Maurice Bernstein, MD
What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.
Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue.
Three members of a hospital ethics committee met with 4 family members and two physicians of the patient to come to a decision about the patient’s further management. The patient, a 67- year-old diabetic male who had been a heavy smoker for most of his life, three weeks earlier had suffered a massive stroke which left him unconscious and unresponsive but able to breathe. Supplemental oxygen by nasal catheter had to be replaced by continuous ventilator breathing support within the Intensive Care Unit when after a week bilateral pneumonia developed and adequate spontaneous breathing ceased. His course was further complicated by signs of progressive renal failure and gastro-intestinal bleeding of unknown cause, which was significant enough to require repeated blood transfusions to maintain a minimally satisfactory blood count. The patient’s mental state remained unchanged.
The attending physician and neurologist presented to the family and the ethics committee a conclusion to terminate energetic treatment because the patient’s condition was progressively worsening despite intensive medical management, the patient would be unable to tolerate exploratory surgery for the bleeding and the neurologic prognosis was that significant recovery was unlikely. The ethics committee reminded the meeting that the repeated blood use was utilizing a particularly scarce resource. The son and two daughters agreed with the physicians’ conclusion but the wife who was the legal surrogate stated that she was told by the nursing staff, confirmed by the physician, that the patient had begun triggering the ventilator and that she felt that this was a good sign and that her husband would have wanted treatments to continue.
One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision. If, as an example, the issue is end-of-life decision-making and family members are in conflict as to whether enough time on treatment has elapsed to be assured that the patient will not recover, a compromise can be often reached.
In the case presented, at the suggestion of the ethics committee members, the family and physicians agreed to seven more days of current management and then meeting again to re-evaluate the situation and if there was no improvement to then agreed to provide solely comfort care rather than the current attempts to cure. While the ethics committee agreed with the physicians’ initial conclusions along with that of the children, the committee recognized that the wife, as the surrogate, had some basis for her initial rejection and that compromise with the wife was appropriate.
Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons. And the “bad” things they may want to do is often just “relatively bad.”