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The Role of Clinical Ethics—Providing Guidance for Tough Decisions

Most medical decisions we face can be resolved with thorough information and advice from our physician. But other decisions — such as those regarding end-of-life care — can be more problematic and emotionally charged. In cases like these, a clinical ethicist can provide valuable input to help family members and physicians reach a consensus about the most appropriate treatment for a patient.

“Clinical ethicists serve both as advisors and counselors,” explains UAB internist and palliative medicine specialist Ryan Nash, MD, who also serves as a clinical ethicist in the hospital setting. “They are patient-centered, while also approaching situations with great respect for the role of physicians. Ethicists have specialized training and experience in working through medical dilemmas. They help to develop an action plan for treatment that will be acceptable to everyone involved.”

The Value of Clinical Ethics at the Bedside

Dr. Nash explains that most clinical ethicists have medical training in internal medicine, geriatrics, palliative medicine, or another specialty. “Clinical ethicists rely heavily on their medical training,” says Dr. Nash. “But the discipline of clinical ethics also incorporates theology, philosophy, literature, history, and ethics, translating these to the application of medical situations.” He adds that clinical ethicists are involved in ongoing community, professional, and patient education.

Dr. Nash stresses that physicians can handle most issues that arise at the bedside without outside assistance. “Ninety-nine percent of cases don’t require an ethicist at the bedside,” adds Dr. Nash. “But for those cases in which dilemmas arise, clinical ethics is the applied science at the bedside. The goal is to equip patients, family members, physicians, and policy makers with information regarding how to provide the most appropriate care in a specific situation. It helps answer the question: ‘Should we do something?’ instead of ‘Can we do something?’”

For example, a clinical ethicist may help guide decision-making regarding a question of whether prolonged mechanical ventilation is appropriate in a situation where the medical prognosis is poor. “The central ethical issue is always uncertainty,” explains Dr. Nash. “If everyone were certain of the outcome of a medical treatment or measure, the ethical dilemma would be eliminated. The role of the ethicist is to provide input and guidance that will help family members and physicians reach a consensus based on the best available information, including the patient’s values.”

Importance of an Advance Directive (Living Will)

Dr. Nash emphasizes that when family members are in the position of making difficult medical decisions for a loved one, they often feel a huge sense of responsibility. “The medical team often feels the burden as well,” he adds. “In cases where the loved has an advance directive — or living will — family members can feel confident that they are honoring their loved one’s wishes regarding medical treatments and end-of-life care. These documents can alleviate the tremendous burden families often feel in these situations.”

He adds that an advance directive is one of the best tools for communicating your values and wishes in medical situations, including end-of-life care. “This document can answer important questions such as: ‘What is important to me?’ and ‘In what environment would I want to be treated?’ I would encourage older adults to use the document as more than a delineation of your wishes. You should also express who you are and how you want to be remembered and treated.”

Dr. Nash stresses it’s best for patients and physicians to work together in developing advance directives. “Patients often don’t have the information they need to develop clear directives,” says Dr. Nash. “That’s why I encourage patients to speak to their physicians when developing these documents so they are able to understand and give informed consent for any medical procedure specified in the directive.”

Important Future Roles for Clinical Ethicists

Dr. Nash says the rapidly changing landscape of healthcare delivery is setting the stage for an increasing role for clinical ethicists in future years. “As the healthcare rationing debate intensifies, clinical ethics will likely play a key role in helping to determine questions of healthcare utilization, including defending patients’ right to treatment and discussing ineffective and unnecessary treatments in order to control costs,” observes Dr. Nash.

He says clinical ethicists will also play an increasingly important role in helping to determine the rights of medical professionals, sometimes referred to as ‘rights of conscience.’ “Medicine, rightfully, has become more respectful of the rights of patients. However, recently there are suggestions that such respect may be taken too far. This is evidenced by a recent legal logic that if a procedure is legal, then it is ethical; and if it’s ethical, it can be demanded as right,” Dr. Nash explains. “But this logic may be infringing on the autonomy of professionals. As our healthcare system evolves, medical professionals could be asked to engage in practices they view as unethical. Clinical ethicists will have a key role in sorting out these future issues.”

Article last updated: December 3, 2009 10:30 AM