Introduction

An Introduction to Doing Medical Ethics
Michael A. Gillette, Ph.D.

Introduction

Imagine that Mr. C is a 15 year-old resident of a state mental retardation facility who suffers from serious genetic anomaly and has a long history of poor nutritional status, reflux disorder and aspiration pneumonia. Mr. C is alert at the present time, but has experienced two hospitalizations within the last six months where he was successfully treated for pneumonia. The attending physician requested a gastroenterology consult, which recommended that Mr. C be made NPO (taken off all oral feedings). Mr. and Mrs. C (Mr. C's parents and legal guardians) are convinced that their son will die soon no matter what is done, and they refuse to allow a feeding tube to be placed. Furthermore, they do not want antibiotics to be used if their son should require future hospitalizations. They believe that Mr. C's recently increased lethargy is a sign that he is dying. The nutritionist involved is convinced that Mr. C will improve with better nutrition. Does the facility have the right to force treatment with a feeding tube over parental objections? In addition to the legal and administrative matters that this case raises, is there a moral obligation to either accede to parental authority or seek to usurp such authority? What resources are available to help staff grapple with the ethical difficulties involved in this situation?

It should be obvious in the above outlined case that major areas of concern surround the ethical obligations that organizations have to those under their care; the rights of clients to receive care that is medically indicated; the rights of families to refuse care based upon their own sets of values; and the desire to resolve difficult situations without resort to costly adversarial litigation. These concerns exist within institutional settings, but are equally prevalent in organizations providing community based services. As community providers are becoming more involved in the support of individuals with increasingly complex medical conditions, the opportunity for confusion and conflict has grown drastically. Medical ethics is the field which addresses these concerns. In addition to dealing with the theoretical underpinnings of our duties in these cases, medical ethics strives to offer practical solutions in a timely way. In order to meld the theories of ethics with the practicality of clinical judgment, clinical ethics programs have evolved over the past 25 years. The opportunities for considering the ethical issues in medicine have grown immensely in recent history, and the term "medical ethics" has invaded the vocabulary of almost every American.

Medical ethics has developed in response to at least three major factors. The first factor deals with advances in technology that have greatly increased the options which are available to patients in modern hospitals. While this increase in technology is without a doubt beneficial in general, there are particular situations in which clients and their families have come to feel that their real options have been restricted as a result of new treatment modalities. This fact is borne out by discussions concerning euthanasia and treatment refusal.

The second development contributing to the growth of the medical ethics field is increased cost and scarcity of resources. Difficult choices must be made between medical purposes and other social programs when allocating resources in our society. Decisions must also be made regarding who, among all possible beneficiaries, will receive resources when there are insufficient quantities available.

The third factor responsible for the creation of modern medical ethics is an increase in the attitude among the recipients of medical services which can best be termed 'medical consumerism'. If patients are consumers, it is reasoned, they should determine what they buy, how, and when. This increased level of patient autonomy has both benefits and detriments. While many patients ought to have more control over their own care, this model of medicine disrupts the traditional paternalistic doctor-patient relationship and raises ethical problems. For instance, ought not the doctor retain some control over the practice of medicine? Are doctors merely contracted professionals, or is there a higher standard to which doctors must attend?

Across the nation, health care facilities and accrediting organizations have come to recognize that problems of the sorts just described do not occur in community hospitals alone. In fact many issues, such as patient autonomy and the right to refuse medication, are accentuated in the developmental disabilities field. While hospital corporations have spent significant time and resources on developing ethics programs, most state governments and community service providers have lagged behind in the development of ethics programs. Recently, staff in the field of developmental disabilities have come to recognize the need for ethics committees and ethics programs. Toward the ends of dealing with these complicated issues head-on and providing support for staff and clients who must often struggle with these types of difficulties, facilities have begun to initiate programs in bioethics. Most commonly, these initiatives are committee based and provide educational programming, a mechanism for case consultation when confusion or disagreement arises in a particular situation, and a procedure for contributing to policy development and review.

Facilities interested in implementing an ethics program should consider offering a series of ethics seminars that target specific disciplines or units. These programs should provide a brief overview of some of the basics of bioethics, and then concentrate on ethical issues that arise in that department's specific setting.

In addition to seminars on ethics for the general staff, an additional group of individuals should be targeted to receive more complete training in bioethics. These individuals will then oversee the activities of the ethics committee or ethics program, and will be involved in the process of case consultation. When situations arise in which there is disagreement or confusion concerning ethical issues, a case consultation procedure can be initiated. It is the purpose of the case consultation function to investigate the area of concern and develop a reasoned approach to answering ethical questions. The role of the consult is advisory only. This service is not meant to replace any decision making authority already in place. Rather, ethics case consultations are intended to augment present decision making procedures by providing information and careful consideration of the ethical aspects of client care.

The ethics committee should also be available to develop recommendations regarding more general policy issues. If, for instance, a question were to arise regarding one client, and the answer given in that case had ramifications for many other clients, it might be appropriate to develop or review policies that govern the sorts of decisions in question. Again, the ethics committee is not empowered to make any final decisions, and will concern itself with the specifically ethical aspects of policy.

In addition to formal programs, informal support can be valuable. If staff are interested in learning more about ethics, if they would like to read about specific issues in ethics, or if they would like to informally discuss a case without instituting a case consultation procedure, resources should be available to provide this support.

Experience is a good teacher when it comes to understanding that the existence of an ethics program is desirable and that such a program can become an indispensable tool for providing quality service. Ethics is more than a matter of personal experience, however. A large body of literature and the creation of a professional area of expertise has developed over the years. A familiarity with some of the basic theories of ethics as well as strategies for ethical decision making is essential to developing a successful ethics program. This chapter is designed to provide a very basic introduction to this field.