an ethics consultation can be of assistance to the health care professional, when consultation from another resource would be more useful, and how to optimize the input of an ethics consultant.

An ethics consultant is an individual trained in resolving conflicts over values in a health care setting, with values being deeply held beliefs, standards, or principles that guide decision-making. These consultants are often trained in varying professional backgrounds of law, social work, philosophy, nursing, chaplaincy, or medicine among others, but they share an expertise in ethics theory and analysis. Consultants are most often called to assist with a conflict in patient care, but people in health care management, research, and administration can seek consultants’ input as well.

Ethics consultants begin by identifying and clarifying the conflict to ensure it is related to ethics. It is not uncommon for them to be called on a legal or clinical matter that is outside the scope of their function.1 Clinicians who are struggling with a challenging case may mistake a legal question for an ethical one. For example, a clinician may ask an ethics consultant about legal liability if the clinician were to prescribe a medication that a patient is demanding but the clinician does not think is medically indicated. An ethics consultant cannot provide expert legal advice about the risk of liability for patient care questions. In such a case, the consultant will refer the clinician to their counsel for an authoritative legal response. 


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Sometimes though, the legal question may lead to a related ethics question. In the example above, if the lawyer indicates that a clinician can provide the requested treatment as the liability for doing so is low, but the clinician is still not sure if they should grant the patient’s request, the clinician can request further advice from the ethics consultant.  The consultant can help gather more information from the various stakeholders — in this case, the physician and patient — to resolve the ethics conflict.

Speaking with the stakeholders directly, as any medical consultant, helps elucidate and amplify what those specific values are. In this case, the first value could be the clinician’s professional responsibility to provide patient-centered care; that is, providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.2 The second value could be that the clinician also has a professional obligation as part of their licensure to only provide treatments that adhere to generally accepted standards of care. 

This example points out an important aspect of ethics consultation: that it does not always represent a conflict over one position that is clearly right and another that is clearly wrong. Rather, the ethics questions are often between one position that is “right” and another one that is “right” in a different way. Thus, the process is often about managing equally reasonable positions that need to be balanced to resolve the problem.

Returning to the example, it becomes clearer how the ethics consultation process can be uniquely helpful in approaching a resolution. By first explicitly identifying the conflicting values, it helps to create a resolution that is responsive to those values, even when one of those values should be prioritized. In other words, even if there is strong ethical justification for the clinician to deny the patient’s request for the treatment because doing so is not consistent with generally accepted standards of treatment, the ethics consultation process helps to promote and honor the other relevant values. This might mean recommending to the clinician that they try to identify the patient’s interests behind the request. Does the patient have mistaken ideas about the utility of the requested medication? Is there a reason behind the request that has not yet been articulated? This approach then creates space for honoring both values: patient-centeredness and professional obligations. 

What should clinicians do when they believe they have an ethical concern and need assistance?  First, clinicians should be aware of how to contact their local ethics resources. The threshold to contact them should be low: It is better to contact them and not need them rather than make an assumption that they may not be helpful.

Second, clinicians should expect that the ethics consultant can help with ethical dilemmas in patient care, but the consultant may first recommend another resource to find the definitive answer to the problem, which might include another clinical service, legal, risk management, or chaplaincy. However, even when that additional service is needed, ethics may be helpful as the issue develops or related ethics questions need to be answered.

Finally, as clinicians begin to work more with ethics consultants over time, they will likely develop a heightened sensitivity to when ethics can be helpful in the course of clinical care. As some like to say, be aware when your ethics antennae go up, and when they do, you can get help.

David J. Alfandre, MD, MSPH, is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

References

  1. Orr RD, Shelton W. A process and format for clinical ethics consultation. J Clin Ethics. 2009;20(1):79-89.
  2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. doi:10.17226/10027

This article originally appeared on Renal and Urology News