Brattleboro Memorial Hospital Clinical Ethics Committee“I’m 78 and have been given a terminal diagnosis. I also had a pacemaker implanted years ago to keep me alive — do I have the right to have it removed now?”“I’m16 and have a drug addiction. I developed a skin abscess from needle use and have just been admitted to the ER. My parents are not aware of my IV drug addiction and they asked the doctor the cause of my skin condition. I asked the doctor not to tell my parents.”“I’m 34 and have been diagnosed with a type of blood cancer. My oncologist informed me that by receiving a treatment which involves blood products, my chances of surviving rise by 50 percent. However, my religion forbids me to accept blood transfusions.What can I do?”
These are the types of questions and issues a hospital ethics committee might be asked to address. The Clinical Ethics Committee at Brattleboro Memorial Hospital provides a place for shared decision-making around medical issues that arise in the hospital, nursing home, or medical office. We are made up of both hospital and community members with varied backgrounds: physicians, nurses, social workers, board members, attorney, clergy, and other local professionals.
When hard choices need to be made or difficult problems need to be discussed about a patient’s medical care and treatment choices, the Ethics Committee helps to facilitate a conversation between patients, family members, and medical staff. A common misnomer is that the Ethics Committee makes healthcare decisions or mandates a medical ultimatum. Rather, we help those involved understand the situation, what the patient wants, and what healthcare options are available under the circumstances. We provide all information and guiding resources to patients and their caregivers – they alone make the final decision regarding medical treatment.
Our group provides a listening ear, helping the patient and medical staff determine the choice that fits the patient’s values and lifestyle. The Committee encourages input from a patient’s loved ones and creates a safe space for difficult conversations.
Four basic principles and guiding questions are used to facilitate discussions between medical providers, patients, and their caregivers:
1. Autonomy:Does the patient have the ability to make his or her own choices?
Autonomy is not simply allowing a patient to make their own decision, rather a provider is compelled to create an environment of patient empowerment. The provider must present all treatment options to the patient, explaining risks in terms that the patient will understand and ensuring that the patient realizes the risks and agrees to all procedures before proceeding with medical treatment. In the case of the patient with blood cancer, the oncologist has the duty to present all information regarding treatment to the patient. Once the patient has been fully informed of their options – and has made the decision to accept or decline treatment – the provider also must respect their choice.
2. Beneficence:Is the welfare of the patient the primary focus?
Providers are obligated to help their patients and refrain from harm. They are faced with the daily balance of risks and benefits of medical actions and are committed to ultimately improving the quality of clinical situations. This principle is often difficult to navigate – many times it is in direct opposition to autonomy. Again, in the case of the patient with blood cancer, the provider’s duty of the patient’s welfare (encouraging ablood product treatment to increase survival)is in contrast with the duty to allow the patient to make their own decisionbased upon person believe systems(refusing the blood transfusion).
3. Non-Maleficence:Who may be harmed by the action?
Non-maleficence means that providers are sworn to do no harm. They should never act with bad intentions towards a patient nor should they provide ineffective or harmful treatments. However, this principle becomes increasingly difficult as many medications and procedures often have harmful side effects. The provider must explain to the patient not only the side effects, but the potential benefit of such a procedure. In the matter of the elderly patient with the pacemaker, the provider is obligated to explain the outcomes of either leaving the pacemaker ‘on’ or deactivating the device or surgically removing the device.
4. Justice:Who is vulnerable by this healthcare decision and how could it be more equitable?
Justice describes the moral obligation of a provider to his/her patient’s medical needs. All patients have the right to be treated equally and available health care resources should be used fairly and sensibly. This principle often addresses the sticky scenario of organ donations. A long-suffering patient in their seventies is in need of an organ transplant, however, an eight-year-old patient just diagnosed with the same medical condition is also on the list. Who receives the organ? The vulnerability of the patients should be weighed and a just and equitable decision should be made.
Often, situations arise that turn these four principles upside down – seemingly with no right answer or positive outcome. In the case of the young, drug-addicted patient, revealing a serious addiction can be life-shattering for families. The Committee would discuss the ethical implications and consider how they could be of service to this situation. Facilitating a difficult conversation between the daughter and parents could be the first step.
An ethics consultation is voluntary and can be requested by anyone: patients, family, or hospital or nursing home staff. The Brattleboro Memorial Hospital Ethics Committee is a freecommunity resource offering ethical guidance, so those making difficult healthcare choices will have more information and insight with which to make those decisions.
This series is written by the Brattleboro Memorial Hospital Clinical Ethics Committee. Should you have questions or suggestions for these monthly articles, please contact the Chair of the Committee, Dr. Thomas H. Lewis atBrattleboro General Surgery, a member ofBMH Medical Group, at802-251-8650.