Doing ethics consultations better

Journal of Clinical Ethics

Volumn 11, Issue 3, 2000, Pages 195-205

  Howe, Edmund G ^a  

^a UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

BIOETHICS AND PROFESSIONAL ETHICS; CONFLICT; ETHICS; HEALTH CARE QUALITY; HUMAN; HUMAN RELATION; MEDICAL ETHICS; NOTE; PATIENT REFERRAL; PROFESSIONAL PATIENT RELATIONSHIP; STANDARD; TRUST; UNITED STATES;

BIOETHICS AND PROFESSIONAL ETHICS; PROFESSIONAL PATIENT RELATIONSHIP;

CONFLICT (PSYCHOLOGY); DISSENT AND DISPUTES; ETHICS CONSULTATION; ETHICS, MEDICAL; HUMANS; PROFESSIONAL-PATIENT RELATIONS; QUALITY ASSURANCE, HEALTH CARE; REFERRAL AND CONSULTATION; TRUST; UNITED STATES;

EID: 0034264140     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (50)

1. M. Bliton, "Ethics Talk; Talking Ethics: An Example of Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 7-24; D. Barnard, "A Case of Amyotrophic Lateral Sclerosis," Literature and Medicine 5 (1986): 27-42; T. Tomlinson, "Ethics Consultant: Problem Solver or Spiritual Counselor?" Human Studies 22 (1999): 43-52; and E. Rabkin, "A Case of Self-Defense," Literature and Medicine 5 (1986): 43-53.
2. M. Bliton, "Ethics Talk; Talking Ethics: An Example of Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 7-24; D. Barnard, "A Case of Amyotrophic Lateral Sclerosis," Literature and Medicine 5 (1986): 27-42; T. Tomlinson, "Ethics Consultant: Problem Solver or Spiritual Counselor?" Human Studies 22 (1999): 43-52; and E. Rabkin, "A Case of Self-Defense," Literature and Medicine 5 (1986): 43-53.
3. M. Bliton, "Ethics Talk; Talking Ethics: An Example of Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 7-24; D. Barnard, "A Case of Amyotrophic Lateral Sclerosis," Literature and Medicine 5 (1986): 27-42; T. Tomlinson, "Ethics Consultant: Problem Solver or Spiritual Counselor?" Human Studies 22 (1999): 43-52; and E. Rabkin, "A Case of Self-Defense," Literature and Medicine 5 (1986): 43-53.
4. M. Bliton, "Ethics Talk; Talking Ethics: An Example of Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 7-24; D. Barnard, "A Case of Amyotrophic Lateral Sclerosis," Literature and Medicine 5 (1986): 27-42; T. Tomlinson, "Ethics Consultant: Problem Solver or Spiritual Counselor?" Human Studies 22 (1999): 43-52; and E. Rabkin, "A Case of Self-Defense," Literature and Medicine 5 (1986): 43-53.
5. "When I first read Mark Bliton's account of his involvement in the care of Mrs. Rose, I got angry." Tomlinson, ibid., p. 43. Rabkin states, "I have just read 'A Case of Amyotrophic Lateral Sclerosis' by David Barnard for the fourth time. I had best say at the outset that I grow angrier with each reading." Rabkin, ibid., p. 43.
6. "When I first read Mark Bliton's account of his involvement in the care of Mrs. Rose, I got angry." Tomlinson, ibid., p. 43. Rabkin states, "I have just read 'A Case of Amyotrophic Lateral Sclerosis' by David Barnard for the fourth time. I had best say at the outset that I grow angrier with each reading." Rabkin, ibid., p. 43.
7. McClung and Smith report, for example, that 44 percent of families in a study found ethics consultation unhelpful or detrimental, which exceeded the 35 percent of subjects who reported this same opinion in their own study. J.A. McClung and A.E. Smith, "Evaluating an Ethics Consultation Service, American Journal of Medicine 103(August 1997): 167-8, citing R.D. Orr, et al., "Evaluation of an Ethics Consultation Service: Patient and Family Perspective," American Journal of Medicine 101 (1996): 135-41.
8. McClung and Smith report, for example, that 44 percent of families in a study found ethics consultation unhelpful or detrimental, which exceeded the 35 percent of subjects who reported this same opinion in their own study. J.A. McClung and A.E. Smith, "Evaluating an Ethics Consultation Service, American Journal of Medicine 103(August 1997): 167-8, citing R.D. Orr, et al., "Evaluation of an Ethics Consultation Service: Patient and Family Perspective," American Journal of Medicine 101 (1996): 135-41.
9. E.G. Howe, " 'Sacred' Research Practices We May Want to Change," The Journal of Clinical Ethics 10, no. 2 (1999): 79-87.
10. Bliton explained," An unwritten rule pertained here. . . . If I pressed further, my question would appear too clearly to be about his conduct. . . . I had to trust his own understanding. . . ." Bliton, see note 1 above, pp. 20-1.
11. Bliton and Finder state, "Bliton 'must risk challenging and becoming adversarial with the very health care professionals upon whose trust and openness the effectiveness of his work ultimately depends'." M.J. Bliton and S.G. Finder, "Strange, But Not Stranger: The Peculiar Visage of Philosophy in Clinical Ethics Consultation," Human Studies 22 (1999): 69-97, p. 79, citing B. Hoffmaster, "Anatomy of a Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 53-68, p. 66.
12. Bliton and Finder state, "Bliton 'must risk challenging and becoming adversarial with the very health care professionals upon whose trust and openness the effectiveness of his work ultimately depends'." M.J. Bliton and S.G. Finder, "Strange, But Not Stranger: The Peculiar Visage of Philosophy in Clinical Ethics Consultation," Human Studies 22 (1999): 69-97, p. 79, citing B. Hoffmaster, "Anatomy of a Clinical Ethics Consultation," Human Studies 22, no. 1 (1999): 53-68, p. 66.
13. Bliton, see note 1 above, p. 8.
14. Barnard, see note 1 above, p. 31.
15. R.G. Miller, et al., "Practice Parameter: The Care of the Patient with Amyotrophic Lateral Sclerosis (an Evidence-Based Review)," Neurology 52 (1999): 1311-23, p. 1312.
16. A. Beisecker, A. Kuckelman, and D.K. Ziegler, "Patients' Perspectives of the Role of Care Providers in Amyotrophic Lateral Sclerosis," Archives of Neurology 45 (May 1988): 553-6, p. 556.
17. E.G. Howe, "Ethics Consultants: Could They Do Better?" The Journal of Clinical Ethics 10, no. 1 (Spring 1999): 13-24.
18. R. Langs, The Psychotherapeutic Conspiracy (New York: Jason Aronson, 1982), p. 317, cited in Howe, ibid., p. 19.
19. R. Langs, The Psychotherapeutic Conspiracy (New York: Jason Aronson, 1982), p. 317, cited in Howe, ibid., p. 19.
20. Lukes argues that "A" can have power over "B" without any sign of conflict. For example, the behavior of difficult patients can engender feelings of powerlessness in nurses who then feel pressured to control patients' behavior. S. Lukes, Power: A Radical View (London: Macmillan, 1974).
21. "The striking finding . . . was how little evidence there was that providing more detailed information about limits to confidentiality . . . has on willingness to disclose . . . . In addition, a straightforward recognition of the client's motivational conflict can 'wipe out" any small inhibitory effect. It may well be that [this is because] this degree of disclosure builds an interview atmosphere conducive to trust. This, indeed, has been my experience" [emphasis added]. T. Muehlman, B.K. Pickens, and F. Robinson, "Informing Clients About the Limits to Confidentiality, Risks, and Their Rights: Is Self-Disclosure Inhibited?" Professional Psychology: Research and Practice 16, no. 3 (1985): 385-97, pp. 395-6.
22. L. Havens, "Seeing Sullivan as Part of 20th Century Developments," Psychiatry 63, no. 2 (Summer 2000): 127-31, pp. 129-31. When consultants inform patients that they justifiably have these feelings, consultants may also avoid inflicting insidious shame.
23. In 25 percent of couples, after they discussed a "happy event" in their relationship, Cortisol or stress hormone levels went up. J. Kiecolt-Glaser, W. Malarkey, and R. Glaser, "Happy Situations Can Increase Stress-Related Hormones in Some People," Reuters Medical News (7 August 2000).
24. P. Maquire, "Improving Communication in Palliative Care," (paper presented at the Improving Communication at the End of Life conference, sponsored by the American Academy on Physician and Patient, in Rochester, N.Y., 3-8 June 2000). A similar phenomenon may exist when doctors ask what are called "structured questions," a series of questions designed to determine patients' illness most efficiently. Many doctors assume that to simply read these questions to patients would be impersonal, and thus offensive. Patients, in fact, appear to appreciate this approach, presumably because these questions go directly to the heart of their concerns.
25. J.E. Groves, "Taking Care of the Hateful Patient," New England Journal of Medicine 298, no. 16 (1978): 883-7, p. 886. Shapiro states, "as [these] patients feel closer and safer, they may feel vulnerable to loss and disappointment . . . . What can you do when your patient experiences you as abusive. . . . [You] must be emotionally open to the pain . . . and examine why the patient has made this attribution at this time . . . weathering the storm. . . sets the recovery process in motion." S. Shapiro, Talking with Patients (Northvale, N.J.: Aronson, 1995), 137-8.
26. J.E. Groves, "Taking Care of the Hateful Patient," New England Journal of Medicine 298, no. 16 (1978): 883-7, p. 886. Shapiro states, "as [these] patients feel closer and safer, they may feel vulnerable to loss and disappointment . . . . What can you do when your patient experiences you as abusive. . . . [You] must be emotionally open to the pain . . . and examine why the patient has made this attribution at this time . . . weathering the storm. . . sets the recovery process in motion." S. Shapiro, Talking with Patients (Northvale, N.J.: Aronson, 1995), 137-8.
27. From R. Perkins and J. Repper, Working Alongside People with Long-Term Mental Health Problems (London: Chapman and Hall, 1996), cited in J. A. Breeze and J. Repper, "Struggling for Control: The Care Experiences of 'Difficult' Patients in Mental Health Services," Journal of Advanced Nursing 28, no. 6 (December 1998): 1301-11. These principles summarize an approach developed for nurses called non-contingent TLC (tender loving care), which emphasizes that if a patient is hitting, this is for a reason: he or she lacks more acceptable ways of responding. Careproviders must be sufficiently flexible to offer such patients new ways, such as giving them unsolicited attention. In clinical practice, professionals may "tend . . . to be overly harsh and punitive toward them (construing them as demanding, manipulative, hostile individuals who need strict limits)." S.M. McIntyre and R.C. Schwartz, "Therapists' Differential Countertransference Reactions toward Clients with Major Depression or Borderline Personality Disorder," Journal of Clinical Psychology 54, no. 7 (1998): 823-31, p. 825.
28. From R. Perkins and J. Repper, Working Alongside People with Long-Term Mental Health Problems (London: Chapman and Hall, 1996), cited in J. A. Breeze and J. Repper, "Struggling for Control: The Care Experiences of 'Difficult' Patients in Mental Health Services," Journal of Advanced Nursing 28, no. 6 (December 1998): 1301-11. These principles summarize an approach developed for nurses called non-contingent TLC (tender loving care), which emphasizes that if a patient is hitting, this is for a reason: he or she lacks more acceptable ways of responding. Careproviders must be sufficiently flexible to offer such patients new ways, such as giving them unsolicited attention. In clinical practice, professionals may "tend . . . to be overly harsh and punitive toward them (construing them as demanding, manipulative, hostile individuals who need strict limits)." S.M. McIntyre and R.C. Schwartz, "Therapists' Differential Countertransference Reactions toward Clients with Major Depression or Borderline Personality Disorder," Journal of Clinical Psychology 54, no. 7 (1998): 823-31, p. 825.
29. From R. Perkins and J. Repper, Working Alongside People with Long-Term Mental Health Problems (London: Chapman and Hall, 1996), cited in J. A. Breeze and J. Repper, "Struggling for Control: The Care Experiences of 'Difficult' Patients in Mental Health Services," Journal of Advanced Nursing 28, no. 6 (December 1998): 1301-11. These principles summarize an approach developed for nurses called non-contingent TLC (tender loving care), which emphasizes that if a patient is hitting, this is for a reason: he or she lacks more acceptable ways of responding. Careproviders must be sufficiently flexible to offer such patients new ways, such as giving them unsolicited attention. In clinical practice, professionals may "tend . . . to be overly harsh and punitive toward them (construing them as demanding, manipulative, hostile individuals who need strict limits)." S.M. McIntyre and R.C. Schwartz, "Therapists' Differential Countertransference Reactions toward Clients with Major Depression or Borderline Personality Disorder," Journal of Clinical Psychology 54, no. 7 (1998): 823-31, p. 825.
30. R.E. Cytowic, The Man Who Tasted Shapes (G.P. Putnam's Sons, 1993), pp. 155, 161-2. For some persons, the thought of a number automatically evokes a color awareness. M.J. Dixon, et al., "Five Plus Two Equals Yellow," Nature 406 (27 July 2000): 365. "Modern emotion theory suggests that James was largely . . . wrong to think of emotions as fundamentally noncognitive." L.C. Charland, "Is Mr. Spock Mentally Competent?" Philosophy, Psychiatry, and Psychology 5, no. 1 (1998): 67-81, p. 71.
31. R.E. Cytowic, The Man Who Tasted Shapes (G.P. Putnam's Sons, 1993), pp. 155, 161-2. For some persons, the thought of a number automatically evokes a color awareness. M.J. Dixon, et al., "Five Plus Two Equals Yellow," Nature 406 (27 July 2000): 365. "Modern emotion theory suggests that James was largely . . . wrong to think of emotions as fundamentally noncognitive." L.C. Charland, "Is Mr. Spock Mentally Competent?" Philosophy, Psychiatry, and Psychology 5, no. 1 (1998): 67-81, p. 71.
32. R.E. Cytowic, The Man Who Tasted Shapes (G.P. Putnam's Sons, 1993), pp. 155, 161-2. For some persons, the thought of a number automatically evokes a color awareness. M.J. Dixon, et al., "Five Plus Two Equals Yellow," Nature 406 (27 July 2000): 365. "Modern emotion theory suggests that James was largely . . . wrong to think of emotions as fundamentally noncognitive." L.C. Charland, "Is Mr. Spock Mentally Competent?" Philosophy, Psychiatry, and Psychology 5, no. 1 (1998): 67-81, p. 71.
33. G. Kenyon, "Some Psychiatrists Show Bias Against Patients' First Names," from Reuters Medical News, reporting on a presentation by L. Birmingham at the annual meeting of the Royal College of Psychiatrists, Edinburgh, 14 July 2000.
34. A.J. Hart, "Differential Response in the Human Amygdala to Racial Outgroup vs Ingroup Face," Neuro-Report 11, no. 11 (3 August 2000): 2351-5.
35. There are endless examples. Another careprovider said, "He was attractive. I felt instant sympathy for whatever he was about to say. . . . Neutral is what I should have felt. Anger is what I could have felt. . . . If he had looked different, crazier or simply less 'boy next door,' would I have been so ready to help him? Or would I have been neutral and gone by the book."
36. V.S. Ramachandran and S. Blakeslee, Phantoms in the Brain (New York: Quill, 1998), 123.
37. J. Lear, "Introduction to Psychoanalysis," in H. Loewald, The Essential Loewald: Collected Papers and Monographs (Hagerstown, Md.: University Publishing Group, 2000). This also was urged by Winnecott, who emphasized that the infant was not an infant without its mother, and therefore helped to launch a major shift in psychoanalytic focus from the unitary self to the invisible relationship between the mother and infant, which has become the well-spring of self-psychology. J.S. Grotstein, in M.I. Little, Psychotic Anxieties and Containment (Northvale, New Jersey: Jason Aronson, 1990), 162.
38. J. Lear, "Introduction to Psychoanalysis," in H. Loewald, The Essential Loewald: Collected Papers and Monographs (Hagerstown, Md.: University Publishing Group, 2000). This also was urged by Winnecott, who emphasized that the infant was not an infant without its mother, and therefore helped to launch a major shift in psychoanalytic focus from the unitary self to the invisible relationship between the mother and infant, which has become the well-spring of self-psychology. J.S. Grotstein, in M.I. Little, Psychotic Anxieties and Containment (Northvale, New Jersey: Jason Aronson, 1990), 162.
39. For a contrasting outcome, see R.C. Christensen and S. Van McCrary, "Treatment Refusal by an Elderly Man Suffering Intensely from Treatment-Resistant Depression," Psychiatric Services 46, no. 2 (February 1995): 181-3. The authors state, "In our view such suffering. . . could serve. . . as appropriate justification for abating life-sustaining procedures" (p. 183).
40. Yet, such unusual actions may bring about legal jeopardy. "Under the threat of negligence suits, doctors are under enormous pressure always to choose the absolutely 'safe' course of action." S.C. Charles and E. Kennedy, Defendant (New York: Free Press, 1985), 214. For ethical criteria for doing less than all, see J. Savulescu, "Should Doctors Intentionally Do Less than the Best? Journal of Medical Ethics 25, no. 2 (April 1999): 121-6.
41. Yet, such unusual actions may bring about legal jeopardy. "Under the threat of negligence suits, doctors are under enormous pressure always to choose the absolutely 'safe' course of action." S.C. Charles and E. Kennedy, Defendant (New York: Free Press, 1985), 214. For ethical criteria for doing less than all, see J. Savulescu, "Should Doctors Intentionally Do Less than the Best? Journal of Medical Ethics 25, no. 2 (April 1999): 121-6.
42. E.G. Howe, "Some Prices of Epiphany and the Occasional Need to Stigmatize Patients to Offset Them," The Journal of Clinical Ethics 5, no. 4 (Winter 1994): 275-82, p. 278.
43. E.G. Howe, "Possible Mistakes," The Journal of Clinical Ethics 8, no. 4 (Winter 1997): 323-8, p. 328.
44. "While policy-making must deliberate about., similars, clinical consultation must focus strictly on differences." R.M. Zaner, "Afterword," Human Studies 22, no. 1 (January 1999): 99-117, p. 105.
45. M.S. Cohen, "Preventing Sexual Transmission of HIV - New Ideas from Sub-Saharan Africa," New England Journal of Medicine 42, no. 13 (30 March 2000): 970-2. But see M. Angell, "Investigators' Responsibilities For Human Subjects in Developing Countries," New England Journal of Medicine 342, no. 13 (30 March 2000): 967.
46. M.S. Cohen, "Preventing Sexual Transmission of HIV - New Ideas from Sub-Saharan Africa," New England Journal of Medicine 42, no. 13 (30 March 2000): 970-2. But see M. Angell, "Investigators' Responsibilities For Human Subjects in Developing Countries," New England Journal of Medicine 342, no. 13 (30 March 2000): 967.
47. This is Paul Farmer, MD, quoted in T. Kidder, "The Good Doctor," New Yorker, 10 July 2000, p. 43.
48. Andarbek Bakayev, MD, a 34-year-old surgeon, continues to treat patients in Chechnya even as there is almost 100 percent unemployment. He treats "anybody," and "does not feel obliged to report the rare occasions when a wounded Chechen fighter asks for treatment." S. LaFraniere, "Doctor Holds On in Chechnya, Treating All Despite Sparse Supplies," International Herald Tribune 22-23 July, 2000. p. 2.
49. A.D. Dreger, "Jarring Bodies: Thoughts on the Display of Unusual Anatomies," Perspectives in Biology and Medicine 43, no. 2 (Winter 2000): 161-72, pp. 161-2.
50. Homer, The Iliad, trans. W.H.D. Rouse (New York: Penguin, 1950), 291-2.