The Role of the Clinician I
Michael A. Gillette, Ph.D.

Imagine that Ms. P is a 17 year woman with moderate retardation who was transferred to a state MR facility upon discharge from a pediatric care center. Imagine further that she is identified under new guidelines as an individual who should be moved into a community based living arrangement. However, the treatment team in this case feels that sending Ms. P to a group home might result in physical and psychological harm for her. In a world where down-sizing of state operated facilities becomes a high priority, we might be faced with a situation in which Ms. P functions on too high a level to remain in the MR facility, too low a level to go home to her family, and too low a level to succeed in a group home. Many are concerned that we, as care providers, might be forced to make some ethically difficult decisions in such scenarios.

This possibility presents a number of ethical issues. First, there is the question of residents who must leave the institutional environment, but who would seem to benefit by remaining. Second, we have the problem of possibly conflicting obligations of providing care according to policy guidelines versus personal perceptions of appropriate care. Finally, we might have a question here of the proper utilization of state resources. Would it be appropriate to ignore state guidelines, or perhaps even to lie in a resident's record, in order to secure the resources necessary for continued provision of institutional care?

Hopefully these questions will not often arise, and in most cases clinical judgment will mesh well with mandated treatment guidelines. However, in the event that personal ethics and organizational policy conflict, moral issues can be intense.

While all of these questions are of interest, one serious concern centers on the moral responsibility of health care providers. How should a clinician respond when he/she feels that continued institutional living is indicated, but the threat of physical harm on transfer to a group home is neither clear nor imminent?

For the present I would like to avoid the issue that might, ultimately, prove to be the most significant. That issue is the welfare and rights of the resident herself. Prior to discussing the question from the resident's perspective, it would be instructive to ask just exactly what the responsibilities of the provider are.

One way to pose the relevant question is to ask whether the MR facility or the clinician would be morally responsible for any bad outcome that might follow if the resident is transferred. In order to develop a negative response to this question we might simply say "I had no choice". If I was compelled to release the resident, then I cannot be held responsible for the results of my actions.

The theoretical argument for this answer is based on a commonly assumed fact of ethics that "Ought Implies Can". This assumed fact supports the idea that it is immoral to hold an agent responsible for something that was not within his/her control. It would, for instance, be unacceptable for me to demand that you jump to the moon in a single bound, and then hold you responsible for your failure to comply. Since you are unable to jump to the moon, it is not your fault that you failed to do so.

This argument would work in the present case if it were true that I am unable to continue to treat Ms. P in the way that seems appropriate. It is unclear, however, that I am truly unable to treat Ms. P. I might, for instance, lie to the relevant parties in order to convince them that they have no choice in the matter. If the lie works, I will bring about the greater good. If the lie fails, then my career would most likely be ruined.

It is entirely possible, however, that sacrificing my career would be a small price to pay in order to do the right thing. Therefore, it would be within my power to affect a better outcome for Ms. P. The price would surely be high, but the 'ought implies can' argument would be avoided. I can help Ms. P, I just don't want to given the cost involved.

I do not wish to argue that the clinician in this case should lie in order to continue treating Ms. P. The cost might be clearly too high in this case to justify the action. It might also be a more important moral duty to satisfy the guidelines as set by a democratically elected legislature. Nevertheless, the argument to avoid moral guilt in this case would be based on an assessment that you did in fact make the proper moral choice in releasing Ms. P, not that you avoid responsibility for the choice by claiming inability to decide otherwise. If this is the structure of the argument, then a careful evaluation of all of the ramifications of your choice must be made.

It might be much simpler, and create a more consistently applicable argument, if we were to find a way to argue that regardless of the specific outcome in any case, the health care provider avoids responsibility altogether by acceding to the guidelines of the facility in which he/she works. If this argument could be made, then the clinician could avoid having to make a careful assessment of every possible result of the choices involved, and could merely claim that as a clinician he/she satisfied all moral obligations. Next month we will consider this possibility specifically.