We Need Everyday Ethics Back in the Hospital
Ethical dilemmas, or value-based judgments denoting “good” and “bad,” occur every second in the world of health care. Problematically, most health care systems do not have a readily available and non-intimidating solution for healthcare professionals, especially nurses, experiencing ethical and moral dilemmas. A 2010 research analysis found that many nurses felt a, “sense of powerlessness and little influence in dealing with others about ethical issues”.1 Ironically, nurses pride themselves on taking the grave privilege and responsibility of being the patient’s “advocate”, of being the patient’s personal champion in the complex world of healthcare. How effectively can a nurse act as an advocate when nurses often find themselves in moral distress regarding their patient’s care? Recurrent moral distress has been shown to leave the nurse more hesitant, more scarred, and less willing to push back against what they see as an “impossible hierarchy”.1
Currently the Joint Commission on Accreditation of Healthcare Organizations (JCHAO) requires hospitals to have some form of a hospital ethical committee. Unfortunately JCHAO’s wording specifying any requirement for this ethical body is relatively vague and thus relatively unhelpful.2 Today, the majority of unit based ethics committees, if there are any at all, are based in the highest acuity units like the Neonatal Intensive Care Unit (NICU).
Ashley Munoz is a new nurse graduate from the University of Virginia in Nursing and Bioethics and was president of her nursing class for two years. She currently works on the NICU at Inova Fairfax Hospital with what she describes as an effective and approachable ethical committee. When asked about her ethics committee Ashley notes, “What is great is that we have a supportive culture where if we have an ethical problem we can easily go to the committee, the head doctor is very kind and approachable. Every unit has unique moral dilemmas and so it makes sense that they all need an ethics committee.”
As a labor and delivery nurse I (generally) do not work with the highest acuity patients, and never with patients on life support. I frequently find myself operating in some ineffable moral tension, difficult to pinpoint because I am so busy with my tasks, which leaves me exhausted by the end of the day. According to the 2010 study new nurses like myself and Ashley show a statistically significant higher rate of moral and ethical distress (and overall stress) in their patient encounters. I feel this stress acutely and want to push back against what a 2004 study found to be an occupational hazard relating to nurses’ excessive, unresolved, moral distress- “jadedness”.1
If a massive patient-care incident occurred, I might call the ethics committee. However, I want something easier, less intimidating, something everyone could feel comfortable using. As a new nurse, I envy Ashley who has easy access to an ethical board. I wish for an “everyday” ethical committee for every unit that is approachable, normalized, and non-judgmental. Most of nurses’ reported, ethical dilemmas are conflicts with hierarchies when trying to enact their duty of protecting a patient’s autonomy, beneficence, and nonmaleficence. Breaches of these basic principles happen, for whatever reason, every day in every hospital. There needs to be an accessible way for professionals and even community members to identify, address, and begin to resolve their experienced or perceived ethical dilemmas, without fear of social or professional repercussion.
The American Medical Association (AMA) Journal of Ethics cited bioethical committees as, “constructive in helping to develop policies and educate clinicians in ways that are likely to promote both patient rights and good health care”.3 They also warn against potential challenges: lack of policy expertise, difficulty in discerning between ethical and organizational concerns, and being unduly influenced by an administration with little help from the institution.3
A very basic, sketch of an ethics committee could look like this. It would begin with even just one person, a third party bioethicist hired by the hospital who holds regular office hours for providers, patients, and families for each unit. A location-friendly, regular opportunity for consultation would achieve the goal of accessibility and normalization. The AMA Journal of Ethics strongly believes, “the vast majority of what are framed as ethical disputes are more accurately understood as problems of communication and group dynamics and can best be addressed by standard conflict resolution processes”.4 In this model, it does not matter if the issue is genuinely “ethical”, what matters is the victim/observer believes there has been a known moral breach. It is then the bioethicist’s role to differentiate between organizational, political, human resource-based, ethical, and other challenges- and point the person towards the appropriate resource. If a policy change or meeting with a health care team is needed, the ethicist will serve as a liaison, organizer, and mediator of aggrieved parties. The biggest hurdle may be a hospital or health clinic administration approving and upholding salary for a third party bioethicist; especially problematic if this bioethicist makes a decision that directly or indirectly undermines a financially constrained administration.
Maintaining bioethics is of vital importance and not just for the mental sanity of staff. Bioethics serves a unique role through, “mediating between the values prevalent in medical culture and those of society more broadly”.4 Nurses are an interpreter between the patient and the health care facility. In order to be effective advocates this new generation of nurses must be able to express their moral dilemmas to an agent of change without fear of repercussion, before a “jadedness” sets in.
Torres, Jennifer, and Raymond De Vires. "Birthing Ethics: What Mothers, Families, Childbirth Educators, Nurses, and Physicians Should Know About the Ethics of Childbirth."The Journal of Perinatal Education18, no. 1 (2009): 12-24. Accessed February 1, 2017. doi:10.1624/105812409X396192.
Ulrich, Connie, Carol Taylor, Karen Soeken, Patricia O'Donnell, Adrienne Farrar, Marion Danis, and Christine Grady. "Everyday Ethics: Ethical Issues and Stress in Nursing Practice."Journal of Advanced Nursing66, no. 11 (2010): 2510-519. Accessed February 1, 2017. doi:10.1111/j.1365-2648.2010.05425.x.