By Trevor M. Bibler.
Clinical ethicists across the nation, and throughout the world, have recently devoted their waking hours to developing triage and allocation policies in response to the COVID 19 pandemic. As these policies develop, we find general agreement that shared processes should take the place of ad hoc, bedside allocation decisions, and that the patient’s short-term prognosis should play an important role in allocation decisions. However, controversy continues to surround the specifics of what such a policy ought to include and what clinical considerations should play a role in allocation decisions. These questions deserve scholars’ sustained attention. The role of the clinical ethicist in discussing allocation decisions with families has not received such attention. I argue that the ethicist should participate in such conversations in many, but not all, circumstances. I will confine my argument to conversations where a group (or allocation officer) determines life-sustaining technology (LST) will be withhold or withdrawn for the sake of reallocating that resource.
SERVING AS A RESOURCE
What clinical ethics is, and what it ought to be, is a matter of debate. Without receding into a lengthy discussion about the nature of the field, I will take Celie and Prager’s description as a representative account. They write that ethicists—as members of healthcare ethics committees—“serve as a consultation resource to help clinicians, patients, patients’ loved ones, and other stakeholders identify, analyze, and resolve ethically complex issues in clinical practice.” First, notice the phrase, “serve as a consultation resource.” There are many justifiable reasons why a healthcare professional is looking to the clinical ethicist as a resource. For example, the healthcare professional may be looking to the ethicist to improve their understanding of the institution’s crisis policies. Even with dedicated education and separation between the responsible physician and the triage decision, a healthcare professional might still have questions or concerns about the policies or the decision. The ethicist’s understanding of the nuances of the policy and the ethical underpinnings of that policy make them well-suited to serve as a resource for the requestor.
Keeping with this description, notice the ethicist serves as a resource to “clinicians, patients, patients’ loved ones, and other stakeholders.” This casts a wide net that includes anyone with a justified interest in the care of a patient. In order to serve as a resource for this patients and families, it would be essential that the ethicist speak with the patient or the family member and gather their own information. Responding to the request directly would ensure an independent assessment of the patient or family member’s position and interests. “Other stakeholders” in this context might also include those with administrative roles, including triage officers. The ethicist should not commit to taking actions that go beyond their goals and scope. However, serving as a resource to these groups entails that the ethicist should begin investigating the questions prompted by the requestor—whomever they may be.
IDENTIFICATION AND ANALYSIS
The ethicist should only take the additional step of participating in these discussions when their skills and professional role commit them to it. If the ethicist can successfully “identify, analyze, and resolve ethically complex issues in clinical practice,” then they should. First, many ethical issues might arise during allocation discussions. A patient or family member might not understand or appreciate the ethical and equity-based reasoning for an allocation decision. Or, they might reject it—insisting that the reason the institution is withholding or withdrawing a LST is based on the patient’s race, social, economic, or ability status. In the likely event that the ethicist finds disagreement, their ability to uncover values, identify interests, and name assumptions can promote an ethically justifiable resolution. Importantly, these issues may arise during the conversation about allocation; therefore, missing such conversations would make the ethicist dependent upon others for information. Gathering first-hand information as the allocation conversation happens is the only way to ameliorate this concern.
Once the ethicist gathers information, they analyze it. Depending on the issues identified, analysis can take many forms. It is likely that the requestor, be they a patient, family member, or healthcare professional, will be seeking information about the institution’s allocation policy. Therefore, knowledge of the allocation policy and how it applies in the specific case would be beneficial. A good policy should include explicit mechanisms for any allocation decision and procedures for an appeal. It would be beyond the ethicist’s scope (and likely lead to bad analysis) to make allocation and appeal decisions at the bedside. However, novel policies may have shortcomings or ambiguities that the ethicist’s analysis can clarify.
The ethicist’s conceptual knowledge and analytic ability might be especially beneficial here. Healthcare professionals may feel as though they are killing patients when making allocation or triage decisions. In this case, the ethicist may point out that neither withholding nor withdrawing an LST is killing because both allow death to occur via an underlying disease process. A visceral feeling of guilt that might follow such actions likely stems from the possibility that the patient’s condition could have otherwise been reversible absent the resource shortage. This is understandable. Allocation decisions happen often outside of crisis—for example, with organ allocation and transplantation. With organ scarcity, some patients will die due their (possibly) reversible underlying disease. A lung transplant medical review board does not kill every rejected patient; a triage officer does not kill every patient that does not receive LST. Ethical analysis and analogical reasoning may help the requestor better understand the nature of withholding and withdrawing an LST when they experience guilt or acute psychological distress over allocation or triage decisions. No other service in the hospital will be able to alleviate distress in this way, and it is unlikely that the ethicist would be able to provide this kind of analysis if they did not participate in discussions about triage and allocation at the bedside.
Resolution of ethical issues is the final skill named by Celie and Prager. Healthcare professionals routinely consult ethicists because they are looking for assistance when speaking about complex ethics issues. They may struggle to explain allocation decisions to colleagues, families, patients, and themselves. The requestor may not feel confident in their ability to adequately respond to questions about fairness, equity, and justice. Even when healthcare professionals agree with an allocation decision, and even if families recognize the need for a redistribution of resources, the conversation could still be vexing. The ethicist’s skills in communication might assist in these conversations, not because the ethicist is responsible for providing emotional support (although this is not inconsistent with the ethicist’s goals), but because the ethicist’s analysis can clarify the issues at stake. In short, adequate resolution of ethics issues often includes assisting with communication. To meet this goal, it is important that the ethicist put their skills in resolving disputes and improving communication to work.
I have mentioned a number of scenarios in which the ethicist should respond to a request for involvement with, something along the lines of “Yes. I can help.” However, this argument does not commit me to the conclusion that the ethicist should respond to every request in this manner. I recognize that there are many instances when the ethicist should not discuss triage and allocation decisions with patients and families. First, the ethicist should not be making triage or allocation decisions. The ethicist should reject any request by a healthcare professional, patient, or family member to do so. Also, the ethicist should reject a requestor’s invitation if the request entails reassessing a triage officer’s decision. In both scenarios, the ethicist should be clear about their role and let the requestor know that they will not make, or reassess, a triage decision. Deciding and reassessing are outside of the ethicist’s role.
Furthermore, the ethicist should also reject a request to take on the responsibility of informing the family of an allocation decision. The ethicist would no longer be “serving as a resource” if they take on the role of the triage officer. I find a significant difference between assisting with conversation about a decision—which the ethicist might do—and informing a patient or family of the decision. Assisting is within the scope and skillset of the ethicist, whereas informing erases the responsibility from the proper authority. In other words, when assisting, the ethicist acts as a resource to improve patient care by identifying, analyzing, and resolving an ethics question; when informing, the ethicist assumes the role of an attending physician or triage officer. The ethicist should not abandon the requestor as they struggle though these processes and policies, but neither should the ethicist overstep their role.
If we assume that the ethicist’s role, goals, and responsibilities include assisting patients, families, and healthcare professionals in responding to ethics-related issues, then the ethicist should participate in conversations about allocation decisions. Implementing triage or allocation policies at the bedside may, on occasion, require in-depth knowledge of ethical concepts and their implementation. The ethicist is well suited to participate in allocation conversations in many, but not all, circumstances. Patients, families, and healthcare professionals who desire the ethicist’s help in these situations should receive it when these requests align with the ethicist’s role. There may be no time in the ethicist’s career when their assistance is more desired and their skills more valued.
(For an opposing view, see: We should sit this one out: Why ethicists should not help discuss treatment allocation decisions)
Author: Trevor M. Bibler
Affiliations: Baylor College of Medicine
Competing interests: None