When morals and medicine conflict: Morning-after pill reignites issues
Balance must be found between ethics and continuity of care
The issue of whether a health care provider can refuse to provide treatments they find ethically objectionable is one that has been around for years, although recently it was again brought to the fore with the approval of the over-the-counter sale of the "morning-after" pill. But, as a recent article in the New England Journal of Medicine1 pointed out, there are numerous situations that may involve ethical rights and obligations, such as administering terminal sedation to dying patients or providing abortions for failed contraception.
For the quality manager, this raises several issues. For one thing, the issue of respecting the ethical and moral beliefs of the clinician can impact staff satisfaction. In addition, while most facilities do recognize the right of clinicians to opt out of certain procedures, they may not all have formalized the policy or created a process through which these objections can be communicated. The other quality concern, of course, is ensuring continuity of care once the provider balks at a given procedure.
How often do such issues arise? "Anecdotally, it's not uncommon," says Farr A. Curlin, MD, assistant professor, section of general internal medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago. "But it tends to group in practice specialties, such as sexual and reproductive health care, and end-of-life situations."
Each state has its own policy covering these situations, as do many hospitals, notes Curlin. "For example, under the state of Illinois 'Conscience Clause,' doctors are broadly shielded from any adverse repercussions of refusing to do what they say they can't in good conscience do. To do otherwise would be employment discrimination, which could result in a fine."
"Beaumont has a commitment to its staff," says Carol Spinweber, MS, RN, ACNP, nursing manager of the neurology/trauma ICU at Beaumont Hospital, Royal Oak (MI). "We want them to be involved in decision making, and we do not want to say 'You have to take care of this patient' — that would not do anyone any good."
Staff members at Beaumont are told the hospital policy is that if they feel uncomfortable for any reason, they should come see their manager and allowances will be made.
Issues not always clear
While there may be general agreement about an approach, some issues are not "black and white," Curlin points out. "Patients should have access to needed medical care, but exactly what that is may not always be specified," he says. "It is not easily resolved beyond disclosure and candor and honesty, and not being coercive."
Resolution may also depend on the procedure, he adds. "Take abortion," he says. "Some people will not be able to refer patients for the procedure because to them it is unethical in such a grave way that they can't even refer them. This begs the question, 'What is needed medical care?'"
True emergencies, Curlin notes, are not a problem. "For example, Catholic Healthcare, which is strictly against abortions, does permit you to treat women patients in whatever way necessary to care for their lives," he points out. "One place where there might be a rub is when 'emergency' contraception is requested, which does not have much effect past 72 hours. A lot of people disagree about whether that is truly an emergency."
Seeking high quality
In issues like these, notes Spinweber, "when you're talking about quality, you're talking about continuity of care." When you say to staff that no matter the issue, if they are not comfortable you will provide for other care, "you must ask yourself, 'How, as a manager, do I provide continuity of care?'"
At Beaumont, once an objection is made, the provider in question is removed from the case. "Then, we identify people who are very comfortable with the treatment," Spinweber says. "So, for example, when we give our daily report, we may say, 'This is the patient and here are the issues that surround them; we'd like to match the family with someone who is able to help them through these issues.'"
There is no problem finding someone on short notice at Beaumont, says Spinweber. "We have a huge team that deals day in and day out with crises, and we have learned to take care of patients, families, and others," she says. "But it is definitely an environment that has to be created. We do that by telling the staff it's OK to say no.
"In other work we've done that is as-yet unpublished, we found there are subpopulations of OB-GYNs who will not prescribe contraceptives," notes Curlin. "They make that explicit up front, and mechanisms are put in place where a clinic can be called, or the triage person is advised the doctor will not prescribe the drug, but if the patient elects to see someone else they can."
The Joint Commission says . . .
There are actually two Joint Commission standards that speak to these issues, notes Paul Schyve, MD, senior vice president of the agency. "The first is a standard we have in our 'Rights' chapter, which states the hospital follows ethical care," he says. One of the elements of performance, he continues, is that leaders ensure that care, treatment, and services are not negatively affected when the hospital grants a caregiver's request to be excused.
"My recollection is that many years ago we put the reference in," he says. "It came up because of ethical or religious reasons, but it is no longer restricted to that. Suppose a caregiver has a particular illness themselves that would make them susceptible to severe complications from infections if they cared for a particular patient? While that may be uncommon, we felt that if the key issue was how to make sure the patient is not harmed, why should we necessarily only talk about conditions where there are ethical questions?"
So, for example, if for religious reasons a provider does not prescribe certain kinds of contraceptive procedures and a patient is delivered at that place, "if the hospital decides to honor that wish they need to find someone else to do it, so the patient is not in the OR with [only] a nurse taking care of them," says Schyve.
The second standard requires there to be a mechanism that can be used by patients and staff to address ethical concerns and uncertainty. "Most hospitals have chosen to do that with an ethics committee, but some have used an ethics consultation service or a consultant," notes Schyve. "In any event, there needs to be some mechanism where the provider can go and say, 'I am opposed to or uncertain about doing certain procedures, and my conscience will not let me do them.'"
Plan ahead
In an ideal world, says Schyve, these situations "really shouldn't occur in the heat of battle." So, for example, "One of the things the individual provider and the hospital should have an understanding about when they are employed is what the hospital does and doesn't do, and what the individual feels they will and will not do." So, in that ideal world, such a person would never even be asked to do those things. "We can then schedule procedures so they are not in on those particular ones," he adds.
Ideally, patients also should be informed ahead of time what the hospital will and will not do. In terms of patient safety, he continues, this is good policy even when ethics or religion is not involved. "So, for example, suppose you are going to have a cardiac exam of the type that it commonly might lead to the patient immediately going to surgery," Schyve poses. "What if you've chosen to have it in a hospital [that didn't do cardiac surgery] and you didn't know ahead of time that if you needed surgery they might have to transfer you? Your not knowing that has placed you at potential risk."
Get involved
Schyve recommends that quality managers become involved in hospital activities that address such conflicts. "I would think a number of people should be involved, even as a team, to figure out how the organization will address this issue. Certainly, someone from the ethics committee or an ethics consultant, and it makes a lot of sense to have the quality and/or safety person involved," he says, "Because ultimately you are concerned not just about ethical considerations, but more importantly, quality and safety in caring for the patient."
More specifically, the quality manager ought to be involved, he adds, "because these are situations which, if not addressed ahead of time, will create a risk for the patient. Those are the No. 1 things you should be concerned about and proactively trying to prevent."
What specific processes can the quality manager put in place to protect the patient if one of these situations does pop up; how would they still protect the patient? "The first element to consider would be, how does the organization staff itself and respond to any kind of emergency?" says Schyve. "Suppose one of the staff members gets really ill in the OR and needs to leave? What process do you have in place, and how does it apply to that situation?"
The second thing to consider, he says, is under what circumstances — if any — would a reluctant staff member be willing to do "X" in an emergency? "For example, it may be something not within their privileges," he explains. "It is something they might normally not be expected to do, but that they would do in a specific situation."
Reference
Curlin FA, Lawrence RE, Chin MH, and Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007; 356:593-600.
For more information contact:
Farr A. Curlin, MD, Assistant Professor, Section of General Internal Medicine and the MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL. Phone: (773) 834-9178.
Paul Schyve, MD, Senior Vice President, The Joint Commission. Phone: (630) 792-5950.
Carol Spinweber, MS, RN, ACNP, Nursing Manager, Neuro/trauma ICU, Beaumont Royal Oak Hospital, Royal Oak, MI. Phone: (248) 898-5897.
The issue of whether a health care provider can refuse to provide treatments they find ethically objectionable is one that has been around for years, although recently it was again brought to the fore with the approval of the over-the-counter sale of the "morning-after" pill.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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