Practical bioethics for the clinician

Introduction

Bioethics and medical ethics are academic terms for a very practical activity: making the right decisions for our patients. All physicians are practising bioethicists. We obtain consent, try to help without harming, and try to be fair. We often make ethical decisions without being fully aware of the process. It is useful to become more conscious of our ethical decision making, not only to resolve dilemmas as they present themselves, but also to prevent problems from arising. Such ethical dilemmas are dreaded by many clinicians, yet they can provide tremendous opportunities to use our clinical knowledge, understanding of the individual, compassion, and interpersonal skills in order to arrive at the best solutions for our patients.  

Ethics consultations

At Burnaby Hospital, our Ethical Resources Committee has been involved in ethics case consultations since 1997. We address questions such as “Should artificial feeding be started or stopped?” and “Should this patient have a ‘do not resuscitate’ order?” A consultation may be requested by a patient, family member, physician, or other member of the health care team. All who are involved in the care of the patient are invited to attend.

The meeting takes place in a hospital conference room, with chairs placed in a circle around a dry-erase board. This is less formal than sitting around a table and does not allow any participants to distance themselves by sitting in a back row. The circle of chairs allows direct eye contact between participants and implies equality among those present.

After everyone in the room is introduced, as the chairperson, I set the tone of the meeting. I state that our purpose is to clarify the ethical issues of the situation, and I emphasize that any recommendations we make are non-binding. Our role is to facilitate decision making.

On the dry-erase board, I print the agreed-upon goals. This is often worded simply as “to determine what is best for (patient’s name).” This may be followed by more specific questions. For example, “Is tube feeding in the patient’s best interests?” or “Will (a specific intervention) improve this patient’s quality of life?” The act of setting the goals in writing brings focus to the meeting and reminds both family and health care professionals that, in spite of differences in opinion, we have the same benevolent goal: the best interests of the patient.

Next I outline, in lay terms, the four principles of bioethics: autonomy (respect for the individual’s preferences), nonmaleficence (do no harm), beneficence (do good), and justice (treat like cases alike). Then all information relevant to ethical decision making in the case is presented. This involves everyone in the room. In their book Clinical Ethics, Jonsen and colleagues describe four topics under which essential information can be gathered, illustrated in the Table.[1]

The attending physicians are asked to present the medical facts. If a physician lapses into medicalese, this information is translated into plain English. The patient and family members are invited to ask questions or request clarification.

If the patient is not competent to make his or her own decisions, those who know the patient best—family or friends—can be helpful for determining what the patient’s preferences would have been. If the patient has written an advance directive, it is respected. If not, family and friends are asked if the patient had ever indicated preferences in previous conversations.

Other health care team members can provide valuable information. Respiratory technicians can provide the family with detailed information about intubation and ventilation. Dietitians can explain details about tube feeding and its costs. Nurses often provide insights on the patient’s perceived awareness and degree of suffering. Social workers can provide further support for both the patient and family members.

Quality of life is considered from the patient’s perspective. Obviously, the patient is the best judge whenever possible, but a formal advance directive can help by outlining how the individual defines an acceptable or unacceptable quality of life. More often, though, we rely on the expressed goals and values of the individual as recalled by those who know the patient best. We ask participants to consider quality of life in terms of three dimensions: degree of suffering, capacity for enjoyment, and awareness. Quality of life would be considered very poor if the patient had a high degree of suffering and minimal capacity for enjoyment or if the patient was in a persistent vegetative state. However, individuals will vary in how they would rate their quality of life even along these dimensions.

Each person at the meeting is asked for his or her opinion. We listen for feelings, and we respond with empathy, validation, and acknowledgment. Our ethics consultation team members are particularly attuned to the fears and other concerns of family members. Consensus will not be possible unless these emotions are addressed.

Sometimes family members will oppose a “do not resuscitate” order because they are not ready to say goodbye to their loved one. Some feel they must fight with hospital staff in order to get appropriate care. Often, patients and their families are overwhelmed with the complexities of medical jargon.

Where appropriate, we address other misconceptions. We explain that the removal of life support, such as tube feeding or ventilation, is not euthanasia. We detail what is involved in palliative care and how it should not be conceived as giving up or decreasing the quality of care. We affirm patient autonomy by urging that family members not override a patient’s expressed wishes.

The ethical implications of alternative courses of action are discussed, particularly with respect to quality of life. When the patient’s autonomy and best interests are affirmed, consensus is almost always reached.

Our ethics consultation team recognizes that the specific dynamics of each case requires a unique solution. Therefore, we do not give generic solutions from bioethical cases in the literature. However, a review of similar cases can help alert us to recurring, relevant issues.

Likewise, as a physician, your special knowledge of the individual and his or her family dynamics will help you apply the principles of bioethics to finding a solution to ethical dilemmas.

Preventive bioethics

Preventive bioethics stands in contrast to the crisis management of ethical dilemmas. It requires ongoing communication among health care providers, the patient, and family members. The goals of treatment are clarified early. Patients and families are educated on the concepts of futility and quality of life.

In his recent JAMA article, Dr William Molloy found that most seniors would choose less medical intervention for themselves than would a family member or stranger.[2] Therefore, it makes sense to give our patients an opportunity to express their wishes in advance.

As physicians, we have a unique opportunity to help ensure our patients’ autonomy through education. We can make our patients aware of the importance of choosing a proxy or substitute decision-maker while they are competent. We can provide references or resources with which they can learn more about medical procedures, advance directives, and ethics in general.

I post articles on these topics in my reception and examination rooms. Some patients prefer these to the old Reader’s Digest issues. Many patients have followed through with writing advance directives. In your own office, you can do a lot in a surprisingly short time.

I have designed a substitute medical decision-maker card (Figure 1)[may be reproduced without permission and given to patients] and recommend that my patients carry it in their wallets in case of an emergency.

Figure 2 [may be reproduced without permission and given to patients] shows a sample notice you could post or make available in your office or clinic to promote the use of these cards among your patients. This will encourage your patients to discuss their values and preferences with their loved ones while they can.

Each of us should consider an advance medical directive in anticipation of a time when we are not capable of making our own medical choices. This can consist of either formal written instructions or simply the appointment of a substitute decision-maker. In either case, we must evaluate our values and discuss them with our loved ones. Preventive bioethics will benefit family members and health care providers in the future and ensure that autonomy is respected.  

Table. Four categories of information for making ethical clinical decisions.

Davidicus Wong, MD

Dr Wong is a Burnaby family physician and has been chair of Burnaby Hospital's Ethical Resources Committee since 1992. He also writes a medical column for two community newspapers on a variety of subjects, including specific disease management, preventive medicine, the doctor-patient relationship, and medical ethics.