By Christopher Guadagnino, Ph.D.

Published October 1996

• React to this article in the Discussion Forum.

PND: What practical relevance does a study of medical ethics have for the practicing physician?

GH: Everything that we do has ethical implications. That does not mean, however, that all physicians know how to think ethically. Probably 90-95 percent of the "ethical issues" with which a physician is presented—he or she can solve them out of his own intuitive ethical nature. There’s that five or ten percent that is a little more thorny that need help from the discipline of medical ethics. When an ethical dilemma occurs, it’s not so much a question of, "shall I do the right thing or the wrong thing," it’s, "which good that I’m trying to achieve is the better good?"

PND: What can a physician do to handle an ethical problem?

GH: In most instances he would either ask advice of a medical ethicist or from the institutional ethics committee at his hospital or medical center. Either the physician, or a nurse involved, or a patient or anybody involved in the case could ask for a consultation with the committee. Typically, there is some disagreement about the care being provided. Many times it is whether life sustaining efforts should be continued or discontinued. And if a case comes in, it is given to the nurse supervisor, who notifies the contact person for the ethics committee. They review the case. They talk to the patient. Probably 80-90 percent of the time in reviewing cases, depending on how sophisticated a hospital is, they may find out that this really isn’t an ethical issue at all; it’s just a misunderstanding of medical facts. The problem may be that the patient and/or the family don’t understand what the diagnosis is, therefore, they don’t understand the advice of the physician. So, the function of the ethics committee in many cases, even when there are true ethical issues there, is one of clarification of the medical facts. Frequently, when the medical facts of the case are identified and then explained to both parties, what appeared to be an ethical issue is really a semantic problem, and it just goes away. If it doesn’t, then it’s the function of the ethics committee, or of the medical ethicist, to see what the ethical problem is and try to help resolve the conflict by working through the different possibilities of resolution.

PND: Can you give an example of such a case?

GH: It may be that the patient has terminal metastatic spread of cancer and there’s the family expectation that, "Dad is only 57 years old and everybody in our family has lived until they were 85. He’s gonna make it." The consultation helps the doctor clarify the issue and makes sure that the patient understands the gravity of the disease. All too often a lot of denial goes on and we have to help get through the denial process by explaining what the disease is, what the prognosis is, and that all chemotherapy has been tried, none of it has worked and there are no more experimental drugs to use. The family may say, "Maybe we should put dad on a ventilator and do renal dialysis and artificial feeding and maybe next week there’s going to be a breakthrough in this case." That kind of hopefulness is understandable, but probably not based in fact. So if you can help people get through their denial that dad or mom really is in the dying process, the ethical issue goes away.

The other instance is, there may be a case where, in spite of knowing the terrible end that the patient faces very shortly, the patient says, "Look, I really do want the ventilator." The doctor says, "Nothing is going to make you better, so I don’t think you should have it." An ethics committee might get in there and find out that the patient knows that he or she is only going to live for a few more days or maybe a week or two with the ventilator; without the ventilator he’s going to die this evening. A need for reconciliation may be identified—that the patient has been separated from, let’s say, a brother or a sister for many years and needs to have a reconciliation before the patient dies. And I’ve seen this happen—sometimes they can’t get off the ventilator. What they’ll do is handle all this with handwriting—express their remorse or forgiveness, and then say, "Okay, now take the ventilator, I’m done." So there’s the difference between efficacy and benefit. Efficacy is defined by physicians: Is this going to work to change the course of this disease? Benefit is something defined by the patient: I will benefit from staying alive long enough to talk to my brother when he gets here from San Diego. And that’s how an ethics committee can help.

PND: How much authority do ethics committees have?

GH: I don’t know of any ethics committee that feels that it makes a binding judgment. Let me tell you what an ethics committee isn’t. First of all, it’s not an institutional review board, which is mandated by federal law and has decision-making authority, working as a gatekeeper and a regulator for experimental research. An institutional ethics committee doesn’t have that kind of mandate, nor does it wish to. It’s there to help physicians and families and patients understand what the ethical constructs and possibilities are—they, in final analysis, have to come to the decision. It’s not the morals police force going around looking for doctors doing something unethical. A lot of people think that an ethics committee is really a quality review board or a risk management committee whose supposed to cover the hospital’s legal situation. That’s not it’s job either. Some people think that it’s a prognosis committee, to issue collective opinions of how long a patient has to live. That’s not the prerogative of the ethics committee, which is a multidisciplinary group. It will have clergy on it, physicians, ethicists, social workers, nurses, community representatives. You can’t make a decision like that by committee, anyway. If doctors need a second opinion from another specialist, that might be something the committee might suggest.

PND: What advice can you give to physicians on how best to use ethics committees?

GH: The how-to is usually spelled out in each individual hospital. If the hospital ethics committee is doing good education and is helping in guideline formulation, then you’re going to have fewer consultations and fewer case reviews. Our job is the same as that of preventive medicine: you should work yourself out of a job. If a doctor is having a real internal problem with a case, he doesn’t have to get a formal consultation, but may come to a member of the committee to seek clarification of issues—the same way a doctor doesn’t get a formal clinical consultation every time he wonders about something. He may ask his colleague at lunch. And if the doctor thinks that there’s enough of a problem—that it’s more than just a personal "I’m really not sure," that there is a conflict with another party who is equally "not sure," then it would be his or the patient’s prerogative to come to the committee.

PND: Might some physicians feel that their autonomy or judgment is threatened if a patient or family calls for an ethics committee involvement in a case?

GH: Sure—that’s why there’s a conflict. One of the functions of the ethics consultation is to do some conflict resolution. A lot of times it is a difficulty of communication. Once those avenues are opened up, the problem goes away.

PND: How can physicians reconcile managed care’s cost-driven incentives from an ethical standpoint?

GH: The best way is to review the contract before you ever sign it and then negotiate with the cost management company about those issues. For example, veracity: if they have something in their contract that says you are not allowed to tell the patient about a therapeutic procedure that they don’t cover. Ethically, I could not sign that kind of contract.

PND: How could a physician ethically manage a situation in which a patient’s health insurer does not cover a needed therapy?

GH: I think a practical way to handle that in an ethical way would be to explain to the patient, "You have a contract with your company. Your company says they’re not going to pay for it. Now, I think you need this treatment. Now you have these options: decide you’re going to go for this kind of therapy and understand that you’re going to get the bill, or decide that you don’t want it." Just make sure that you’ve explained all this to the patient clearly. Document, not only that you’ve told the patient, but that you told them that they may be responsible for the financial outlay.

PND: What if it’s a patient on Medicaid?

GH: Then all you can do is tell them: "This is what you need, and they won’t pay for it." What else is there to do? Big money has seen that there’s big money in the exchange of money and medicine. That’s a societal problem, and society is going to have to finally figure out that this is not the best way to treat human beings. People are not widgets. As clinicians, the major contribution we can make to cost containment is to practice effective and competent medicine. And that will generally be the least expensive kind of medicine. But at the same time, I think that justice and beneficence would demand that a doctor has to provide effective and beneficial and necessary care, or at least point out to the patient what that care is. Sometimes a doctor can negotiate with the insurance company. I think that’s part of a physician’s obligation. But if I do that and they still say, "No, we won’t pay," then you have to say, "Look, I did my best, I tried to explicate the issues in this situation. The M.B.A.s have overruled the M.D.s."