Our ethics consult team meets monthly to review cases and to self-educate. This month, we are looking at three recently published journal articles:
1. Cassel C, Guest J. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA: The Journal Of The American Medical Association [serial online]. May 2, 2012;307(17):1801-1802.
Once upon a time, I believed that we could solve our health care problems — by which I meant access and affordability — by reducing waste. This is no longer, if it ever was, true, but I still believe that when as much as 30% of healthcare spending is wasteful, there’s no reason not to make reduction in unnecessary (and often harmful), overused, and duplicative interventions one of our public health goals.
To take just one example, Consumer Reports’ 2010 survey of 1200 healthy 40 to 60 year olds with no known heart disease or risk factors revealed that 44% had received screening or tests for heart disease in which were very unlikely or unlikely to offer benefits outweighing risks.
To promote the reduction of waste, 9 medical specialty societies have joined the American Board of Internal Medicine Foundation and Consumer Reports in a campaign called Choosing Wisely. Each society has come up with a list of five things — tests, treatments, or services — that are commonly used in their specialty, whose use should be reevaluated by patients and clinicians. Adding up the clinicians in the nine specialties, as many as 374,000 clinicians are potentially involved. Of note, the idea of picking just five items comes from bioethicist Howard Brody’s article, “Medicine’s ethical responsibility for health care reform: the Top Five list” (N Engl J Med. 2010; 362(4): 283-285).
Consumer Reports’ role is to create and disseminate consumer-friendly versions of the lists, and partner with other organizations to reach the widest possible audience. Click on the Choosing Wisely link above to see the lists for each specialty. Here’s just a snippet from the American College of Physicians (click on the image to open a PDF with all five):
2. Campbell A, Derrington S, Hester D, Lew C. Her own decision: impairment and authenticity in adolescence. The Journal Of Clinical Ethics [serial online]. 2012 Spring 2012;23(1):47-55.
This is a case study involving a 17 year old young woman, a recipient of a kidney transplant, who is noncompliant with her medications, using crystal meth regularly, and depressed but not suicidal. She is admitted to the hospital for intensive anti-rejection treatment. Her grandmother is her guardian. She has been hospitalized for breast cancer.
The case is reviewed from bioethical, a legal, developmental/philosophical perspectives, which is great. I was a little confused by the legal piece. Amy T. Campbell notes that even if the state law says a 17 year old is a minor, there are cases in which she may be able to make her own health care decisions, relating to (a) the procedure (for example, family planning), or (b) her unique situation (perhaps she is “emancipated” under the state’s guidelines). So far so good.
She then adds that “it may be determined that an adolescent has sufficient maturity, as developmentally and contextually understood, to make certain decisions, or at the very least to take on a shared decision-making role.” I am fine with “take on a shared- decision making role”, because I think that’s what we should be aiming for with every patient, to the extent their cognitive capacities, maturity, and health allow it. But my understanding is that if this patient is a minor under the law, we need to either identify a decision-maker and allow that person to make the decisions, or help the patient file for emancipation. Whether this patient is mature, whether she has DMC … those are important questions as we pursue shared decision-making, but they don’t go to the basic legal question of: does this minor have a legal right to make her own health care decisions.
Legalities said, it is going to be hard to get staff to force treatment on an unwilling 17 year old.
The third commentator, Cheryl D. Law invokes Hilde Lindemann’s notion of “holding someone in her identity” which I do think is very important in a case like this. We need to understand how this patient got to this place. We need more context and a richer narrative to understand her behavior. How did she go from being a compliant 15 year old for whom a transplant was approved to being a crystal meth user who doesn’t care about anything? I would also be curious to know how she came to our hospital.
The missing piece in putting together this narrative is not just the patient’s grandmother, but any associated whatsoever. I would be shocked if she had no boyfriend, no best friend, no roommate, no aunt or uncle or cousin, no coworker, no one with whom staff could talk to forge a better understanding of who she is and why she is making these choices. The assistance of social workers and case managers will be vital in this task, and the assistance of nurses will be vital in helping staff get to know this patient.
I appreciated this case discussion very much as it reveals the complexity of so many real ethics consult cases, a complexity of both the challenge and the tools needed for its resolution which is tool often missing in the literature.
3. Robichaux C. Developing Ethical Skills: From Sensitivity to Action. Critical Care Nurse [serial online]. April 2012;32(2):65-72.
I liked this one because it focuses not on the big obvious ethics cases, the ones that come to us with the word ETHICS stamped on them (futile treatment, withdrawal of life sustaining treatment, etc.), but on the everyday ethical issues that crop up in critical care nursing.
One of the scenarios discussed is an 8 year old with a bullet wound whose distraught mother refuses to let go of him. The nurse figures out how to let the mom get on the bed with the child, moving things where necessary. As the author points out, the nurse in this scenario correctly identified an ethical issue and implemented a justifiable action. Moreover, she showed moral courage because there may have ben criticized by peers or by physicians.
Robichaux references The Four Component Model by James Rest, as presented in Moral Development: Advances in Research and Theory (New York: NY: Prager; 1986).
She also refers to “lateral hostility” a new-to-me concept: “unkind discourteous, antagonistic interactions between nurses who work at comparable organizational levels and commonly characterized as divisive backbiting” (that quote is from Alspach G., “Lateral Hostility between critical care nurses: a survey report.” Crit Care Nurse. 2008; 28(2): 13-19). Let me amend that: clearly, having been a health care consultant for a decade, I have encountered it, but I didn’t realize it was a phenomenon under investigation. Anyway, Robichaux presents a scenario of lateral hostility in the context of Rest’s four component that is very helpful.
Robichaux is maybe a little too optimistic about the ability of ethics education to actually make more morally sensitive, more ethically motivated clinicians, at least based on data I have seen. She also spends some time trying to offer definitions of “ethical” versus “clinical” and other types of dilemmas. Asa philosopher, my approach may be a little different, but the more I work in the health care setting, the more I think that what counts as an ethical dilemma depends less on some inherent feature of the situation than on whether clinicians believe they need ethics tools to address it.
