Bioethics Forum Essay
Measure Twice and Cut Once: The Value of Health Care Ethicists in the Pandemic
It would seem to be a great time to be a health care ethicist. A pandemic raises many dramatic and urgent issues within hospitals, research institutions, and our public health infrastructure. If you are a bioethicist who can write fast or are willing to talk to a reporter, you can find a venue for your thoughts. While we are still immersed in the new normal created by the pandemic, we are probably already in a position to make a few observations on how ethics is faring as a discipline or as a service within the health care setting. After all, the pandemic created the need to address a variety of issues in a semi-urgent fashion. Because the bioethics community is rather small (e.g., the leading professional organization, the American Society for Bioethics and Humanities has a membership of under 2,000), we can easily gain some general impressions.
Undoubtedly the major success story of ethics in the pandemic has been the role of ethicists in ventilator triage policies. Starting in March, a flurry of activity took place in which ethicists shared drafts of policies and discussed the ins and outs of their various features in electronic venues such as the MCW listserv. Various groupings of ethicists, including local and regional groups, shared information and sometimes worked together to interpret emerging guidance documents and a rapidly developing literature. An article by the Association of Bioethics Program Directors is a snapshot in time of the early part of this process, when few hospitals had such policies and were trying to not only develop a them but also to determine and contribute to national standards. Closely tied to this issue was the question of whether DNR orders for patients with Covid would be done according to established standards of shared decision making or warranted more paternalistic approaches owing to these crisis or near-crisis circumstances.
It would be helpful to have systematic qualitative data on how the involvement of ethicists proceeded, e.g., was this activity primarily driven by ethicists raising these topics with hospital leadership or did hospital leadership seek out the expertise of ethicists? Bioethicists generally seem to believe that they have had a seat at the table in regard to these policy decisions. Of course, DNR and various end-of-life policies have long been associated with clinical ethicists and ethics committees.
Concurrent with the development of triage policies, many other policy decisions with major ethical implications were being made for hospitals and health systems. For instance, hospital executives were deciding when to order the cancellation of elective procedures and how much space to convert to additional ICUs. Visitor policies quickly evolved, including whether to allow visitors to patients dying of illnesses other than Covid-19. Decisions concerning how to utilize limited institutional stockpiles of personal protective equipment, particularly masks, had to be made. Currently, choices are being made regarding testing policies for staff, furloughs, and salary cuts. But few if any of these deliberations have included health care ethicists.
It’s frequently said that the crisis situation created by the pandemic highlights existing structural weaknesses. Health care ethics seems to have been able to draw on its institutionalized status in facilitating end-of-life decisions to participate in deliberations on triage policies and approaches to DNR orders. But in regard to organizational decisions with ethical implications, the participation of ethicists has been less routinized and more dependent on informal relationships. Such relationships can often yield very fruitful results when senior leadership in a health care system learn that their ethicists often provide helpful input to difficult discussions on potentially heated issues. But the pandemic points out the inadequacy of relying solely on informal relationships.
Informal relationships may have a reasonable yield when decisions are considered in way that is not especially time-constrained. When considering a new policy or strategic initiative, executives likely ask themselves typical questions concerning who are the key stakeholders and sources of relevant expertise to include. But in an emergent or actual crisis, the CEO of a health care system may well summon key administrative and clinical executives– the cabinet–and develop policies in a fairly decisive manner. Ethicists may not even know of the formulation of a policy until it is deployed. At that point, offering reflection on the policy’s weaknesses may not be especially welcome.
Of course, the informal relationships on which clinical ethicists depend for organizational influence have in many places been stressed by the high rates of turnover among health care leaders. Consolidation and reorganization of hospitals and health systems over the last decade have led to a situation in which accumulated relationship capital can be wiped out suddenly and fairly frequently. As a result, it is important that the input of trained clinical ethicists be institutionalized among senior leadership. Many Catholic health systems have created positions with titles such as vice president for mission and ethics. Designed to guarantee that the founding religious order’s focus on the charitable and spiritual mission of the hospital is preserved, such positions make sense within any nonprofit, mission-driven health care institution.
In order to succeed in a mission leader role, two conditions need to be realized. First, clinical ethicists would do well to acquire organizational and leadership skills. Such courses are offered in a few highly specialized graduate-level mission leadership programs, but there is no reason that bioethics graduate programs cannot incorporate more offerings along these lines. Second, ethicists must use their informal relationships to convince health care leaders to institutionalize such input. C-suite types sometimes view ethics as cumbersome and unwieldy in the real world of health care. Ethicists will need to show them the advantages of gaining their input early and how it can lead to better decisions. Ethicists must continue to help CEOs to see ethics as a tool that helps them “measure twice and cut once.” In a crisis, speed is important but so is efficiency and efficacy.
Mark G. Kuczewski, PhD, HEC-C, is the Michael I. English, S.J. Professor of Medical Ethics and director of the Neiswanger Institute for Bioethics at the Stritch School of Medicine at Loyola University Chicago. He is a Hastings Center fellow. Twitter: @BioethXMark
Thank you Mark Kuczewski, for this excellent essay. As a lawyer specialised in medical law and an active member of a clinical ethical committee, I fully agree on that ethics is often neglected among health care leaders but most important if we want to create a better health care for the future generations. Not only in terms of possible pandemic decision making but also as processes will get standardised and more efficient with digitalisation, it will need a closer integration and a stronger influence of clinical ethicists.