What has Karen Quinlan taught us?

Rosemary Flanigan

June 15, 2009

I was surprised by Lorell’s identifying June 11, 2009 as the 24th anniversary of Karen Quinlan’s death, nearly 10 years after being weaned from the respirator.

That news reminded me of being young—and still teaching—and how I used the “Matter of Quinlan. Supreme Court of New Jersey 1976” when I taught ethics. I wanted the students to see the best arguments on issues, whether pro or con—and this case was the best example of legal reasoning, supported by good philosophical distinctions, that I could find for end-of-life issues.

I hope the students all memorized this “holding”: “The State’s interest to maintain life weaken, and a patient’s right of privacy grows, as the degree of bodily invasion increases and as prognosis dims.” I think that’s brilliant—and I hope I said it often enough that it drilled a hole in their heads.

Using the ordinary/extraordinary means distinction and the distinction between direct killing and allowing to die, the Supreme Court Justices declared 7-0 “. . .upon the concurrence of the guardian and family of Karen, should the responsible attending physicians conclude that there is no reasonable possibility of Karen’s ever emerging from her present comatose condition to a cognitive, sapient state and that the life-support apparatus now being administered to Karen should be discontinued, they shall consult with the hospital ‘Ethics Committee’. . . .”

I wonder how long it took the hospital to get an “Ethics Committee” up and running!!

So many years later—so many trips to the courtroom. But I hope that responsible advance care planning has eliminated many other such trips.

Educating Our Emotions

Rosemary Flanigan
June 10, 2009

A recent column by David Brooks caught our attention. It’s entitled “The Empathy Issue” and discusses the role of emotion in judicial decisions. A friend suggested we substitute “judge” with “ethics committee person” and see how it reads.

The role of emotion’s interplay with reason has long fascinated philosophers and others. Even the substance or matter of ethics—our moral judgments—are strongly influenced by emotion. And the advice at the end is of paramount importance: it is not that we rely on emotion but how we educate our sentiments/emotions” within the bounds of manners and morals, tradition and practice.”

Right now I am having a hard time corralling my own emotions over the issue raised in the new Cambridge Quarterly, viz., adolescent decision-making. (I thought back in 1995 when Bill Bartholome shepherded the issue through Pediatrics that we sought adolescents’ assent along with their parents’ consent—a practice re-affirmed in 2006, that we had reached closure.)

Meanwhile, let’s think of educating our sentiments/emotions.

Link: The Empathy Issue, New York Times, May 29, 2009

Hospital Ethics Committees -- Then & Now

Hospital ethics committees evolved in the late 1970s and into the 80s.

In this edition of The Bioethics Channel Rosemary Flanigan talks about how hospital ethics committees began and their future.

A Physician's Reflections on Bioethics

Robert Potter, MD

April 1, 2009

Dr. Robert Potter was a revered physician and medical educator in Kansas City for 30 years before moving to Oregon in 2004. In the decade prior to his departure, he served as a scholar and consultant for the Center for Practical Bioethics.

In this edition of The Bioethics Channel Dr. Potter reflects on bioethics then, now and in the future.

Link:

Podcast: The Bioethics Channel

DNR Best Practices?

Rosemary Flanigan
April 1, 2009

Remember my telling you about the patient with terminal renal cell carcinoma who is incompetent, has had a guardian appointed, and the team of 7 physicians caring for him thought it appropriate to have a Do Not Resuscitate Order.

I heard this morning that he has it!!! The ethics committee, after discussing “at length the various legal, moral, and ethical reasons both for and against instituting a DNR when the patient no longer possesses the decisional capacity to decide for himself,” concluded that the 2 physician specialists would co-sign the DNR and that the team leader would write a treatment plan to be shared with unit staff regarding what measures would or would not be taken in the event of a medical emergency.

Personally, I think that was a defensible outcome; I assume that the guardian agreed. Amazingly, during the course of all this, they were able to find family members whom he had not seen in 5 years and who were satisfied with the DNR and the treatment plan.

My peek into the future of healthcare reform tells me that there will be more DNR orders initiated and encouraged by physicians along with patient/family proposals. What my “peek” doesn’t tell me if whether or not there will be some “best practice” guidelines that will simply mandate a DNR order, regardless of physician OR patient OR family concurrence.

What do you think?

Cambridge Quarterly and Ethics Committees

Rosemary Flanigan
March 16, 2009

I let my subscription of Cambridge Quarterly expire, and just renewed it. I have long treasured CQ because it targeted ethics committees—and still does, I guess, though I have found this current issue rather thin.

The main section features revisiting vulnerability. The lead article defines it as “To be vulnerable means to face a significant probability of incurring an identifiable harm while substantially lacking ability and/or means to protect oneself,” and then goes on with articles about different kinds of vulnerability and different sites (research sites, especially) where different groups are especially vulnerable.

Yes.

But it was an article by a trio of Australian women discussing “Developing ‘Ethical Mindfulness’ in Continuing Professional Development in Healthcare” that I especially enjoyed—it’s the issue of ongoing education in one’s competence to recognize an ethical moment and to analyze it.

That sums up the 25 year history of the Center’s work—but the women’s approach is especially through the use of narratives. Still, it is not enough to do a superb job of educating well if the receivers of all that good learning do not practice what they’ve learned.

Nothing new there, but it’s good to be reminded.

Musings on Organizational Ethics

Rosemary Flanigan
February 1, 2009

At any minute, Hans will be e-mailing me that I’m committing a FALLACY (“composition and division”, we used to call it)—but I have been thinking of the role of the ethics committee and of MEMBERS of the ethics committee (no, Hans, I do not expect of the members what I expect of the whole—but. . . .) regarding organizational ethics.

In the document, “Core Competencies for Health Care Ethics Consultation,” credit is given to Myra for her comments on an early version of the section on Organizational Ethics and she and Robert Potter, MD have written extensively on the subject. (Robert edited a whole edition of HEC Forum on the topic.)

So over the week-end I thought about us in the ethics committee movement and wondered how we were doing in this regard.

The areas are broad (health care business—cost shifting and billing practices; interactions with the marketplace—endorsing products, market promotion; societal and public health obligations; institutional obligations in training future healthcare providers or in performing research; and general business issues) and the ability to handle them requires a new kind of education.

The report concludes, “We encourage additional efforts, including both empirical and conceptual research, to define more clearly the scope of organizational ethics consultation; the most effective and efficient organizational structures for its delivery. . .; the degree to which it should include preemptive, unsolicited interventions; the appropriate approaches for dealing with organizational ethics issue; and the knowledge and experience that it demands.”

Can you give me any examples of such “empirical and conceptual research”??? HELP! Thanks.

Integrated Ethics: More than following the rules

Rosemary Flanigan
January 28, 2009

I was happy to read in Health Progress (Jan-Feb, 2009) that Ron Hamel of Catholic Health Association praised the U.S. Department of Veterans Affairs’ model for integrating ethics throughout its many institutions.

The model addresses three levels: decisions and actions, systems and processes, and environment and culture. I especially like the emphasis on leadership in creating the environment and culture.

What behaviors of leaders foster such a culture? They talk about ethics, encourage ethical discussions; they communicate clear expectations for ethical practice by recognizing when expectations need to be clarified, being explicit, giving examples, and explaining underlying values; they practice ethical decision-making by identifying decisions that raise ethical concerns, addressing ethical decisions systematically, and explaining the reasoning behind decisions; and finally they support the local ethics program by knowing what it is (!!!)and what it does.

I know two of our discussion group are connected with VA hospitals—Nina out in Salina, KS and Terry here in KC. I’d love to hear the two of you tell us if the program is working!!!

The Center has long pushed for integrated ethics programs. Dear Robert Potter wrote and spoke extensively on the issue.

THANKS. Any comments from the rest of you?

Link: Fostering an Ethical Culture: Rules Are Not Enough, Ron Hamel, PhD, Health Progress, January/February 2009

Observing Martin Luther King Day

Rosemary Flanigan
January 19, 2009

Happy Martin Luther King, Jr Day to all. We just had a program at the Center—and didn’t 86 people show up!! I think people want to celebrate together.

First, I thank Francie for her MOST THOUGHTFUL organizational ethics issue from the perspective of an emergency department doctor. Questions like these MUST be addressed!!

How do the rest of you handle continued care for the un/underinsured?? I know that the Center, under Terry Rosell's leadership, has developed a service in the Kansas City area in which specialists sign up to see a certain number of such patients on a pro bono basis—but that is charity trumping justice. It need not be that way.

AND, just to use one e-mail, a friend at the Consortium gave me “Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers” from the 2008:149:861-868 issue of Annals of Internal Medicine. This is a great article for ethics committee education—excellent real arguments when the physician says, “I can’t tell she’s dying; it will destroy her hope.”
MARVELOUS!

Happy day!

Respecting Patient Plight and Hospital Mission

Rosemary Flanigan
January 13, 2009

Myra Christopher and I are teaching a class this week at the Kansas City University for Medicine and Biosciences. This is one of the three medical schools we have in KC and it has recently added a graduate degree in Bioethics. Terry Rosell is an adjunct faculty member there and we at the Center help him out from time to time.

Myra and I are to talk about ethics committees—an easy task—and I thought that the last hour’s case analysis should be in organizational ethics instead of clinical ethics—maybe because clinical ethics receives the major focus throughout the course.

So I looked in Kuczewski and Pinkus’ Casebook, and found one that the authors did NOT use as an ethics committee consult; instead, it is correspondence between the CEO and the CFO. I thought, “Why not have the CEO send the correspondence to the ethics committee?” and that’s what I did when I adapted the case. The ISSUE is non-payment of emergency room bills, especially prescription drugs.

I think it is a dandy ethical analysis to try to create measures that both respect the patient’s plight AND respects the mission of the hospital to act as good stewards of its resources.

HELP!!! What do you think?? (I’ll tell you some of the “CFO’s” suggestions later, but I see no reason why those suggestions couldn’t have been equally made by a good ethics committee.)

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Practicing on the newly dead

Rosemary Flanigan
December 11, 2008

When we “argue” (discuss?) at an ethics consult, we find ourselves sometimes arguing about erroneous conscience decisions, I think.

FOR EXAMPLE, let’s say as an intern, a physician may have practiced intubation on a newly dead patient without family consent. Years later, in retrospect, the physician may have arrived at the judgment that this was wrong to do and that he/she will teach medical students not to do it.

AH HA!!! So medicine needs to be practiced, and this particular procedure probably needs a lot of practice. What would lead the physician to see that such “practicing” was not a good thing?

What about the physician who doesn’t need to practice anymore—but still sees that practicing on the newly dead is better than not practicing at all so he/she does not teach medical students to avoid doing so?

Would you argue with this physician?

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