Working together to address ethical challenges in healthcare

Decisions on whether to resuscitate an elderly patient, or how much chemotherapy to offer a patient with advanced cancer, present dilemmas in healthcare that should be supported, write Dr Louise Campbell and Dr Joan McCarthy

Working together to address ethical challenges in healthcare

Decisions on whether to resuscitate an elderly patient, or how much chemotherapy to offer a patient with advanced cancer, present dilemmas in healthcare that should be supported, write Dr Louise Campbell and Dr Joan McCarthy

Most patients being treated in hospitals aren’t thinking about the ethical aspects of their treatment or the way treatment decisions are made for or with them.

Most of them are focused on getting through the treatment, on managing their illness, or on recovery. But healthcare is fraught with ethical issues and healthcare professionals face ethically-challenging decisions on a daily basis.

When we talk about ethics, we talk about our judgements about what is right or wrong, good or bad, and how we defend those judgements to ourselves and other people.

In healthcare, ethical issues are most prominent in the care of patients towards the end of their lives, involving decisions such as whether or not to resuscitate a frail older person, how much chemotherapy to offer to a patient with advanced cancer, or whether or not to insert a feeding tube into the abdomen of a person with severe dementia.

These kinds of situations are often ethically challenging because they involve disagreement or uncertainty about what is best for the sick person, and this uncertainty cannot be resolved simply by referring to medical facts and statistics, precisely because people have different views about what is good or bad, beneficial or harmful, depending on their life experience and belief systems.

A patient’s own view on her quality of life may differ from a doctor’s opinion about what is in her best medical interests and this may create tension or conflict, even where there is excellent communication between the patient, the family and the healthcare team.

Situations in which a patient is too incapacitated to express her wishes are even more difficult for staff and family members who have to make a treatment decision on that patient’s behalf. While the law does provide some direction in this area, it is too general to apply to every specific instance and health professionals often require further guidance and support.

Clinical ethics is a field of practice in which health professionals from a variety of disciplinary backgrounds, including ethics, work together to address and, where possible, resolve ethical challenges or dilemmas arising in the clinical setting.

This collaboration most often takes the form of a structured process, for example, a dedicated clinical ethics committee which meets regularly to review cases referred to it by staff, patients, or families.

While clinical ethics committees may be invited to review or provide guidance on complex decisions, their job is not to police decision-making or to take over the role of clinical decision-makers.

Their role is to advise and support clinicians and, where necessary, to open lines of communication in order to ensure that all parties involved in the decision — including patients — have a voice.

Although clinical ethics has gained considerable ground in North America and and Europe, it has yet to make an impact on the Irish healthcare landscape, with only a dozen or so clinical ethics committees in existence across Ireland.

In part, this is most likely a result of a complex interplay of social and historical factors unique to Ireland, although research from other jurisdictions has shown that some health professionals and hospital executives are skeptical about the effectiveness and legitimacy of clinical ethics as an approach to resolving ethical dilemmas in healthcare.

Critics of clinical ethics see it as impinging on the authority of clinical decision-makers, interfering with patient care, and hampered by lack of specialised clinical knowledge among committee members.

These criticisms raise important questions about whether a focus on addressing ethical challenges in healthcare provision can actually improve the quality of patient care.

However, advocates of clinical ethics argue that building capacity among healthcare professionals to make ethically-competent decisions can benefit patients, reduce staff burnout and streamline care. Ultimately, a lot depends on how the clinical ethics committee is seen by the organisation within which it functions: a committee cannot be effective if it doesn’t have the support it needs from the management of the organisation.

What is clear is that regulatory bodies such as the Nursing and Midwifery Board of Ireland and the Irish Medical Council are attaching increasing importance to the development of ethical and professional competencies among registered health professionals.

The last 10 years have seen growing recognition of the importance of specialised ethics training in medical, nursing, and allied health curricula and undergraduate and postgraduate ethics programmes have become more comprehensive and better structured.

This week sees a major international conference on ethics in healthcare taking place in Ireland for the first time. The 19th International Nursing Ethics Conference, Gender, Justice and Care, organized by Dr Joan McCarthy of the School of Nursing and Midwifery, UCC and running on Saturday and Sunday, has attracted experts and scholars from all over the world.

This groundbreaking conference will offer health professionals, academics and interested members of the public the opportunity to learn about and discuss the ethical issues which are at the forefront of contemporary nursing practice.

It will also provide those of us working in the field of healthcare with an opportunity to think about the mechanisms which are available to support Irish health professionals in dealing with the ethical conflicts they confront on a day-to-day basis.

This in itself is an invaluable opportunity to reflect on where we’re going.

Dr Louise Campbell, School of Medicine, National University of Ireland, Galway, and Dr Joan McCarthy, School of Nursing and Midwifery, University College Cork

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