Jeffrey W. Bulger, PhD, HEC-C
PhD Philosophy—Biomedical & Clinical Ethics.
HEC-C Healthcare Ethics Consultant Certified. American Society of Bioethics and Humanities—ASBH National Certification Commission, 2019.
HEALTHCARE ETHICS CONSULTATION
Rights and Duties
Patients with Decision-Making Capacity—DMC have a civil right to be fully informed and a moral duty to themselves and to others to actively participate in decisions concerning their course of treatment. So that patients can exercise this right and fulfill their duty they must be informed of their diagnosis, prognosis, proposed treatment, other therapeutic options, and the risks and benefits of each course of treatment. When a patient is unable to make decisions regarding treatment, a Power of Attorney for Healthcare—POA proxy, or an appointed surrogate, who is usually a family member or a loved one, will do so. The primary goal will be to make decisions in accordance with the patient’s best interests, as determined by the patient’s personal goals, values, and priorities and is referred to as substituted judgment.
Informed consent means that the patient/representative has been provided all the relevant information necessary for the making of an informed decision, they understand that information, and then freely and thoughtfully agree to a procedure and/or treatment that is planned for promoting the patient’s best interests as determined by the patient’s personal goals, values, and priorities. Therefore, the information disclosure should should address the following:
2. Treatment options, including no treatment;
3. Benefits of each option;
4. Risks of each option;
5. Prognosis for each option;
6. Quality of Life expectation for each option; and
7. Best treatment option that aligns with the patient’s personal goals, values, and priorities.
Both the patient and/or representative cannot provide a meaningful consent unless they are truly “informed” and understand. This means they must be encouraged to ask questions.
It is a patient’s civil right and moral duty to understand as much about their medical care as possible. This means that the patient and/or representative will need to ask questions and the physician will need to be the primary source of answers, so that together they can engage in shared decision-making. The physician should not only help the decision-maker to have sufficient understanding but should also help them come up with questions that they ought to be asking. Other members of the interprofessional team that care for the patient are also a good source for the decision-maker to enquire about what questions to ask and they can also be a good source of answers that focus on their specialty such as nurses, social workers, chaplains, etc. Each specialty can help in different ways by addressing different types of questions and concerns. Medical decisions are difficult, but they can be made easier by thoughtful discussions.
Healthcare dilemmas, often come with incomplete information and therefore only have incomplete or probable answers. The patient needs to spend time thinking about their diagnosis, prognosis and treatment options by discussing them with family, friends and healthcare providers so that they can make sure that their personal goals, values, and priorities are respected when others may need to determine what is in the patient’s best interests. For seriously ill patients, Practitioner Orders for Life-Sustaining Treatment—POLST, can be used to document the patient’s and/or representative’s treatment decisions.
An ethical dilemma arises when there is conflict between: civil rights; moral duties; ethical principles; or personal goals, values, and priorities, all of which are good in themselves, but not all of which can be satisfied in a particular situation. For example, sometimes the moral duty of preserving life conflicts with the ethical principles of: respecting patient wishes—Autonomy; relieving suffering—Beneficence; assuring equal access to healthcare—Justice.
Life-Support Systems are regularly used to help patients recover from an illness. Ventilators, for example are frequently used after surgery to support a patients’ breathing until they wake up enough to breathe on their own. Unfortunately, there are situations that occur in the course of serious illness that may require the patient, or their family, to make a decision about sustaining life. Although life itself has great value, there are times when the burdens of treatment—Nonmaleficence such as pain, suffering, emotional cost, etc., to the patient and family outweigh the potential benefits. Continuation of treatment may merely extend the process of dying and interfere with the expression of personal goals, values, and priorities held by the patient. Under such circumstances, a patient may decide to forgo, or withdraw, life-sustaining treatment such as Medical Nutrition and Hydration—MNAH. This is legally acceptable and ethical, and most religions recognize the right of the patient and family to make such choices. The patient and/or representative must know that deciding to forgo or to withdraw life-sustaining treatment in no way means that medical care will stop. In fact, good supportive medical care, with patient comfort as the primary concern, may become even more intensive at this time. It is helpful for the patient and family to think about these possible dilemmas before they occur. Advance Care Planning—ACP is one such way to inform and document such family discussions.
Resuscitation is potentially a life-saving set of procedures carried out on a patient whose heart and/or lungs have suddenly stopped functioning. It usually includes external compression over the breast bone to attempt restarting the heart, electric shock to also attempt restarting the heart, placing a tube in the windpipe to attempt forced breathing, administering drugs to attempt restoration of blood pressure, etc. However, there are situations when the attempt to resuscitate is not appropriate. For example, at the end of a terminal illness, the patient or family members may not want aggressive and invasive procedures as they provide little benefit to the patient and do not maximize the patient’s goals, values, and priorities. The physician should bring up the question as to whether or not attempted resuscitation should be performed. It is important that such a decision be discussed with the patient’s family and close friends. If the patient decides to Do Not Attempt Resuscitation—DNAR this decision should be put in writing in an Advance Directive—AD or Living Will. The patient should also appoint someone who knows their goals, values, and priorities to make decisions for them should the time come when they no longer have Decision-Making Capacity—DMC. This patient representative is legally referred to as the patient’s healthcare proxy or surrogate. The proxy appointment can be done by completing a Power of Attorney for Healthcare—POA.
Healthcare Ethics Consultation—HCEC is “a set of services provided by an individual or group in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care.” (1) It is advisory in nature and may make recommendations but not binding decisions.
The Healthcare Ethics Consultant—HEC helps patients, loved ones, and clinical professionals in the shared decision-making process. Because of their experience and skills, the consultation will serve as an additional resource to the primary decision-makers; patient, family, and physician. The Healthcare Ethics Consultant does not make any decisions. Rather, the Healthcare Ethics Consultant provides a forum of respect where the ethical, medical, psychosocial, administrative, and legal issues can be addressed along with treatment options and recommendations regarding patient care.
ASBH Code of Ethics
The American Society for Bioethics & Humanities—ASBH states that the Healthcare Ethics Consultant—HEC shall: “identify and support the appropriate decision maker(s), promote ethically sound decision-making by facilitating communication among key stakeholders, foster understanding, clarify and analyze ethical issues, and provide justification when recommendations are presented.” (2) In carrying out this commission the Healthcare Ethics Consultant is ethically and professionally obligated to:
1. Consult using HEC standards;
2. Act with integrity in the performance of their role;
3. Manage conflicts of interests and obligations;
4. Respect privacy and maintain confidentiality;
5. Contribute to the advancement of the HEC field;
6. Communicate responsibly; and
7. Promote healthcare justice. (3)
Anyone can request a Healthcare Ethics Consultation—HCEC (e.g., medical staff, employees, patients, and families) for help in resolving an ethical dilemma by contacting the Healthcare Ethics Consultant—HEC. It should be remembered that the Consultation is not meant to replace, but rather to assist, those directly involved. If problems and concerns still remain after communication between and among the patient’s family, attending physician and the Healthcare Ethics Consultant, then the Hospital Ethics Committee can be convened for further assistance.
Hospital Ethics Committee
The Hospital Ethics Committee is made up of a cross-section of interprofessionals. The professional disciplines usually represented are:
Social Work Services
Home Health Services
Other disciplines may also be invited as needed for special case reviews.
AMA Code of Ethics
The American Medical Association—AMA, Code of Medical Ethics Opinion 10.7 (4) states that Hospital Ethics Committees are to facilitate decision-making in individual cases, and assist in institutional ethics related educational programming and policy development. In carrying out this commission the committee should:
A. Serve as advisors and educators rather than decision-makers. Stakeholders are not required to accept committee recommendations, but should explain their reasoning if they do so.
B. Respects the rights and privacy of all participants.
C. Ensure that all stakeholders have timely access to the committee’s services.
D. Structure the committee so that it is staffed, and supported appropriately to meet the needs of the institution and its patient population. Membership should represent diverse perspectives, expertise, and experience, and should include one or more community representatives.
E. Adopt and adhere to: a) policies and procedures governing the committee; b) activities of the individual ethics consultants; and c) medical staff by-laws. This includes resolving competing responsibilities and documenting committee recommendations in the patient’s medical record.
F. Draw on the resources of appropriate professional organizations and national specialty societies.
* Faith-Based Institutions or other Mission-Driven Institutions have a dual responsibility to:
G. Uphold principles to which the institution is committed.
H. Make clear to patients, physicians, and other stakeholders that the institution’s defining principles will inform the committee’s recommendations.
Individuals may initiate contact with the Healthcare Ethics Consultant—HEC and/or the Hospital Ethics Committee—HCEC by requesting a referral from hospital staff: physician, nurse, social worker, chaplain, or by directly contacting the Ethics Healthcare Consultant, or Chair of the Hospital Ethics Committee.
Note: Because of the sensitive nature of these deliberations patient privacy will be respected and patient confidentiality will be maintained as mandated by: a) ethics, such as the Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants; b) Federal and State law, such as the Health Insurance Portability and Accountability Act—HIPAA; and c) organizational policy, such as institutional policy.
Jeffrey W. Bulger, PhD, HEC-C
Professor, Foundational Sciences & Humanities—FSH
Director for Bioethics & Humanities, Master Teacher Guild
CHICAGO MEDICAL SCHOOL
Rosalind Franklin University of Medicine and Science
3333 Green Bay Road, North Chicago, IL 60064-3095
1. American Society for Bioethics and Humanities. (2011). Core Competencies for Healthcare Ethics Consultations (2nd ed.). Glenview, IL: Author.
2. American Society for Bioethics and Humanities. Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants. Chicago; ASBH; 2014.
3. American Society for Bioethics and Humanities. Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants. Chicago; ASBH; 2014.
4. AMA Principles of Medical Ethics: II, IV, VII. Code of Medical Ethics Opinion 10.7. AMA Web Site. Available at: https://www.ama-assn.org/delivering-care/ethics-committees-health-care-institutions