Performance, Talk, Reflection: What is Going On in Clinical Ethics Consultation

116 Pages·1999·2.31 MB·English

by  Richard M. Zaner (auth.)

PERFO~NCE,TALK,REFLECTION
What is Going On in
Clinical Ethics Consultation
Edited by
RICHARD M. ZANER
Vanderbilt University Medical Center, Center for Clinical and Research Ethics,
Nashville, Tennesee, U.S.A.
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
A C.I.P. Catalogue record for this book is available from the Library of Congress
ISBN 978-90-481-5222-3 ISBN 978-94-017-2556-9 (eBook)
DOI 10.1007/978-94-017-2556-9
Printed on acid-free paper
All Rights Reserved
©1999 Springer Science+Business Media Dordrecht
Originally published by Kluwer Academic Publishers in 1999
No part of the material protected by this copyright notice may be reproduced or
utilized in any form or by any means, electronic or mechanical,
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Table of Contents
Richard M. Zaner, Introductory Remarks I
Pertinent Roles and Experiences of All Authors 5
Mark J. Bliton, Ethics Talk; Talking Ethics: An Example of Clinical
Ethics Consultation 7
Fran~oise Baylis, Health Care Ethics Consultation: 'Training in Virtue' 25
Tom Tomlinson, Ethics Consultant: Problem Solver or Spiritual Counselor? 43
Barry Hoffmaster, Anatomy of a Clinical Ethics Consultation 53
Mark J. Bliton & Stuart G. Finder, Strange, But Not Stranger: The Pecu-
liar Visage of Philosophy in Clinical Ethics Consultation 69
Richard M. Zaner, Afterword 99
.... Human Studies 22: 1-3, 1999.
IJIlif © 1999 Kluwer Academic Publishers.
Introductory Remarks
RICHARD M. ZANER
Vanderbilt University Medical Center, Center for Clinical and Research Ethics, 319
Oxford House, Nashville, TN 37232-4350, U.S.A.
In what follows, three sorts of reflective writing are presented. The first kind,
by my colleague Mark J. Bliton, is a description of a clinical ethics con
sultation, more generously detailed than most that have been published, yet
obviously limited as a documentation of the experiences at its source. It is
followed by three examples of a second kind in the probing commentaries by
highly regarded figures in biomedical and clinical ethics - Fran~oise Baylis,
Tom Tomlinson, and Barry Hoffmaster. Finally, these are followed by a third
variety of reflection in the form of responses to those three commentaries, by
Bliton and Stuart G. Finder, and my Afterword - a further reflection on some
of the issues and questions. While the consultation was conducted by Bliton,
Finder not only assisted at one point (he is the "colleague" mentioned in
Bliton's manuscript) but frequently participated in the discussions that are
invariably part of our clinical ethics consultative practice at Vanderbilt. It was
thus natural for Finder to participate in the response.
Each of these essays is fascinating and important on its own; together,
however, they constitute a truly unusual and, we believe, very significant
contribution that will hopefully figure prominently in subsequent discussions,
and in shaping and deepening an endeavor - clinical ethics - still in
much-needed search of its own discipline, method, rationale and place in the
domain of clinical practice more generally. This group of essays is also quite
unique, addressing as it does the coherence of a form of practice - and, it must
be emphasized, several forms of writing about as well as theoretical proposals
for understanding that practice - whose current and future character remains
very much in contention.
Because this kind of endeavor - writing about and publishing such
reflections by different individuals on a single clinical situation - has not been
attempted, or appreciated as more than of merely passing interest as regards
clinical ethics consultation and practice, it seems appropriate to suggest, at
least in a preliminary way, some of its peculiarities.
While an introduction was of course part of the initial idea for this proj ect,
as the essays evolved and eventually began to take final shape, it became ever
more obvious that certain difficulties, even hazards, had to be addressed in
2 RICHARD M. ZANER
order for the project to make sense to readers who may be as unaccustomed
as were the authors to engaging such matters in a kind of sustained con
versation. To help bring out a number of these intriguing matters, it was decided
as well that I should write a reflective conclusion to the project.
An initial version of Bliton's portrayal of his involvement in the clinical
ethics consultation documented here served as an example of a clinical
encounter in Bliton's doctoral dissertation (Bliton, 1994). For the present
project, that version had to be somewhat shortened and rewritten so that it
could stand on its own, independent of the specific context and emphasis in
his dissertation. The version found in this Special Issue is the result, a version
that is both unified and fragmentary: unified insofar as it has a clear beginning,
middle, and end (pace Aristotle), and as such can be read as telling a certain
story about Bliton and his involvements in a particular clinical situation;
fragmentary insofar as the story told is limited to Bliton's documentary
perspective. Moreover, his telling illustrates a selective emphasis on facets of
the encounter which exemplify moments of moral experience in clinical ethics
consultation.
The current version here is thus quite different from the initial case report
he, like any of the ethics consultants on our service, completed at the time of
the consult simply as a part of our practice-protocol. But, in view of even these
differences, Bliton and Finder perforce had to exercise considerable discipline
in constructing their response to the three commentators, none of whom had
access to the original version or the abbreviated and somewhat perfunctory
formal Case Report, much less their frequent, ongoing conversations that are
also part of our clinical practice.
Since I was not involved in the consultation, nor as deeply as Finder in the
conversations, I agreed to read Bliton's manuscript and his and Finder's
response, paying particular attention to the dangers implicit to appeals to
information about the encounter not also made available to the commentators.
At the same time, I should note that I directed Bliton's doctoral studies and
headed his dissertation committee. Thus, I have both known a good deal about
the original situation, and had numerous occasions to discuss it with Bliton
(and, to some extent, Finder). Finally, although the three of us discussed the
present project many times and eventually together agreed to do it, the decision
about which clinical situation to use was left to my two colleagues.
The commentators were, it should also be emphasized, provided with an
unusually detailed description of a consultative situation, along with Bliton' s
ongoing reflections of what he was thinking about at the time and afterwards,
as he reconstructed events and conversations while writing up the case for
his dissertation and, later, rewriting it for this project. Additionally, each of
the three commentators' contributions were treated to several careful readings
by the three of us, separately and together, with an eye on helping the authors
INTRODUCTORY REMARKS 3
express their views with as much clarity as possible.
We are, I must say, deeply grateful to Professors Baylis, Tomlinson, and
Hoffmaster, not merely for their patience in bearing with our labors, but even
more for the uncommon candor, insight and rigorousness they each brought
to the project. That situations like the one in Bliton' s manuscript often provoke
strong and passionate responses will doubtless be no surprise - whether
because of its relative novelty, its risky nature, the high stakes involved, or
something else. It is in any event a striking feature of ethics consultations that
the people directly or even indirectly involved tend at times to feel rather
passionately about what is said (and not said), what is done (and not done),
and what is then reported (or, it may be, left out). Even so, such energetic
feelings, much less the candor of my colleagues' response to such passion,
are rarely if ever apparent from published reports. For this reason alone, a
considerable debt of gratitude is surely owed to our commentators - reflective
and deliberative, yet passionate and forceful as each of them are.
It is perhaps enough at this point merely to make note of these rather
different types of writing and something at least of the vexations invariably
provoked by situations like that reported by Bliton. Then, at the end of the
discussions, it will be necessary to engage these matters more directly.
Reference
Bliton, Mark J. (1994). The Ethics o/Clinical Ethics Consultation: On the Way to Clinical
Philosophy. Dissertation, Department of Philosophy, Vanderbilt University. Ann Arbor,
MI: University Microfilms.
.... Human Studies 22: 5--6, 1999. 5
..... © 1999 Kluwer Academic Publishers.
Pertinent Roles and Experiences of All Authors
Fran~oise Baylis, in 1990, was awarded a grant from the Social Sciences and
Humanities Research Council of Canada on "Health Care Ethics Con
sultation." The Health Care Ethics Consultant (Humana Press) was published
in 1994 upon completion oft his project. The importance of character and virtue
in ethics consultation is central to this work. A few years later, Baylis was
named to the Society for Health and Human Values and the Society for
Bioethics Consultation Task Force on Standards for Ethics Consultation. The
Final Report of the U.S. Task Force, which revisited the issues of training,
accreditation and certification, was published in the summer of 1998. In this
Report the importance of character and virtue is contested. Throughout her
career, Baylis has worked with a number of Ethics Committees in Canada and
the United States. For a few years, she was a fulltime bioethicist at the Hospital
for Sick Children in Toronto, Ontario, Canada. She now has a full-time
academic appointment in the Medical School at Dalhousie University and most
of her consulting with hospitals now focuses on policy issues rather than case
consultations.
Mark J. Bliton joined the Center for Clinical and Research in 1987 as the
Senior Fellow primarily responsible for the Center's involvement in Vanderbilt
University Hospital's Neonatal Intensive Care Unit. With Dr. Zaner, he
conceived and ran the Pilot Project in Clinical Ethics at Saint Thomas Hospital
in Nashville during 1990 and served as the Associate Director of the Clinical
Ethics Program at Saint Thomas during 1991 and 1992. He served as the Chief
oft he Clinical Ethics Consultation Service under the newly organized Clinical
Ethics Center at Saint Thomas Hospital during 1994. Having been a Clinical
Ethics Consultant at Vanderbilt University Medical Center (VUMC) since
1991, he has been Chief of the Clinical Ethics Consultation Service at VUMC
since 1994. He has also served on VUMC's Ethics Committee since 1990 and
was a consultant to Saint Thomas' Ethics Committee during 1990--1994.
Stuart G. Finder has served as a Clinical Ethics Consultant at Vanderbilt
University Medical Center (VUMC) since he arrived at the Center for Clinical
and Research Ethics in 1991. In that capacity, Finder has been primarily
responsible for clinical ethics consultations occurring in the areas of adult
critical care medicine and surgery. During 1992 and 1993, Finder also served
6 PERTINENT ROLES AND EXPERIENCES OF ALL AUTHORS
as a Clinical Ethics Consultant at Saint Thomas Hospital, splitting duties with
Dr. Bliton. He has been a member of the VUMC Ethics Committee as well as
VUMC's Liver Transplant Selection Committee since 1991, and has been a
member oft he Heart Transplant Selection Committee at Saint Thomas Hospital
since 1992.
Barry Hoffmaster, while he was Director of the Westminster Institute for
Ethics and Human Values from 1991-1996, worked as an ethics consultant
for two acute care hospitals (primarily in adult and pediatric critical care) and
for a long-term chronic care and rehabilitation hospital. He also has served as
an ethics consultant for a short-term assessment and treatment facility for
children with developmental delay.
Tom Tomlinson is Clinical Ethics Consultant and co-chair of the Biomedical
Ethics Committee of Sinai Hospital in Detroit, and also serves on the Ethics
Committee ofIngham Regional Medical Center in Lansing. He has provided
consultation on ethics policy and training for ethics committees for Henry Ford
Hospital and Horizon Health Systems, among others.
Richard M. Zaner began his career in biomedical ethics when he founded
and served as the first Director for the Division of Social Sciences and
Humanities at the Health Sciences Center ofthe State University of New York
at Stony Brook (1971-73). A year after arriving at Vanderbilt University in
1981, Zaner founded and became the Director of Vanderbilt's Center for
Clinical and Research Ethics, out of which he coordinated all clinical ethics
consultation, education and research at Vanderbilt University Medical Center
(VUMC). In 1984, Zaner formally launched Vanderbilt's Clinical Ethics
Consultation Service, which he continues to Direct, and he has served as
co-chair ofthe Vanderbilt University Medical Center Ethics Committee since
1990. After conceiving and running, with Dr. Bliton, the Pilot Project in
Clinical Ethics at Saint Thomas Hospital in 1990, Zaner served as the Director
of Saint Thomas' Clinical Ethics Program, overseeing its transition into the
Clinical Ethics Center at Saint Thomas Hospital in 1993. Since 1985, Zaner
has been a member oft he Advisory Board ofTennessee Donor Services, where
he chairs its Committee on Ethics and Legislation.
.... Human Studies 22: 7-24, 1999. 7
.... © 1999 Kluwer Academic Publishers.
Ethics Talk; Talking Ethics: An Example of Clinical Ethics
Consultationl
MARK. J. BLITON
Vanderbilt University Medical Center, Center for Clinical and Research Ethics, 319
Oxford House, Nashville, TN 37232-4350, U.S.A.
Abstract. This written account of a clinical encounter - depicting fragments of a more
extensive array of events - attempts to exemplify many facets and associated complexities
of clinical ethics consultation. Within the general telling, I provide more detailed portrayals
of several key events. In section I, I document briefly my initial interactions at the beginning
of the consultation, focusing on the information gained - in the context of those interactions
as I read the medical chart of Mrs. Rose. Next in section 2, I briefly describe my initial
conversation with Mrs. Rose's three sons. Section 3 illustrates several questions raised in
sections 1 and 2. Then section 4 presents my encounter with Paul, the youngest son, as he
was carrying out his vigil at his mother's bedside in the hospital. Section 5 chronicles my
interactions with several care providers involved in Mrs. Rose's situation, including two
different meetings that occurred with Mrs. Rose's attending physician. I conclude in section
6 by telling about a conversation I had with Mrs. Rose's middle son, Russell, approximately
one month after Mrs. Rose died.
apophainesthai
passes in & out
of more difficult things
and by so passing
apophainesthai
Charles Olson, The Maximus Poems
1. What's Going On?
The beginning of this consultation had two features that were unusual. First, I
received a call from one of the executive secretaries in the administrative suite
at the hospital-suggesting administrative anxiety, concern, and expectations
that were already focused as an urgent need for me to respond immediately. The
other significant feature was that the request for ethics consultation came from
the patient's son, Russell Rose, who was associated with and had knowledge
about health care facilities. The secretary said that Russell knew hospitals such
as this had ethics committees, and he wanted to talk with a representative about
his mother's treatment. I agreed to meet with him as soon as I could and then
asked where I could fmd his mother in the hospital.
8 MARK J. BLIrON
Mrs. Rose was on the second floor, a complex that included forty critical
care intensive care beds, and seventy-five step-down intensive care beds. Most
of my consultations occurred in that area. I walked down the long, carpeted
corridor busy with the hustle and bustle of respiratory technicians, dietitians,
unit clerks, and nurses shuttling back and forth among the various rooms.
While I was familiar to most of these people, my presence usually signaled
that a certain kind of problem was occurring. Nurses, residents, and other
physicians experience and immediately interpret the mere presence of other
providers.
I gathered Mrs. Rose's chart from the station facing out from her room,
and my first clue to what was going on came when I asked a nurse who Mrs.
Rose's nurse was. After pointing Molly out among the other nurses, she
informed me that Molly had had a relative who had treatment withdrawn, thus
"telling" me that Molly herself would surely be understanding of Mrs. Rose's
situation. I went to Molly; we sat down and I tried to find out why I was called.
She said she didn't know who had called, but she did know that the family
was concerned that their mother "would not want to be hooked up to the
ventilator. "
Her words, their tone, and her demeanor - one of careful, descriptive
speaking, but not engaged with their concern as a problem - suggested that
she was not entirely in agreement with the family. So I asked her.
"She's really sick," Molly said, "but she might get better. Besides, there's
a No-code on the chart. It's too early to just let her die, at least that's what I
think. You know what else, the residents really feel undermined by the family
going down and calling you."
It was revealing that in the time that Russell had gone down to the
administrative offices and come back for a visiting hour, the residents and the
nursing staff on the unit already knew that I had been called. "Undermined:"
already intimated was a theme that, in their concern about the level of medical
intervention, this family was thought to be circumventing the efforts and
assessments of the residents.
Molly asked, "Do you want me to find them?"
While she went to get the residents I returned to reading the chart. Mrs. Rose,
eighty-four-years-old, had a history of atherosclerotic heart disease, coronary
insufficiency, cancer of the colon, and breast cancer. The latter had been
surgically managed by a modified right radical mastectomy. She had been
hospitalized for nine days before her son's request for ethics consultation. She
had been admitted to the hospital to undergo a uterine suspension and bladder
repair. However, the evening prior to her admission, she developed a temperature
of I 02.3 and had "shaking chills." On the morning ofa dmission, her temperature
remained over 100 and the surgery was postponed. Within two days, a mild
pneumonia was diagnosed, which subsequently worsened dramatically.