Research
Research on Clinical Ethics
Summary: This project identifies ethical issues faced by various health care providers in clinical practice and how they respond to them. Particular focus is on the extent to which providers use and value ethics consultation.
| Section: | Ethics and Health Policy | ||||||||||||||
| Principal Investigators: | Marion Danis, M.D. Christine Grady, Ph.D. |
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Background: Health care providers confront many ethical issues and dilemmas in their day to day practice. Some of these issues are inherent in the provision of health care to patients, and others are more infrequent, unique, or stressful. Over time, health care providers develop ways of responding to and coping with the issues they face. This may include working with colleagues to prevent or resolve certain issues and using ethics resources, including formal ethics consultation services, when available. Better understanding of what are the ethical issues that health care providers face in their practices and how they respond to them can lead to more focused efforts to minimize the stress associated with ethical issues and provide the needed resources to handle ethical dilemmas most appropriately.
Along with research aimed at understanding ethical dilemmas from the perspective of clinicians, our research has focused on evaluation of ethics consultation from the health care practitioner’s perspective. This research fills a gap in the literature regarding ethics consultation. Over the last two decades the practice of ethics consultation has matured. The goals of ethics consultation have been articulated, the core competencies required to carry out consultation have been identified, methods for setting up consultation services have been published. But little has been written about the range of consultation practices and about the value of consultation to practicing clinicians.
Departmental Research Initiative: We have conducted several national surveys to identify the ethical issues faced by clinicians, the extent of stress and conflict they incur, and the perspectives of clinicians about ethics consultation and other ethics support services. The first study was a national survey of internists in the United States, Respondents most commonly reported dilemmas regarding end-of-life decision-making, patient autonomy, justice, and conflict resolution. Comparing subspecialists, Critical Care specialists were significantly more likely to participate in consultations than General internists, or Oncologists (4.1, 1.4, and 1.3 consultations in the preceding 2 years, respectively (P<.0001). Physicians with the least ethics training had the least access to and participated in the fewest ethics consultations; Dilemmas about end-of-life decisions and patient autonomy were often referred for consultation while dilemmas about justice, such as lack of insurance or limited resources, were rarely referred. While most physicians thought consultations yielded information that would be useful in dealing with future ethical dilemmas (72 percent), some hesitated to seek ethics consultation because they believed it was too time consuming (29 percent), might make the situation worse (15 percent), or that consultants were unqualified (11 percent).
Subsequently, we conducted a parallel survey among generalist physicians in Europe. In that study we were able to ascertain the ethical issues that concern European physicians and found that while somewhat differing profiles of ethical concerns arise in these countries, the type of help they seek is fairly similar in all countries.
We also conducted a national survey in the United States of nurse practitioners and physician assistants practicing in primary care. These provider groups are growing in size and importance particularly in primary care. They face unique ethical issues because of variation in state practice acts and organizational hierarchies. These practitioners described major challenges balancing their obligations to patients with the economic pressures of practice. Over than two-thirds reported that insurance constraints have interfered with their ability to provide quality care for their patients and more than half reported daily-weekly interferences. Nearly half of respondents have been asked by a patient to mislead insurers to assist them in receiving appropriate care yet a quarter responded that they were unsure if they would be willing to comply with a patient’s request to mislead.
Subsequently, we conducted a survey of practicing nurses and social workers from four states in different census regions of the United States to learn about the ethical issues that nurses and social workers face, the extent to which these issues cause stress and affect job satisfaction and retention. Importantly, we have found that many nurses and to a lesser extent social workers have never had any ethics training at all and that those clinicians who are less well educated and experienced in ethical issues, are less likely to seek ethics consultation — a finding that should be of concern and ought to be addressed. We have also discovered that while many are concerned about retaliation when requesting an ethics consultation, this does not deter their requests.
Impact of Research: We have presented our work at the first and second international conferences on ethics consultation. Results of the European survey have been presented to the newly formed European Clinical Ethics Network. This is a new organization created in 2005 to exchange experiences between ethics consultants from different European countries. Our survey is one of the only transnational studies of ethics consultation available.
A physician from Croatia, Iva Sorta-Bilajac, is planning to use our survey with physicians in her country to help develop ethics consultation services there.
Dr. Hurst has presented our European survey results at the first national meeting of clinical ethics committee members organized by the Swiss Academy of Medical Sciences in April of 2004. One concrete result was that it encouraged a colleague from the German-speaking part of Switzerland to develop an ethics consultation service for a network of outpatient physicians.
As a result of surveys conducted by Connie Ulrich, she has been invited by the Joint Commission of Accreditation of Healthcare Organizations to serve on a task force to develop a survey to assess ethics services at healthcare facilities.
Future Research Initiatives:
• Assessing the Quality of Ethics Consultation
Health services are generally carefully monitored and assessed for quality of the service delivered. There has not been any effort to date to assess the quality of ethics consultation services. We therefore plan to develop a survey tool to assess the quality of ethics consultation. We have piloted the survey tool, have used it to determine benchmarks for good ethics consultation practices, and plan to conduct a national survey.
• Creation of a Multi-Center Database
Since 1999 the Department of Bioethics has used a database program to capture the information for all consultations conducted by the Clinical Center Ethics Consultation Service. We will use this database to systematically examine ethical issues and their approaches used by clinical ethicists to resolve them.
We hope to make this database program available to others so that we might jointly begin to collect a multi-centered data on ethics consultation.
Publications:
DuVal G, Clarridge B, Gensler G, Danis M. A national survey of U.S. internists’ experiences with ethical dilemmas and ethics consultation. J Gen Intern Med. 2004;19:251-258.
Hurst SA, Hull SC, DuVal G, Danis M. How physicians face ethical difficulties: a qualitative analysis. Journal of Medical Ethics. 2005;Jan;31(1):7-14.
DuVal G, Gensler G, Danis M. Ethical dilemmas encountered by clinical researchers. Journal of Clinical Ethics. 2005;16:267-276.
Ulrich C, Danis M, Ratcliffe SJ, Garrett-Mayer E, Koaiol D, Soeken KL, Grady C. Ethical conflicts in nurse practitioners and physician assistants in managed care. Nursing Research. 2006;55:391-401.
Hurst SA, Perrier A, Pegoraro R, Reiter-Theil S, Forde R, Slowther AM, Garrett-Mayer E, Danis M. European Physicians’ Experience with Ethical Difficulties in Clinical Practice. J Med Ethics. 2006 (In Press).
Hurst S, Slowther A, Reiter-Theil S, Danis M. Should Ethics Consultants Help Clinicians Face Scarcity in their Practice? (Soll Ethikkonsultation Aerzte bei Mittelverteilung Helfen?) in Ethikkonsultation heute — ein Kompendium. Europäische und Internationale Perspektive. Reiter-Theil S, Ohnsorge K, Leuthold M, Eds. Lit-Verlag, Münster. (In Press).
Danis M, Adrienne Farrar A, Grady C, Taylor C, O’Donnell P, Karen Soeken K, Ulrich C. Does Fear of Retaliation Deter Requests for Ethics Consultation? Medicine, Health Care and Philosophy. (In Press).
